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 really remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Dr. Kate Cronan, who is a pediatric emergency medicine physician. She is associate professor of pediatrics at Jefferson Medical College in Philadelphia, director of Health Content Integration for the Nemours Center for Children’s Health Media and senior editor for www.KidsHealth.org.

Beyond being a child advocate, Dr. Cronan is an active and enthusiastic health literacy champion and now co-chairs the Language Proficiency and Health Literacy Committee at Nemours/Afred I. duPont Hospital for Children. Welcome, Kate.

Kate: Hi.

Helen: I’ve long been interested in how communicating with children is different from communicating with adults, so I invite you to put on your health literacy hat and clue us all in. What is so special about communicating with children?

Kate: In the pediatric world, our healthcare team finds that we’re dealing very frequently with someone who is definitely at a low literacy level. By that, I mean children. They’re babies and growing children, so we know that their health literacy level could be low from the outset.

Helen: Does it almost make it easier to know that? I know when you communicate with adults you’re thinking, “I wonder what level to communicate at.”

Kate: It does make it a little bit easier because we go into the room or wherever the nurses and the doctors are seeing patients, and we know that we’re going to be talking to little ones and toddlers on up. They’re not going to have the level of understanding as adults may have.

Helen: When you talk about health literacy, are you talking about the vocabulary or the context? How are you framing this when you talk about low health literacy for kids?

Kate: A lot of it is the vocabulary for kids because they’re definitely not going to understand the words that doctors or nurses may use with adult patients who have a higher literacy level. There is a lot about the words that kids won’t understand. We have to also keep in mind something else, which is the fear factor.

Helen: You’re an emergency room doctor, so you’re seeing people at the height of fear.

Kate: Usually I am. In some cases people come to the emergency department and it’s not really a terribly fearful situation that they’re coming in for, but the child nevertheless is scared in an ER or even in a doctor’s office.

Helen: They’re even just scared of getting a shot or not being with mom for a moment. You know there are issues there that can make communication harder, so what do you do?

When I think of health literacy, we communicate in so many ways, but I know the two biggies are talking with people and giving written information. Maybe we can take this one by one. For our listeners, what should we consider when talking with children?

Kate: The first thing I’d like to discuss is that when we begin talking, we do have to be aware of the fact that we actually have two patients in the room. That is another thing that makes this unique. We have the child, but in most cases the child did not come alone. They’re too young, so we also have the parent.

When we’re talking, we are talking to the child some of the time and some of the time we’re focusing on talking to the parent. That makes it challenging.

Helen: Do you have an example? Of course I know what it’s like to bring a child into the doctor, but make it real for us. What is this like? What kind of a situation would this be?

Kate: Let’s say I go into the room and I know there’s a child in there. The child has a high fever. That’s why the parent brought the child in. If the child is old enough that he or she can understand me, in other words not a little infant but a 2 to 3-year-old who’s verbal, I will actually start by talking with the child first. I don’t get into the history completely, but I start addressing the child.

Meanwhile, the parent, grandparent, babysitter or caregiver is standing or sitting there and listening to what I’m saying to the child, so they’re already beginning to process the kinds of things I’m going to be talking about. That actually helps because the parent or caregiver gets to listen twice.

Helen: At what point do you start talking with the adult?

Kate: Once I start to feel that the child is a little bit more at ease and I’ve done some introductory things, then I will start talking to the parent. Sometimes we’re actually talking to the parent and the child at the same time. There are different phases.

Helen: What about how you set up in the room? Kids are little and adults are big. How do you position yourself to be able to do this?

Kate: That’s a really good point. What I do applies for pediatric visits in offices too, not just in the ER. I walk in and I see where the child is. They’re usually lying on the stretcher and the parent is usually sitting on a chair or sitting right next to the stretcher with their arms around the child.

I go into the room and introduce myself. I often say, “Hi. I’m Dr. Kate.” I don’t always say my last name because I’m thinking that they might have a friend named Kate, and it’s just easier and it makes them feel less scared.

Then, if there’s room, I’ll sit on the stretcher right next to the child or bring up a stool or a chair right next to the stretcher or bed. I’ll sit close to the child so I can focus on the child, but I’m trying to keep my back away from the parent because I don’t want to have them behind me. We can really set it up very quickly once we walk in the room.

Helen: You’re really pretty much eye level with the child and the parent and looking at both of them.

Kate: Yes. Sometimes I’ll turn my head back and forth of course to make sure I’m making eye contact with both. Often I’ll gauge by what the child looks like. Are they looking fearful or very sick? If they’re looking very sick or I know it’s something very serious, I may not have the time or the luxury to say some of the things I normally say.

