Helen Osborne: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 conversations with some pretty amazing people.

Today, I’m talking with Lauren McCormack, who is Vice President of RTI International’s Public Health Research Division and also Adjunct Associate Professor in the UNC, or University of North Carolina, Gillings School of Global Public Health.

Lauren’s research bridges the fields of health communication and health policy, and involves developing, testing and evaluating interventions to promote patient-centered care, patient engagement and informed decision-making.

An overarching goal of Lauren’s research is to improve the public’s understanding and use of medical evidence in healthcare decision-making.

Lauren and I have known each other for several years. That includes serving together on the Clinical Effectiveness and Decision Science Advisory Panel for PCORI, otherwise known as Patient-Centered Outcomes Research Initiative.

At one of these meetings, Lauren spoke briefly about evidence-based strategies to improve health communication. I wanted to know more. That’s why I’m interviewing her. I think we can all learn a lot from Lauren.

Welcome to Health Literacy Out Loud.

Lauren McCormack:Thank you, Helen. I appreciate being here, and I always enjoyed our work together on the PCORI advisory board, so looking forward to talking today.

Helen Osborne:That’s great. Let’s get right to it. Evidence-based communication strategies. When I and others think of communication strategies, we usually start with the concept of “It’s a lot about our word choice.” But I know you think it’s much more. It goes way beyond our words. Tell us more about these evidence-based communication strategies.

Lauren McCormack:Great. Happy to do that. As we all know, patients and healthcare professionals have to make decisions every day based on the information or, as Helen was saying, evidence that’s available to them.

Some of that information, I think, is helpful, and some of the information is not necessarily helpful. One of the things that’s important to make it helpful is when it’s communicated effectively. Some of these communication strategies can be ways to improve the effectiveness of the communication.

We all know that people learn in different ways. Some people are visual learners, some people like that inter-personal communication and others just like to read.

Helen Osborne:Some people like to listen to podcasts. Don’t forget.

Lauren McCormack:Exactly. There are a number of communication strategies. I thought I would share a couple of them today and give some examples. Then also, I think we talked about trying to include some tips for some of your listeners if they’re interested in applying these in practical ways.

Helen Osborne:Sure. I always want to hear about the how-to. The Health Literacy Out Loudlisteners are just hungry for ways. How can we make it better today than it was yesterday? I welcome hearing those. Yes, tell us more about these evidence-based communication strategies.

Lauren McCormack:As you mentioned, these focus on promoting the use of clinical evidence. The audiences here are patients as well as healthcare professionals.

Helen Osborne:How about the public, too?

Lauren McCormack:And the public, absolutely.

The first one is targeting the message to certain audience segments or groups. I think this is one of the maybe easier strategies to implement. Some folks may already be familiar with this.

Essentially, it’s designing communications for certain subgroups. Subgroups could have certain characteristics like age or cultural background.

People like to see themselves in some of the communications and people who are making similar health-related decisions. The goal here is to make the materials more interesting and appealing. That’s what the targeting strategy is like.

Helen Osborne:Can you give us an example of the targeting? You talked about age or culture or something. What would that be like in a written communication to target a group?

Lauren McCormack:For cultural considerations, you might want to use visuals or imagery of certain people of that age group or particular gender. Visuals, I think, are key when you’re using this targeting technique.

Helen Osborne:Use perhaps a gentleman with a turban, beret or baseball cap?

Lauren McCormack:Exactly.

Helen Osborne:Great.

Lauren McCormack:Targeting can often be used with another technique, which is narratives. This one really is delivering the communication in the form of a story or testimonial. It’s often used in entertainment education.

This is where people share their personal experiences with a decision, like how they made it, why they chose the decision that they made and even how it turned out going back one year later.

I’ll give an example if that’s helpful.

Helen Osborne:Sure.

Lauren McCormack:We did some work a few years ago in prostate cancer where we did some videos and interviewed gentlemen who were making a decision about whether or not to get screened for prostate cancer.

We actually showed both sides of the decision where one gentleman decided to get screened and another gentleman decided not to get screened.

He shared the thinking process that he went through in a narrative to come to the conclusion that he made.

Helen Osborne:That’s just an example of making it personal.

I have a couple of questions about that. You used the word “screen.” I’m pretty sure I know what you’re talking about, but we get to word choice. That word screen, I don’t know how or why we came up with that one in healthcare. I’m looking out my window right now and there’s a screen there. Do you ever think about the word choice?

Lauren McCormack:Absolutely. Word choice is very important, so thanks for pointing that out. Screening is also equated with getting tested for a certain condition.

