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—hearing what health literacy is, why it matters and ways every one of us can help improve health understanding.

Today I’m talking with Dr. Bonnie Braun, who served as the first director and endowed chair of the Horowitz Center for Health Literacy at the University of Maryland’s School of Public Health.

Bonnie is a lifelong adult educator. Her many accomplishments include authoring nearly 100 peer-reviewed articles, founding and chairing Health Literacy Maryland, and leading the creation of the award-winning consumer curriculum Smart Choice Health Insurance. Welcome, Bonnie.

Bonnie: Thank you so much. It’s good to be with you today.

Helen: We’ve met, and our worlds have overlapped for many years, but I notice a consistent theme in all that you do. It seems to all be about learning and teaching. What greater message have you learned from talking and teaching audiences of all ilks over the years?

Bonnie: You know adults really want to learn when they’re ready to learn, and that’s when they realize they have a need or a problem. For the teacher, the challenge is to try to find that teachable moment when they’re ready. The passage of the Affordable Care Act produced that teachable moment when it came to health insurance purchasing.

Helen: I want to get back to this. You said that people learn when there’s a need or a problem. Health insurance reform and the Affordable Care Act gave us the problem. Is that correct?

Bonnie: It did because now is requiring additional people to purchase health insurance, many who never have. It also changed benefits in the law, which affects everyone who already had health insurance.

To add to that, most people have never learned how to make health insurance purchases. They’ve never studied it, they don’t know how to do it, and they just simply dread it and are very confused. That produced what I was calling a teachable moment.

Helen: We’re at that teachable moment right now. Where do you even start in doing all of this teaching? That’s a massive problem.

Bonnie: I think we begin by saying, “The law itself is confusing and complex. What can we do to simplify it enough that most people most of the time can get it and use what they now understand to act on it?” That’s the premise of health literacy. It’s understanding, acting, comprehending and doing something with that.

We got quite a team together and we began to go back and review adult learning, education, psychology, and other theories that would be appropriate to help people first of all become empowered and believe that they could take control and make a decision so they increase their confidence.

Helen: You knew that was the problem. It was really confusing and complicated. You’re making it simpler and you want people to be able to use it. Then what?

Bonnie: Then we said, “How do we help people make sense of this?” I have long been a fan of framework.

Helen: What’s framework?

Bonnie: It’s a way of structuring information. It’s a tool where a person can go into something that either they’re completely unaware of or know nothing about and begin to make sense of it.

Helen: What do you mean by a framework? Give us an example. I think of a house being built. It has a frame.

Bonnie: Yes, it’s like that. That’s a structural, physical frame upon which everything else is put. So is our skeleton, which the rest of us is wrapped around.

The idea if you’re trying to learn something is that there is some sort of structure that a teacher can help provide. I have often found that old Socratic method of questions upon questions is a good structure.

If you know the right questions to ask, then you usually can make progress at figuring out what it is you need to do, how you’re supposed to use something or whatever the outcome is as a result of it.

Helen: I want to know about those questions. Are those the questions that you think your learner has or are those questions you ask yourself as the teacher?

Bonnie: They’re questions of the learner because it all begins by putting the learner in the center of the frame. It’s what it is that they would likely need or want to know.

In fact, we constructed an entire health insurance literacy curriculum on the basis of what consumers were telling us. They were confused about what they wanted to know, so it does start with the person.

The questions would be questions they would have. What is it that they need or want to know? Sometimes as a teacher you’re amplifying that or inserting something because they didn’t even know they didn’t know something.

Helen: You amplify that, so you need to know who your learners are. You can’t just make assumptions. You can’t just say, “I know a bunch about healthcare reform, therefore I’m going to teach you this and that and you’d better learn it.”

Bonnie: That’s right.

Helen: It’s the other person centered, right? What do they want to know? What are they going to do about it? Are those the kinds of questions?

Bonnie: Those are exactly the kinds of questions. Then it’s my job as a teacher to help guide them to the answers, and in some cases add a few more questions that they didn’t know they should be asking.

When you do that, they become more empowered. They’re not dependent on you, the teacher. They’re not dependent on a fact sheet. They now understand the questions and some answers, and then you help guide them to where you find the answers. That becomes transferable. They can do this again in the future.

Helen: Is this just teaching one person at a time? I know that your program is a whole curriculum. Are you talking about really getting through to one learner at a time or is this something that can apply to populations?

Bonnie: You can apply it to populations. That’s where drawing on some of the research really comes in, which is what we did in the case of the health insurance literacy. There is a lot of research out there about what consumers know and don’t know. We combined that with what we know about learning. If it was a science, we’d be saying it was a hypothesis.

We sat up and said, “We believe that if we reduce confusion when we teach people how to increase their capacity and their ability to make a decision, ask questions and do critical thinking, they should be able then to make a smart choice.”

We then set out to test that. That’s how we began to know it works across populations. We don’t have to go individual by individual.

Helen: Does it work for all populations? I know your background is in adult learning, but does this work with professionals and everybody else along the spectrum?

