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, hear what health literacy is and why it matters, and ways we all can help improve health understanding.

Today I’m talking with Dr. Cynthia Baur. Dr. Baur works in the Office of the Associate Director for Communication at the US Centers for Disease Control and Prevention, or CDC, and leads CDC’s Health Literacy and Plain Language work.

Among Dr. Cynthia Baur’s many responsibilities and accomplishments is that she is a lead author of the National Action Plan to Improve Health Literacy and one of the developers of CDC’s new Clear Communication Index. Welcome, Cynthia.

Dr. Baur: Hello. It’s nice to be with you, Helen.

Helen: I’m so excited to hear about this new tool for developing and assessing CDC’s public communication products, and I want to hear all about it. Since I, and likely many other podcast listeners, don’t work at the CDC I’m eager to hear what this new index means for the rest of us. Let’s take it from the top. What is this new Clear Communication Index?

Dr. Baur: The index is a set of four questions and 20 scoreable items that people can use to develop their public communication materials.

Helen: Does public communication mean communicating with the public? Is it that straightforward?

Dr. Baur: It’s pretty much any segment of the public that you would like to think about. I know that a lot of times people hear the word public and they think about consumers, patients or caregivers.

For public health communicators, the public can also be clinicians, health departments, people working in community-based organizations, or policymakers at the national, state or local levels. We have a wide variety of publics.

Helen: It’s any materials for the public. What is the index? Tell us more about that.

Dr. Baur: We developed the index to deal with a couple of issues that we noticed in our own communication work.

One is that people come to communication work from many different backgrounds. People come from social science, journalism, advertising and public relations, and technical and scientific writing backgrounds.

Although we were all wearing the hat of communicators, we were bringing some different understandings and approaches to communication.

Helen: I find that really helpful. I’m part of a group called the American Medical Writers Association. It’s the same thing. We come from a wide variety of backgrounds yet we all call ourselves medical writers.

Dr. Baur: One of the challenges we were having is when we were having conversations about good communication, we thought we might talk about the same things but sometimes they were a little different. The index allows us to structure and systematize our discussion of good communication practice.

Helen: Is it also setting the tone of what is good communication?

Dr. Baur: It’s setting the science in addition to setting the tone. As you and I have discussed, there are many other tools out there. Some are freely available like ours and others are for a cost. Many of those tools can reflect personal opinion or aggregation of what people perceive as best practice.

Because we’re a science-based agency, we felt it was very important to take a science-based approach to these four questions and 20 items in the index. It’s both the science and the tone of good communication practice.

Helen: Then it’s accessible for whoever is communication to whoever they are communicating with.

Are you looking at mainly print information here? Is this a way to look back at what you’re doing or to look forward as you’re creating new ones?

Dr. Baur: You can do both. You can look backward at things you’ve already created and that you may want to revisit and revise, or you can use the index to create new materials. In fact, what we’re trying to do is move our staff toward using the index in the creation of all new public communication products at CDC.

Helen: Wow! Is this unlike anything else that’s out there because it’s so science based?

Dr. Baur: Yes. Some of your listeners may be familiar with CDC’s Simply Put guide.

Helen: We’ll have a link on the Health Literacy Out Loud website for that.

Dr. Baur: In Simply Put, there’s appendix A. Appendix A is a very nice checklist of many good communication practices.

I would go into meetings of health communicators at CDC and out in the field and ask people how many of them were using this checklist in Simply Put. I would rarely get a hand, so I began to wonder what it was about this checklist that was not useful or not well-known among our own staff as well as people in the field.

That’s what really prompted us to start taking a look at the Suitability Assessment of Materials, or the SAM.

Helen: That’s by Doak, Doak and Root. I will have a link for that too.

Dr. Baur: We also wondered about some other checklists and whatnot that are in the field.

There were some very positive things about these existing tools, but we wanted to include those things that really have a strong evidence base for their effect on clarity. And we wanted a focus set of items that people can deal with in a relatively short period of time.

The third thing is that we wanted to reduce the subjectivity in the scoring process. You will notice in our item statements that we don’t ask people to assess qualitatively how well or how poorly something is done.

Helen: You’re taking out the opinion. When you say subjective, you mean your opinion, such as, “Do you think this is pretty good?”

Dr. Baur: That’s right. It’s not possible to remove opinion entirely, but you will see in each of our 20 item statements that the people who are doing the scoring are not asked to think about how well or how poorly something is done.