I think word choice has got to be part of and integrated with any of these strategies that people use. It’s like the baseline necessity for making sure communications are clear.

Helen Osborne:It’s not just our word choice, but so much more than that. We also really need to consider whether our readers would understand words as we’re using them.

Thank you for the example about prostate cancer. For listeners, maybe we don’t have access to telling full big stories. We’re writing something brief. How would you use narrative in a short way?

Lauren McCormack:Sometimes narrative just needs to be a sentence or two about a decision a person made, why they made it and why it was right for them. It really doesn’t have to be lengthy. There’s that sweet spot between too much and too little.

Some people like a lot of information, and that’s another technique where we’ve used layering of information. This can be done electronically where people can click and go deeper into a website if they want more information, versus putting all of that on the first page of the website that comes up. That can be a turnoff to some people if it’s overwhelming. Layering can be another technique.

Helen Osborne:We need to be very conscious of that, whether we do very short booklets or longer, more comprehensive ones.

Already you’ve given us a wealth of information. There’s targeting, narrative and layering. Are there more?

Lauren McCormack:There are a couple more. I’ll just mention them quickly.

Tailoring is different than targeting because it is communication designed for an individual person and it’s based on information from that individual.

I’ll give you an example here. Say a person is asked a short five-question survey, for example, and they answer in “yes” or “no.” We at one time developed an HIV tool that based on the answers to those five questions, they received one of 50 different messages that were developed and could be tailored on that. That really helps make it more meaningful and structured.

It can be also not just the content, but the timing. A person might get the text message, for example, once a week instead of twice a week, because that’s what they preferred.

Helen Osborne:That’s really helpful. I hear these terms and I was never all that clear about the difference between tailoring and targeting. That’s really helpful. One is about a person and one is about our characteristics.

There’s something else you and I were talking about that really intrigues me. You use the term framing. Can you explain that a little bit more?

Lauren McCormack:Sure. Framing can be one of the more complicated strategies, I think, because it involves communications that convey the same message but in alternate ways.

For example, you might emphasize what a person could gain or lose by making a certain choice. A specific case here would be one in 100 people have a bad outcome after a certain treatment versus 99 in 100 have a good outcome. You can see it’s the flip.

Helen Osborne:I’m going to speak from personal experience. I had a shot and I had a very unusual side effect. It was really scary. I’m that person who’s 1 in 100. I don’t care that 99 people didn’t have it. It was me. How do we communicate that?

On the other hand, most people don’t even need to think about it because it’s rare.

Lauren McCormack:That’s right. I think you made a good point there in terms of rare conditions. We generally have information at the population level, like this 1 in 100 or one in a million, but a lot of people, like you said, Helen, are concerned about, “What about me? What’s going to happen to me?”

Often, they want to know information about, “Am I in a higher risk group? Am I more likely to be one of the people in the one or the 99?” That kind of information or contextual data is also important to communicate to people.

There’s some research that shows that framing is helpful and effective. We do need to be careful that we don’t go overboard and confuse people with too many statistics and use certain strategies like presenting statistics in absolute versus relative risk.

Helen Osborne:Can you explain that a little more please?

Lauren McCormack:Sure. With relative risks, you might hear someone say, “There’s a 30% increase in this if you do that.” That increase is hard for people to calculate because it’s increased from what or based on what? In other words, what’s the denominator?

It’s a little bit better to present it as the one in 100, which is more of your absolute risk, versus a comparison to something else they may not be familiar with.

Helen Osborne:Using our numbers and how we do that is certainly important in our messages, too.

When you talk about positive and negative things, a lot of times, because I do a lot of plain language writing and editing, it’s about instructions, let’s say, after surgery what you can and cannot do.

I’ve learned along the way that it’s better, as often as possible, to state things in the positive about what you can or should do rather than “do not, do not, do not.” What are your thoughts about that?

Lauren McCormack:Just like there are different kinds of learners, there are people with different kinds of preferences. Certain strategies are probably going to be more effective with certain kinds of people.

This is where formative research can help identify what might be more effective for particular subgroups. This, again, ties back to the targeting. There’s not a one size fits all out there.

I’ll mention that I think it’s important to study the effect of our communication on outcomes, both short-term and long-term outcomes.

We look at things like people’s awareness and knowledge. Are they having discussions with their healthcare providers? I’m sure you’re very familiar with shared decision-making and joint decisions. Those are things we can look at to see the impact of our communications on these outcomes.

