HLOL Podcast Transcripts

Health Literacy

How Visual Cues Help Readers Read (HLOL #95)

Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some truly remarkable people about what health literacy is, why it matters and ways we all can help improve health understanding.

Today I am talking with Josiah Fisk, who is founder and president of More Carrot, a firm that combines plain language with information design to create simplified, user-centric documents.

While Josiah often works on consumer financial products, he also has experience with healthcare providers, software companies and even the IRS. More Carrot is a global company with offices in Boston and Luxembourg.

I met Josiah at a Plain Language conference, and then read his article about information design that was recently published in the journal Clarity. Josiah and I recognize the irony of doing this audio podcast all about visuals. We will do our best to paint pictures with spoken words. Welcome, Josiah.

Josiah: Thank you. I’m very glad to be here.

Helen: You describe your business as information design, but I have also heard the term graphic design. Are they the same thing?

Josiah: They are very similar, but they are different. They use a lot of the same tools, but they use them in different ways for different purposes. If you are a graphic designer, typically you might be interested in trying to catch the eye or set a mood. You are trying to perhaps introduce some images that are eye-catching or convey a personality or feeling.

Helen: Like with pictures, drawings and illustrations?

Josiah: Yes, but also with design features like use of type, color and different things. You are essentially trying to draw attention.

Helen: What is information design?

Josiah: There we are using a lot of the same tools. We may be using color and images. We are certainly using type and simple graphic elements like lines, boxes and so forth, but we are using them very functionally.

We are trying to make the content the hero or the attention point, so to speak, and we are assuming at this point that someone is interested in the content and just wants access to that.

We are trying to make this an experience where everything is visually set up to help you navigate through the content, find what you want and so forth. We don’t want people to say, “What a nicely-designed form, legal document or whatever.” We want them to say, “That was easier than I thought to fill out that form.”

Helen: I see you have worked financial products. I don’t see those as really compelling to read, and certainly not tax forms from the IRS. How would information design work on something like that?

Josiah: We all know that they’re not going to be anybody’s idea of a beach read, but that also isn’t the point. These are transactional documents where we are trying to get some bit of business done, whether we are compelled to do something or whether it’s because we decided to do something.

Therefore, this is the transactional part of that decision, like deciding to buy something or invest some place or whatever. We just want to get this part over with. To try to do something simple, yet not insulting or confusing, and that doesn’t look like a mess has some value to the customer experience.

Helen: When you talk about the customer experience, is it just like “I can do this,” or is it more than that, like “I will do this,” or “I want to do this,” whether it is reading it or filling out the form or something?

Josiah: It sounds a little bit ironic, but one thing that helps us is that generally people have a well-founded sense of dread about these interactions or very low expectations.

Helen: That is true.

Josiah: For instance, one of the interesting things is that we are all very interested in healthcare and health. It is a very personal thing and it has a lot of emotional content associated with it.

It is very important to us, and yet we tend to give up rather readily on understanding a lot of the forms or documents that one sees in the course of interactions with the healthcare and medical system. I know I certainly do.

Helen: Most of the people listening to this probably are concerned about healthcare materials. Do you see healthcare documents almost like a financial prospectus or a form that we have to fill out for the IRS or something? Is it the same way and we’re equally unenthusiastic about it?

Josiah: In that way it is, but it is something where we actually do care very much about the topic, yet we somewhat dread the interaction. We go into it with an assumption that we’re probably not going to be able to understand this or that it’s probably going to be a real trial to go through the form, interaction or whatever.

We tend to give up rather easily. If we see something that is difficult to understand, we say, “I knew this was going to be difficult.” What we are trying to do is to have something that when the person looks at it, they are able to say, “Actually, this seems like maybe I could understand this.”

It doesn’t sound like much of an improvement, but the important thing to understand about this is that so often it is the difference between something being read and not read or something being completed properly or maybe not at all.

For instance, one of the interesting things that we have discovered in financial services is making some of the forms a little bit easier. Let’s say you want to move your IRA from one firm to another. There is a lot of paperwork, and it is not easy.

It is very interesting. The company to which you would like to transfer your money has a great interest in seeing this transfer happen. They have put out the ads, spent all of this money on marketing, and finally persuaded you that you’re going to move your money there.

Then they send you this pile of paperwork. Basically the entire thing sits on your kitchen counter for six months, and then it goes into recycling because you couldn’t figure out the form.

Helen: I know that you are helping make it clear for us in healthcare. I did promise listeners that we would paint a picture with our words. Can you paint a picture of what transforming healthcare documents into something that people actually would read would look like?

Josiah: Sure. It starts at a very simple level. You will laugh when I say this. When we fill out a form, we can all agree that it is pretty amazing the number of times when you aren’t sure whether you are supposed to write above the line or below the line.