We’ve tried to just include those things where you can look at a material and say, “Is it present or absent?” Secondarily, once you’ve determined if it’s present or absent, you can have that discussion about the quality.

Helen: I think we should take it from the beginning. I’m looking at the score sheet as we are talking, but our listeners probably have never seen this before. Can we put all of this into context? Could you tell us about those four questions and the 20 items or however you want to introduce us to this? Then we can talk about how they might use it.

Dr. Baur: Okay. The four questions are all open-ended questions. We asked people to think about their primary audience, the health literacy skills of their primary audience, the primary communication objective and the main message of the material.

Those are all open-ended questions because it’s not possible to think about assigning a quantitative value to, “Who is your primary audience?” The important thing is to know who that primary audience is and then make the decisions about how to present the information according to your knowledge of that primary audience.

Helen: In preparation for this, I actually tried that for the Health Literacy Out Loud podcast series. Even though you’re talking about written information, I found going through this exercise really helpful. I thought about who the audience is and who my podcast listeners are.

I came up with people who somehow care about health communication. What do they know about this? I didn’t really think of their health literacy skills, but you asked questions about their motivation, attention and distractors. That was a really important question to think about.

You asked about the primary communication objective. I worked hard to come up with that and it became very clear to me. Then you said, “What is the main message?” I’d just like to share what I came up with for Health Literacy Out Loud.

I see the main message of these podcasts as, “Here’s the problem and here’s what you can do about it.” I went through your exercise and found it very helpful. Thank you.

Dr. Baur: We’re finding that before people even get to the scoring process, the four questions are really bringing clarity to their communication practice that they might not have had before. A lot of communicators think they’ve answered these questions in their head, but then when it actually comes to producing the material, it starts to get a little fuzzy.

When you press them on who their primary audience is or what their main message is, they have a hard time articulating it. Having to answer those four questions upfront really helps them focus on making decisions about the right language to use.

For example, you can’t really make an evaluation of whether you’re using jargon or not unless you know who your primary audience is

Helen: That’s great. Thank you for that. I hope that I build it into my practice to always be thinking as clearly as that one-page list of four questions, but this is more than that. Please talk about the items that are within the index too.

Dr. Baur: We have 20 items organized into several categories and four parts. The index has what we very creatively called parts A, B, C and D. Part A contains those items that we consider that core, meaning that they would apply to the largest group of materials we deal with.

You asked me originally whether the index just applies to written materials. Actually, the index can be used with a very wide variety of materials including Facebook posts, tweets, prepared responses that call center representatives use and scripts for podcasts. At CDC, pretty much everything we do begins its life as a written product even if it’s delivered orally, like in the form of a podcast.

In part A, this broad set of items we think apply to a very big range of materials, we talk about main message. We actually have four questions about main message. You have to answer again, “Does the material contain one main message?”

There are several things related to main message that we know affect people’s comprehension. One of them is, “Have you drawn attention to the main message?” Another is, “Have you provided a visual that helps people understand what the main message is?”

Next is, “Have you put the main message in a place in the material where they can easily find it?” That means at the beginning.

Helen: You talked about part A. What are B, C and D?

Dr. Baur: I just want to mention a couple of other things about part A before we move on. That’s where we also include the items about jargon and some of the design principles that people probably are familiar with in terms of bulleted lists and chunks with headings.

There’s one that might be a little bit different for people to think about in terms of explaining what you know and don’t know about a topic. From the work on science literacy, as well as crisis and emergency risk communication, we know that it helps people understand when you tell them both what you know, what you don’t know and what you’re doing to find out.

That might be a slightly different item that people hadn’t really thought about affecting clarity.

Helen: Do you know what I didn’t hear in there? Reading grade level.

Dr. Baur: That’s right. We don’t include reading grade level in the index. We tell people that if they want to do a readability assessment of the material they can do that, but the index was really designed to broaden people’s understanding of what affects clarity. Short words and sentences are a small part of what affects clarity overall.

Helen: Cheers for you. That’s great. I always get frustrated when people do that as the beginning and end of what they should be doing. That’s one more reason I’m so delighted with your index.

Briefly, can you just give us a heads-up about the other parts?

Dr. Baur: Sure. Part B has three items about behaviors. In part A, there is an item that talks about a call to action.