Bonnie: In my experience it does because our professionals also want to know, “What is it that I need to know to do ____?” If they wanted to learn to be an interviewer like you are, what is it that they’d need to learn to do? Why is that important and how do they do it?

Helen: It’s what, why and how—great journalistic questions.

Bonnie: They are. In fact, that’s how we ultimately began the curriculum development. It was on the back of those three big questions with two sub questions.

The first one that we’d lead with was why because that gets people’s attention. Why is it you’re here today? Why is it you want to know about health insurance? Why is health insurance important? You can draw out from people then what they are searching for.

Helen: That’s part of your framework. You need to know why. That’s where you start. What’s the next part of that framework?

Bonnie: I start there not every single time, but we certainly did in this case because people were confused by the law and were asking, “Why do I need to even get insurance? Why do I need to pay attention to the law if I already have it?” That seemed like a good entry point for us, and it seems to be working from our testing.

Then there’s the what. What is health insurance? What do I need it to do? What am I trying to achieve with it? That’s where we begin to introduce, for example, that the number-one cause of personal bankruptcy is health costs.

After you work your way through some of the whats, then it’s about how. We were inspired by something called Ask Me 3. Some of your listeners would be familiar with that. That’s a framework.

Helen: Ask Me 3 is good for in-person health information. What is it? What do I need to do? Why do I need to do it? Is it that kind of framework?

Bonnie: It is, but the thing I always noticed missing was what I called an Ask Me 4, which was how. How do I do it? That’s what we have added. You know why it’s important you know what you need to do, and now how do you do it?

In the case of the health insurance that’s where we introduce tools that can take you through. We say, “Use these tools. They’ll lead you to the point where you can make a smart choice.”

Helen: Bonnie, I feel like I’m going down a road like in that poem. Do you take the road less traveled or more traveled? You’ve been talking about the framework and how that applies to health insurance. That’s great. I gather that is working. You are testing it.

I’m also interested how Health Literacy Out Loud listeners can apply some of your lessons learned about the framework into their practice, whether it’s about insurance or any other form of health communication. That’s where I’d like to go next. What can listeners do with this framework regardless of what they are communicating?

Bonnie: It might not be three questions. They might decide there are some more questions or they might not want to put it in a question format, though I find that people really resonate with questions and answers.

At least in the United States among English speaking people, that’s a very understood convention. If that would work no matter your field of interest or practice, then I would recommend starting with that.

Helen: Is that in person and in print or just in print?

Bonnie: It’s in person, in print or in video.

Helen: Start with the question and answer format. What else should all of us be considering?

Bonnie: You have to understand the intent and purpose of this communication. Is this something that you’re initiating or something that someone else has initiated? Is someone else the targeted learner? Who wants to learn? I think every professional has to think about these questions.

It’s a theme and variation to start with the end in mind, but it’s the same notion. What is this intended outcome and who has this intended outcome? You need to step out of yourself and say, “It’s not what I want you to do. It’s what, in effect, you want to do.”

That’s part of the shift that’s occurring in the healthcare area. We’re now becoming more patient centered, jointly problem solving, jointly preventing a health problem or addressing it if there is one there. It takes into account what’s important to the person.

Helen: That would be relevant whether it’s about a disease, staying well or accessing the system through insurance.

Bonnie: Exactly. This kind of framing would work anywhere throughout all of healthcare. Health insurance literacy is just a variation.

The whole patient-health professional encounter should be structured in such a way that they say, “What’s your purpose in seeing me today? What do you want to do while we’re here? How will you be able to follow what I’ve recommended for you? What problems might arise?” and things like that.

That’s where you start to really look at the individual and not just throw out some standardized, “this, this and that” reply.

Helen: That’s really interesting, Bonnie. It almost feels like it has come full circle because you’re talking about one more specific topic of learning and teaching. Then you broadened it to apply to many situations, and then come back full circle to the topic.

Those are wonderful lessons for all of us. I hope that people everywhere can be learning these broader lessons, the what, why and how. In fact, we focused on that in our podcast.

What about the health insurance part? For people who want to know more about your curriculum, is there a way people can access that information?

Bonnie: Yes. We call our program Smart Choice Health Insurance. You could google that. It’ll pop right up. It is available also through the University of Maryland Extension. That’s the outreach arm of the university. We also have a website called Insuring Your Health. The workbook that we use is there, along with educator resources and consumer resources.

Also, feel free to contact me if you want to learn more about this and about how to become a certified educator. Stay tuned to find out what we keep learning as we expand our education across the nation.

Helen: Bonnie, thank you so much for setting up this framework, for teaching us the importance of having a framework, and for helping us all learn more about learning and teaching. Thanks for being a guest on Health Literacy Out Loud.

Bonnie: You’re so welcome. Thank you for inviting me.

Helen: I learned so much from Dr. Bonnie Braun about learning, teaching and having a framework for health education. 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 monthly 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 more information, along with important links, at www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? I sure hope so. 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.