If they look like they have a fever but they’re not too sick, what I might say right off the bat is, “I don’t have any needles,” and I’ll show my empty hands because so many children want to know is, “Am I getting a shot?” Even 2 or 3-year-olds and up want to know that.

I will say, “I don’t have any needles,” which doesn’t mean I may not have a needle later. If I really believe that they’re for just a cold, to get something out of their nose or something minor, I will say, “There are no shots today.” Then you can see the relief set in.

Helen: What I’m hearing from you is that you’re setting a positive tone. You’re establishing a relationship, introducing yourself, hearing from the one the most important one in the room, which is the child, and setting that positive tone for communication. Those are health literacy principles that hold up for all ages.

Kate: That is true. There are a couple of other things I do that may be more specific to kids. I’m still engaging the child before I even get to the big questions. I’ll say, “I love your boots. Those are such cute boots,” or, “Your hair is done so nicely. Who did your hair?”

If they’re a little bit older, I may ask, “What grade are you in? What’s your favorite thing to do after school?” Anything that can engage the child and make them less fearful sets the stage for me to get into the more medical concerns.

Helen: In a very positive way, I’m hearing all of those lessons we learn and apply elsewhere, except now you’re personalizing it. You’re finding what’s really special about that person in that situation. That’s great.

You mentioned earlier that you know children have limited vocabulary, particularly in this situation when it comes to health, body parts and illness. What are some examples of where they might have struggles and what would you do about it?

Kate: One of the words that could be problematic for the child would be the word pain. All of us know what that means, but if the child came in and the concern is about pain of some sort, I will ask the child, or the parent if the child is too little, to say it to me, “What kind of words does your child use for pain?” They won’t say, “I’m in pain,” or, “I have abdominal pain.”

What they might say is something like, “It’s a boo-boo,” or, “There’s an ouchie here,” and they’ll point to where they maybe fell on their wrist. They’ll use different words. I’ll make a mental note of that.

As I go through, I’ll say, “Is this where your boo-boo is?” or, “Is this where the ouchie is?” as I’m touching them. It helps me to get that framework right from the get-go for what they use instead of pain.

Likewise, for other types of complaints such as it hurts when they urinate or they’re having pain in the groin, a child typically does not know what urinate or groin mean.

I’ll ask the child, parent or both, “What kinds of words does your child use for the private parts? Do they call them private parts? Do they say ‘down there’ and point? What do they call breasts, the penis and all these parts? I may need to examine that area.”

Helen: What I’m hearing from you is a good health literacy principle is matching language. For example, if someone has diabetes, they might call it diabetes, but in some regions of the country they might refer to it as low sugar or something. That’s not the true medical term, but it’s a way of establishing relationship and using the right words.

Kate: Exactly. We do tailor it of course to the region they came in. If they came in for a cut, then I would be talking more about that and doing the same framework.

It works in a lot of situations, but there are certain key words that we know they’re not familiar with that we frequently ask about, like urinating. That’s another one where we’ll say, “What do they say for urinate?” If the parent doesn’t seem like they would know that word and if I have some clues, I’ll say, “Do they use pee?”

Helen: Is there ever a time you need to teach the fancier medical term and not just use the child’s language?

Kate: There are times when I do need to teach that. Sometimes it’s more related to a medication’s name. Instead of “the pink liquid,” it’s really helpful to have them know what the medicine is when they leave.

Sometimes there are other medical terms too that they need to know. If I diagnose them with appendicitis, as big as it is, they’re going to need to know that word because it’s going to be used throughout the hospital stay once they get surgery, so I will use that.

Helen: That’s great. Can we go with that appendicitis example? That brings up a lot of issues that interest me. It’s an inside body part. You can’t look at your own appendix. Appendix and appendicitis are different. How would you go about teaching something complicated like that?

Kate: First of all, I would point on the body to where the appendix is. If they came in with pain, it’s not necessarily going to be right there. It might be that their whole belly hurts. Once I figure out with the help of a surgical colleague that it is most likely appendicitis, I’ll then point to where the appendix lives.

I’ll also get a picture. I’ll go and grab a simple picture of the bare bones of what the inside of the abdomen looks like. The appendix will be on there and I’ll show them. That helps a lot for both parent and child.

Helen: You’re using pictures and words, and you’re touching. It sounds like it would be great to talk with you if you needed to talk about children.

Can we get into writing too? I know you do a lot of writing. It’s such a fallback way in health communication, I know you’re also very involved with www.KidsHealth.org. How would you go about communicating with children in print and on the web? What makes that special?

Kate: On the web and in other written formats, we try to do some of the same things that I just described. We try to use words that are going to be familiar to the parent because the parent is usually the one reading the instructions or reading the website. We do have a kid’s section on our website. Children definitely read that and it’s written at their level.