For example, I mentioned that policymakers are sometimes an audience for public health communication. You can think about an example where CDC has evidence-based programs that they would like communities to use and policymakers to know about.

Our main message in our call to action would be framed around those evidence-based programs, but there’s not a health behavior associated with that. We separated out the health behaviors into this other section, part B, so that people could just look at those materials where a health behavior is an important part of the overall set of information. There are three questions about behaviors.

Then we have part C, which is about the use of numbers. Although many of our materials include numbers, not all do. We decided to make these three items about numbers optional depending on the characteristics of the material. If you have numbers in your material, you use the three questions about numbers. If you don’t have numbers, then you don’t use those questions.

We ask people to think about if their audience would use these numbers. Do you provide an explanation of the meaning of those numbers? For example, it’s not just the number of cases of a particular infectious disease. Do you explain the meaning of the significance of that number of cases?

Seasonal flu is a great example. You could tell people that there were 100 cases of seasonal flu in Atlanta. People would need some explanation to know if that is a worrisome number or not. Is 100 a large number or a small number? Is that near me or not near me? Is that something I should be concerned about or not?

Helen: That’s very different from looking at numbers in a whole other way, such as risk probability and all of that.

Dr. Baur: That’s right.

Our last section is explicitly about risk. In public health, we make many statements about what people are at risk for or what they can do to reduce their risk. In addition to explaining the numbers, we ask people to explain the nature of the risk that people might be exposed to or that they could avoid.

If they’ve talked about a behavior that may or may not produce a risk, we say that they need to talk about both the risks and the benefits of the behavior because sometimes the risk might be more obvious and the benefits less obvious or vice versa. To give a balanced and clear explanation, we direct people to talk about both the risks and the benefits.

Finally, when it comes to probabilities, we know from the vast literature on numeracy and data presentations that if you’re going to use a probability, you need to also provide a written explanation and a visual if possible, to help explain that probability.

Helen: We’ve actually talked about that on some other podcasts. One was with Dr. Brian Zikmund-Fisher to talk about the part-to-whole ratio and all that. There’s so much to it.

I’m just so impressed with this index, Cynthia. Thank you for helping to develop this. It seems like a very useful device that all of us can use. You really are answering my question about, “What does this mean for the rest of us?”

I’m going to bring this full circle and see if this addresses the focus I wanted to have for Health Literacy Out Loud. Remember when I said the main message was, “Here’s the problem?”

Dr. Baur: Yes.

Helen: I think we focused on, “Here’s the problem.” How do we all understand the same way what we mean by good communication, and how do we get there?

The other main message is, “What are we going to do about it?” It seems like this index is not only a way to look at what we’re doing but what we can be doing about it. How can our listeners learn more about this?

Dr. Baur: We’ve posted both the user guide and the score sheet in the form of a fillable form at www.CDC.gov/healthcommunication. This is freely available to anyone who wants to use it. Our user guide provides actual examples of each one of the 20 items so that people can see what they should be looking for in the material.

We also have done a number of presentations for external groups on how the scoring process works. We’ve presented a number of conferences and we will continue to present.

We’ve invested in a lot of training for our own staff. Dr. Christine Prue in the National Center for Emerging and Zoonotic Infectious Diseases was the co-developer with me of the index. She and I have trained close to 700 staff here at CDC in the scoring process with the index. She continues to do a lot of training with groups she interacts with, and I do as well.

We’ve made a very strong commitment to the training process because we believe that while the index is as clear and straightforward as we know how to make it, the ability to develop and assess materials using this lens of clear communication is a learned skill.

Helen: I so much agree with what you’re doing. You’re continuing the training and the teaching by talking with us on Health Literacy Out Loud. We may not be the insiders of CDC, but we can all be learning from this. I thank you so much for all that you’re doing for everyone.

Dr. Baur: I really appreciate that. Chris Prue and I have made a real commitment to focusing our agency on clarity and sharing this with other people who do the same kinds of communication that CDC does. We’re happy to share this with everyone else.

Helen: Thank you for sharing it with all of us on Health Literacy Out Loud. Listeners, I hope that you continue this not only by seeing the index, but by giving it a try and teaching others about it. Together we really can make a difference. Thanks, Cynthia.

Dr. Baur: You’re welcome.

Helen: I learned so much from talking with Dr. Cynthia Baur, 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.

NewHealth Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find more information, along with a lot of important links, at the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.org

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.