Even things like self-efficacy and self-confidence in people. Are they able to engage in those discussions and ask questions in a physician’s office? Do they intend to use the information that we’re sharing with them?

Helen Osborne:That’s the work that you do at RTI? You’re looking at the evidence of our communication?

Lauren McCormack:Yes. Exactly. That is some of the work that RTI colleagues and I do, in terms of decisions that people make. Are they informed? How can we help them make more informed decisions and present the information that facilitates that?

Helen Osborne:It sounds like it’s taking plain language and moving it even that much further. We have the strategies, tips and how-tos. Those are very good. We have a long, robust history and evidence behind them. But it sounds like you’re then taking that into the practical application of what people actually do after they read or hear our words.

Lauren McCormack:That’s exactly right. What’s the outcome of all the work that communicators are doing? Is it helping people make decisions? Do they feel that it is an improvement upon what they knew before?

Helen Osborne:I’m curious to hear what you’re learning. I also am curious about another topic that you bring up at our PCORI meetings. You and I have chatted about it a bit and it really fascinates me. That is how do we communicate when the outcomes or evidence seems iffy and uncertain, like, “Experts don’t all agree on this”? What do we do then? That seems to be happening more and more these days.

Lauren McCormack:I think this is going to be an issue that’s here to stay for a while as the science continues to evolve and new studies come out. How do we communicate to people in this situation when there are gaps in the evidence?

Compared to messages about quitting smoking or healthy eating that are fairly straightforward these are not. Some tips and strategies are to talk about the evidence that is currently available, or in other words, what is known. But also say what is not known at this time and what’s happening to help uncover and improve the science and lead to additional information being available.

You can also talk about how strong the evidence is. What I mean by that is maybe talking about what kinds of studies have been done so far to develop that evidence.

Is it just one or two studies, or have there been a handful of studies done by different researchers? Are they well-designed studies? Was there a sufficient number of people in them, or was it just a few people in the study? Were the studies long term? In other words, you’re getting the picture in terms of the quality.

Helen Osborne:I am. I know you’ve been doing some work on this. Can you make it a little more vivid for us about what this would look like?

Lauren McCormack:Yes. I’ll give you an example here with respect to opioids.

Helen Osborne:That certainly is a hot topic these days.

Lauren McCormack:It is. The evidence is generally considered to be insufficient supporting the use of opioids for chronic pain long term.

When patients use opioids as their doctor tells them, these drugs can help reduce the pain in some people. They may not work for everyone and they may not work for the long term. They can even lose their effectiveness or stop working altogether for certain people.

That is an area of uncertainty in the science that, I think, needs to be communicated to folks so they can make a decision with that information in hand.

Then we can tell people that scientists are still studying this issue and research is underway to better understand it. But in the meantime, obviously the decisions need to move forward.

Doctors can help set realistic expectations for patients with chronic pain. It may not be that all of the chronic pain can go away, but there are options and choices for them and they have to make a decision that’s right for them.

Helen Osborne:We’re all doing the best we can in understanding a medication like opioids. We’re moving it forward. We don’t have all the answers. I’m almost getting this parallel. Is that almost what we’re doing in how we communicate?

We’re doing the best we can with the tools we have today. But those recommendations might change a little bit in the future on how we do it. Or is this communication science pretty firm and deeply entrenched?

Lauren McCormack:Science is always evolving, so I think that was a good parallel that you made. The field is constantly learning in communication science, health literacy and also medicine. We need to make sure that we’re disseminating that information and adjusting our strategies over time.

I think it’s most important that we’re using the tools that we have available to us in communication science. They do exist, and there’s some literature supporting them, but the research needs to continue.

Helen Osborne:Thank you. You are confirming. You are making me feel better about the hard decisions I sometimes have to make. Such as, “How do I word this difficult concept a little bit more clearly?”

I’m building it on strategies that have been proven and tested. Sometimes I have to make decisions. But I adjust as I go along and do the very best I can to make it that much better for readers now.

It sounds like you and folks you work with are really helping move this forward in a more robust way.

Thank you, Lauren, for all you do. Thank you for sharing it with us on Health Literacy Out Loud.

Lauren McCormack:Thanks for having me.

Helen Osborne:As we just heard from Lauren McCormack, communicating clearly is more than just choosing simpler words. There’s a lot to how we frame our message, put it into context and make it relevant to our audience. Doing this is not always easy.

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

NewHealth Literacy Out Loudpodcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio, Google Play and the Health Literacy Out Loudwebsite, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? I sure hope so. If you did, tell your colleagues and tell your friends. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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