Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Barbra Kingsley, who is co-founder and Managing Partner of the Kingsley-Kleimann Group, and she also is Chair of the Center for Plain Language.

Dr. Kingsley is an expert in information design and plain language with a deep understanding of how individuals, particularly vulnerable populations, use print and online information.

She believes that all clear communication not only invites understanding but also breaks down barriers so that everyone can thrive.

I met Barbra when she presented a session about plain language at a virtual health literacy conference hosted by the Institute for Healthcare Advancement, or IHA. She and Dr. Rima Rudd spoke about legal cases they are working on that have to do with the readability of some very important public documents.

I am delighted that Barbra accepted my invitation to be on this podcast and tell us more.

Welcome, Barbra.

Dr. Barbra Kingsley: Thank you so much, Helen. I’m excited to be here.

Helen Osborne: Legal cases and readability, that sounds like an intriguing combination indeed. Tell us more.

Dr. Barbra Kingsley: We all encounter legal documents every day, and we don’t even think about it a lot of times. We encounter contracts, privacy notices and all kinds of documents that are there to disclose legal information.

I think we all somewhat expect that they’re very hard to read, and I think we’re trying to look at it a little bit differently and say, “Let’s not accept that. Let’s try to find a way to make those legal documents as plain as any other document that we get.”

Helen Osborne: That’s what you and Rima were working on? Just to make everyday legal documents easier for everyone?

Dr. Barbra Kingsley: The case that Rima and I were working on was actually a case out of North Carolina dealing with the Department of Motor Vehicles. It was specifically notices that were being sent to people about the fact that their licenses had been suspended.

These notices were very difficult to understand and, of course, very difficult for people to respond to, which meant that it was more likely that their licenses were going to remain in suspension. That’s a major issue for most people in the US.

Helen Osborne: Someone did some violation or multiple violations and they get this document in the mail. Is that correct?

Dr. Barbra Kingsley: Yes.

Helen Osborne: Then they may or may not follow through on that. You came in to be looking at those documents. Was there some concern about their readability?

Dr. Barbra Kingsley: I think what the case was really about was that people were getting these notices that were very difficult to read and understand, and then simply not being able to respond appropriately because they weren’t getting the information they needed from those notices.

The notice might say, “You need to show up for court on this date. You need to pay this amount.” But these were very convoluted notices, so it was very difficult for people to read the notice and be able to act appropriately.

Helen Osborne: Did you actually do a readability assessment on it? I know that’s kind of a hot topic in the health literacy world. How important is it to do those things you can find on your word processor about readability? Is that what you did to analyze these? Or was there more to it?

Dr. Barbra Kingsley: Actually, we looked at them primarily through the lens of the Programme for the International Assessment of Adult Competencies. That’s one lens through which we would look at literacy.

Helen Osborne: That’s PIAAC?

Dr. Barbra Kingsley: Exactly.

Helen Osborne: We’ll have a link to that on your Health Literacy Out Loud web page. I know that’s a mouthful, but it’s also a very important way of looking at how people read, understand and use materials.

Dr. Barbra Kingsley: Absolutely. We also looked at it through the lens of the Center for Plain Language. We have a set of criteria that we use to look at how plain a document is. It’s really looking at it through those criteria.

Then we also did think about readability. Readability is a very hot topic. I think of readability as one diagnostic that you can use. Readability formulas can give you, I think, somewhat of a first-level diagnostic of what’s happening in a document. But then you really need to go a little bit deeper using some other lenses.

Helen Osborne: Our readers are everywhere. This is what you do all the time. I do this a lot. Let’s take a step back.

Dr. Barbra Kingsley: Sure.

Helen Osborne: Let’s take a step back, and if you would, please define for us what you mean by plain language, And give us a bit more information about what is involved in assessing readability using one of those tools that’s out there.

Dr. Barbra Kingsley: Sure. I’m going to use the definition that we use at the Center for Plain Language, which is that “a communication is in plain language if its wording, structure and design are so clear that the intended audience can readily find what they need, understand it and use it.”

That is the definition that not only the Center uses, but also the other two major international plain language organizations have adopted as their definitions.

Helen Osborne: Thank you for making that clear. I’m a big champion of that definition.

Put into context, please, what’s involved in analyzing readability itself.

Dr. Barbra Kingsley: When readability formulas really were designed, they measured different aspects of a sentence. They’re looking at things like the syllables. It’s a mathematical formula.

We have these. We’ve all seen these on even our word processor. It will say something like, “This is an 8^thgrade reading level,” or a 5^th grade reading level.

But it is somewhat of a gross measurement, because there are things that it doesn’t take into account. For example, you can have certain words that are longer, such as “grandmother” and “hamburger.” Those have several syllables, but they’re very familiar to everyone.

A readability formula can’t make that distinction of what words you necessarily would know and would be familiar to you versus others that are long, esoteric and complex.

Helen Osborne: Sometimes even very short words carry a lot of meaning that may not be clear, such as the word “risk.”

Dr. Barbra Kingsley: Exactly. Wonderful example.

Helen Osborne: Readability gives this formula. You said it’s just a gross measurement. I’m glad you put that into context. There are many better, more thorough ways to be looking at materials. You talked about the Center’s standards.

For our listeners, please give us a few other examples beyond words. What would affect the readability or usability of a material?

Dr. Barbra Kingsley: One of the things that I really try to talk to people about is the fact that words are really just one aspect of what makes up a piece of information. You have the words, and then they become sentences. Now the sentences become part of what creates understanding.

When you really start thinking about it, it’s also the logical structure of the information. Is the information organized in a way that people would understand? Does it put the main message up front?