It is something as basic as that. “Am I putting this in the right box? Am I putting this information in the right place? I’m not quite sure where they want it.”

Helen: I’m thinking about those health history forms or something. When you go to a new provider or a specialist, that is the first thing we get. We might start with those questions. “How do I even fill out this form?”

Josiah: That’s right. A second thing, and another very simple visual cue, is how much room do they give for certain answers? We have all seen where the phone number gets an entire line, and then the entire address gets half a line or something like that. It is very disproportionate. It is a little bit better if you have way too much room than if you have too little room.

In many cases, if you’re not sure how much information someone is asking for, the amount of room that is left is a visual cue that they are asking for a lot or a little, except if you have just been through the form and the visual cues were all pretty bad.

If there was as much room for the zip code as for the whole rest of your address, then you are not sure what they are asking for because you can see that they’re not using their visual cues meaningfully.

A lot of this stuff is not necessarily very complicated or difficult. It’s things that we are doing that catch people off balance so they’re not sure.

Helen: I certainly can think of zillions of forms I’ve seen where that is problematic. What are they even thinking?

Our listeners probably are interested in health information. They’re likely not nearly as skilled as you and knowledgeable about information or graphic design, but we know our content. What could we be doing to help?

We should have a shorter amount of space for our zip code than for our address, but what else could we do to make our readers be able to read and actually act on and follow our healthcare information?

Josiah: If we are talking about forms and things, there are a couple of things. One thing is that it is really nice if you can get a form that doesn’t have a whole lot of boxes or parts on it that they then tell you to skip.

It is really nice to get a form where you can just go through and fill out what you’re supposed to fill out and not have to worry and think, “Did they say I needed to do this one or not? What is that one on there?”

Helen: You want an answer to everything, so don’t have any that say, “You can skip this one.”

Josiah: It’s common where you see forms where they just hit certain things with a yellow highlighter and say, “You only need to do the highlighted things and not the rest of it.” That is okay, but first of all, you would often have a much shorter form.

Second, it just makes it seem to people that you are better organized. They can just sit down, start at the top of the form and go through it. That is one thing with forms that would be very helpful.

Helen: Can I ask you a question about the skipping part? If people are designing a form and they are like me in my hospital days, I had no training on how to write a form. I was just told to go do it on one piece of paper. I had no idea what I was doing.

You also try to cover every contingency. That is probably why you have, “Skip this if it doesn’t apply.” How do you recommend we get beyond that hurdle when people are different and our audience varies?

Josiah: We’re talking about two different things. If something doesn’t apply, then it should be clear that you skip ahead to something. I think that is okay.

Maybe I’m just talking from personal experience as much as anything, but the majority of times that I have been asked to fill out a form for any kind of healthcare situation, they don’t want you to fill out the whole thing. There are things on there that would apply, but they don’t ask you to fill them out. It makes you wonder, “Why is it on there then?”

It is always nicer if it can look as if it is really meant for you and the situation. The funny thing about these is that they have a certain emotional and psychological component to them that we don’t think about because we are so used to it, but it is definitely there.

Helen: I can see how either welcoming or not welcoming a form could be, so thank you for answering that.

For many people, it is not just forms that we are writing. We are also writing patient education material about a topic. Is the concept of information design relevant to that too?

Josiah: I think that it is very much. It is interesting to me the tone that is taken in a lot of these communications. It is nice to have it be a professional, serious tone and not a somber or scary tone, but something that looks as though it is going to be informative and doesn’t do too much to try to have nice photos or things that look cheerful, pleasant or whatever.

I think that less of that and simply more information and presenting things as they are from the patient’s standpoint and being a bit more businesslike actually is okay.

Helen: I know you are also a huge advocate of plain language, as I am. Are you talking about the words or about how you use headers, spacing, bold print or something like that?

Josiah: All of the above. It is certainly the words, but it’s also the choice of photos, how big the photos are and how many there are. You tend to see a lot of cheerful, reassuring photos. I don’t think there is anything wrong with that, but there is a little bit of confusion between the marketing mode and the information or educational mode.

Helen: I’m thinking of a project that I consulted on. If you just looked at photos all by themselves, you would think that every patient was delighted to be there and every nurse or clinician was just as happy as could be because everybody was smiling and chipper, but it was all about when you’re really sick and in the hospital. What do we do about that? That is quite a disparity.

Josiah: That is a great example. No one is pleased to be sick and in the hospital, but if you are, what you want is information. You want to know what is going on. That is really where the boat is being missed in some cases.