Younger kids like 3-year-olds that I can say the word pee to in person are not going to be reading. We gear it very carefully to the parent, child and teen levels, but we keep our literacy level roughly around sixth to eighth grade. That can vary with some of the articles and some of our instructions.

Helen: You’ve intrigued me again. You’ve raised all these issues I want to know more about. Let’s get back to the word pee. You’re either on the web or in print. You did all your good stuff when you were talking, but maybe the child has a bladder infection or something, so you really need to talk about that function. What would you do in print or on the web when you come to urination?

Kate: What we’ll do in print and in our discharge instructions is put both words. Instead of just putting pee, because there’s a high chance that a parent will probably know a higher-level word, we will put both words. We might say, “Come back to the emergency department if your child is urinating (peeing) less.”

We’ll explain it like that, or we’ll write bowel movement and in parentheses write poop. In print, and especially on the website, we’ll definitely use the higher-level word, but we’ll put in the simpler word as well.

Helen: That’s great. What else do you want listeners to know about? Our listeners are people who all somehow care about health communication. What else do you want us to know?

Kate: There are a couple of other things I just wanted to mention that can help ease a child’s worries, and a parent’s for that matter.

For example, any time when I’m in the room, I’ll refer to the nurses and the technicians by saying, “My friends are going to come in and check your heartbeat” and things like that. I’ll refer to them as my friends so it will make them less scared of the next people coming in.

Also, when I go to look at their throat, I’ll say, “I’m going to put a little Popsicle stick on your tongue really gently. Then I can see the back of your mouth.”

The nurses will say that they’re going to put the blood pressure cuff on and it’s going to hug the child’s arm. It does squeeze and they get scared of that squeeze, so we’ll say “It’s really hugging your arm and it’s going to be really quick.”

If the child is resisting the examination, we can try to make that a little fun too. I’ll say, “I’m looking for Dora in your ear,” or, “I hear chicken nuggets are gurgling in your stomach,” depending on the time of day. I say things to make it a little bit more fun.

Helen: When you get to the word choice and you talked about nurses and techs as your friends, do the other people on the team use consistent language with you? When they talk about you is it their friend, Dr. Kate?

Kate: That’s a really great question. About the hugging with the blood pressure cuff, that is pretty much universal. I hear all the nurses saying that. As a result, the doctors say it if we’re doing the blood pressure. That’s pretty common.

As for the question about the friends, we probably fall short a little bit because I don’t think everybody says that, although I do hear other nurses and colleagues referring to people as their friends. We have to keep in mind that we use this friend type of talk for the younger kids.

I obviously wouldn’t say to a 13-year-old, “My friends are coming in.” I would say, “The nurse is coming.” For younger kids, it’s all to make them more at ease. A number of us do use the word friend and almost everybody calls me Dr. Kate in the ER. The nurses would tell the patient, “Dr. Kate is going to come in,” or other people would too.

A lot of the doctors go by doctor and their first name. It’s a community that knows each other quite well. It’s not perfect yet, but we’re getting more consistency in how we speak.

Helen: I’m hearing so many health literacy best practices from you. I have one more question. I want to ask you about the role of teachback. That’s such a consistent recommendation to make sure our messages are understood. Is that something you build into your practice and communication?

Kate: I built that in this year. I do it more and more. In the emergency department, you can imagine it’s fast paced in many cases and we don’t always have enough time to do a long teachback, so we make it very brief.

My decision has been to get other people on board. I’ve actually introduced it to the whole group of the emergency department. We’re going to have training sessions on it in the near future. Yes, I do it whenever possible when it’s not a dire emergency.

Helen: When we started in the beginning, you said you really have two patients, the child and the adult. Do you do teachback with both or just with one?

Kate: It really depends on the age. If it’s a much younger child, I don’t expect to do teachback with them. If it’s an older child, say 9 and above, I will do teachback first with the child. I’ll then say to the parent, “Is there anything you would add about the medication?” or whatever I’m teaching back about. I’ll get both people’s input.

Helen: Look in your crystal ball. What do you see ahead for health literacy and pediatrics?

Kate: I feel that pediatrics is going to come into its own on this. We’re probably a little behind compared to adult health literacy because we weren’t thinking about it as early as it was being applied to adults.

From many conversations I’ve had in various groups, pediatrics is really moving ahead and moving at a faster pace now than we ever did to be more cognizant of health literacy with our patients and families.

Helen: I’m so glad that you’re really a champion not just for children but for health literacy. Thank you so much for sharing that with listeners of Health Literacy Out Loud.

Kate: You’re welcome.

Helen: I learned so much about pediatrics and health literacy together from Dr. Kate Cronan, 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, sign up for the free enewsletter, What’s New in Health Literacy Consulting.

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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.