We’re often taught as writers to write inductively, so we’re sort of writing to lead up to our conclusion. In actuality, people who are using documents every day need that main message up front. They need to know what is expected of them, what decision they’re trying to make and, especially in today’s world, to be able to get to that information quickly.

In addition, I would overlay on top of that the concept of design. You can have a very well written document and it can have the clearest language in the world, but if the design is unclear, it can be really impenetrable in some cases. I’ve seen documents with great readability scores, very easy to read, but very difficult to use because of the design.

I think when you think about all of those things together, the language, the organization, is the message up front and is the design clear, all of those things together create a document that is clear, plain and easy to use.

Helen Osborne: Thank you, Barbra. I know that this is what you do. You’re certainly a pro at writing this way. What would you recommend for podcast listeners? Let me describe them a little bit.

We all care about communicating better today than we did yesterday. But many people might be on their own working for small clinics. They may be in health, public health, librarians, academics or students. We come from a variety of backgrounds and might have very limited resources or time. We care, but may not know a lot about what to do.

What would you recommend for improving materials so that they are easier for others to read, use and understand on the first go-round?

Dr. Barbra Kingsley: I think the first thing I try to remind people is that we all tend to get a little bit into what Steven Pinker calls the “curse of knowledge.” What that really means is that we know our information better than anyone else, so when we write, we tend to write what we know. We forget that other people don’t share that knowledge.

The first step is really almost taking a step back from our own knowledge and saying, “Who is my audience? Who is my user? What would they understand or not understand? Where does our knowledge base diverge?”

Then it’s being able to really think about it from the perspective of the users. That can be very difficult because, again, we get very attached to our own knowledge. That’s Step 1.

I think, also, as you write, there are many great references, and perhaps we can share some of those on your website, Helen, that can help people with the actual writing. But one step I think is critically important is to try and test it with users.

Whenever I bring this up to people, they say, “I don’t have the resources to be able to test.” Maybe I’m a sole proprietor. Maybe I’m somebody working within a health system and I’m just one person. I try to remind people that testing doesn’t have to be expensive. It really doesn’t have to cost anything.

When we think about testing, we’re trying to take something we’re creating and putting it in front of another person, someone who doesn’t share our knowledge.

We can walk down the hallway to somebody in a different department and say, “Hey, I am writing this guide on how to deal with diabetes in someone who was just diagnosed. Can you take a look at this and tell me what would be confusing to you? What would you do next after getting this?” I find that most people are very helpful and enjoy taking part in helping us develop our content.

I always joke that my mom, who is 87, has probably reviewed more documents than most people because I find her to be a very good initial test subject. I’ll just put something in front of her and say, “What do you understand of this? When you look at this, what would you do next? What is difficult? What do you think someone would find confusing?”

Helen Osborne: That’s neat. I’m going to give a shoutout. My mom is long gone, but my mom helped me, too.

I was writing a chapter in my book about older adults and what to do at healthcare appointments. One of my recommendations was to ask a lot of questions.

My mom turned to me and said, “Dear, I was brought up that it is rude to question people in authority. I am never going to ask the doctor any question.” Boy, did I learn a lot by that. Yes, we want to get those outside opinions.

Thank you for all of these tips. We’re going to have a lot of resources on your Health Literacy Out Loud web page, including that to the wonderful Center for Plain Language, for which you are currently the Chair.

But I want to circle back. You said, “Say the key message up front,” and I want to circle back to it. What’s happening with that case about the Department of Motor Vehicles and those everyday notices that are going out to folks?

Dr. Barbra Kingsley: There are actually several cases. The current case is a case in South Carolina, and that is continuing. There was one in North Carolina and now in South Carolina. South Carolina is continuing to wend its way through the legal system.

Part of what the legal team that’s working on this is trying to explore is “Could people really understand what their rights were and be able to act on them appropriately?”

I think this gets to the core of, really, the concept of social justice, which is are we giving people equitable information and an ability to act in a way that’s in their best interest? If they have information they simply can’t understand, then are they really able to do what they need to do to respond?

These are things that have really important consequences. Losing your driver’s license is a big consequence in a world where being able to get to work or take your children to school or daycare using a car is very important in our lives.

Helen Osborne: Barbra, I totally agree with you. I’m going to put this into a health context, too. This might be about driving a car, and that can affect so many parts of someone’s life. But the way you just described it, it’s really about social justice, being equitable and helping people act in their own best interest. That’s health literacy, too.

Dr. Barbra Kingsley: Absolutely.

Helen Osborne: Thank you so much for all you’re doing. I’m eager to hear more about the result of that case. You’re operating on a very big and very public sphere. I think we can all cheer you on for being part of such a big effort. But all of us can make a difference every day, too.

Thank your for sharing all of this with us on Health Literacy Out Loud.

Dr. Barbra Kingsley: Thank you, Helen. I appreciate being a part of it.

Helen Osborne: As we just heard from Barbra Kingsley, it is so important to communicate all messages in ways that are equitable and fair and people can act on the information in their own best interest. In other words, we need to consider our audience and write in plain language. But doing so is not always easy.

For help clearly communicating your health message, take a look at my book, Health Literacy from A to Z. You might be especially interested in Chapter 28 that is all about plain language.

Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

Health Literacy Out Loud podcasts come out every few weeks. You can get all the episodes for free automatically by subscribing at www.HealthLiteracyOutLoud.com, or find us on Apple Podcasts, Google Play, Spotify, iHeartRadio, RadioPublic, Stitcher and probably all the other places you can find podcasts these days.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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