I will give you another example that I encountered with my health insurance provider that I thought was an example of the wrong visual cue completely. They basically were insisting that all of the people who had the plan I had be transitioned to a program where you would receive prescriptions by mail. You couldn’t just go to the pharmacy down the street anymore.

That is fine. They made a policy decision. It was probably cost based. I understand, but the way they sent it was like a marketing piece with all of these pictures of happy people talking about how wonderful the service was.

I didn’t have a choice. They just told me I’ve got to do this. They’re trying to sell me on something when they were actually telling me I had to do it. Why don’t they just tell me I have to do it, why they’re doing it and how to do it? Let’s just get on with this?

If you are in the marketing department, it is tempting to continue to use the same look and feel and photos in your informational and marketing things, but I think that people are in a different frame of mind.

One of the things that you can do that seems a bit paradoxical is that you can gain more respect and goodwill from the customer if you know when to stop selling and start simply telling about informational things. That is really what they want.

Helen: That is such an interesting point, Josiah. I also know who writes documents. Sometimes it is clinicians, and clinicians know medical stuff. Sometimes it is business, and that sounds like what you are talking about. Sometimes it is marketing. We all have a different purpose when we come at this one.

Josiah: That is true. When something is written by clinicians, you can have a different issue where things are too in depth, too technical or have too many words that are unfamiliar.

You have to look at it and see if the term in the professional sense is very readily understandable to a layperson. Then perhaps it is a little bit of an easier sell.

Helen: You are talking about balancing. You are balancing a lot. I asked you about balancing the needs of the clinician versus business versus marketing.

You’re talking about the balance between the needs of the reader and defining or not defining, plain language, what things look like and how attractive they are. That sounds like an awful lot to juggle at one time. How would you recommend someone put all of these moving pieces together?

Josiah: A lot of it is simply stopping at various points in the process, taking a deep breath, taking a step back and asking the question, “Could my mother, sister, brother, father or whoever understand this? Is this something they would do well with?”

Are we saying the right things? Are we going into the right level of detail? Are we organizing this properly and does it look right? Does it look like what it is? Is it a marketing piece that looks like a marketing piece, or is it an educational piece that looks like a marketing piece? That might be a problem.

Here is another thing where the visual can be very important. It is helping different components of the documents look like what they are. If something is a little educational and something that a novice would want to know but that other people wouldn’t, it is good practice to pull that out, label it well, and make it look different visually so that people can see that it is something that is related.

That is something that is done very often, but that same technique can be used more often. Something like that is more valuable, for instance, than a pop quote where a certain quote is taken out and put in the margin or set large in the middle of the body of type. That is a nice technique that is eye catching, but it doesn’t necessarily help anyone navigate or find different things.

What I would prefer to do when we are in an educational or informational situation is to have more sub-heads and break things up more so that I can see, “Do I want to read a paragraph about this?”

You often have information that you don’t know what it is about until you get to the end of the paragraph. Then it is too late to decide whether you wanted to read that paragraph or not. You already read it.

Helen: Josiah, you have so many ideas. I am fascinated. I keep thinking about documents that do this and projects I have worked on, but we don’t have time to cover it all. How can listeners learn more about informational design?

Josiah: There are a number of ways. I can certainly recommend the books by Edward Tufte, who is very well known.

Helen: We will have the links on the Health Literacy Out Loud website.

Josiah: Those are an excellent way to understand. They are more about making very complicated things simple.

Just looking at examples of things that you see in real life that seem very good or very bad can help. Sometimes people cite the design of Apple and how the packaging tends to be simpler and not as complicated. They don’t ask you to spend half an hour reading the box. Look at examples like that. When you have a good experience or a bad experience, what seems to make it that way?

Helen: Thank you. I will put some of those there. What about your business? How could someone learn more about More Carrot?

Josiah: You could go to www.MoreCarrot.com. It is very simple.

Helen: That is very simple, I’m sure there is a big story behind it, but we’ll save that for another day. I want to thank you so much for being a guest on Health Literacy Out Loud and sharing with all of us ways to make the complicated simpler. Thank you so much, Josiah.

Josiah: Thank you.

Helen: I learned so much about information design, putting all of that together and writing documents from Josiah Fisk, and I hope that you did too, but health literacy isn’t always easy.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free enewsletter What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find them on iTunes, Stitcher Radio and on the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.


"As an instructional designer in the Biotech industry, I find Health Literacy Out Loud podcasts extremely valuable! With such a conversational flow, I feel involved in the conversation of each episode. My favorites are about education, education technology, and instruction design as they connect to health literacy. The other episodes, however, do not disappoint. Each presents engaging and new material, diverse perspectives, and relatable stories to the life and work of health professionals.“

James Aird, M.Ed.
Instructional Designer