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 Dr. Rima Rudd, who has been a member of the faculty at the Harvard T.H. Chan School of Public Health for over 30 years. Rima’s work focuses on community health, inequities and literacy-related barriers to health information, services and care.

Rima is one of the founders of, and leaders in, health literacy studies worldwide. She is also a long-time and dear colleague.

I heard Rima give a presentation at a virtual health literacy conference about an expanded health literacy model. I thought that this model was so clear, compelling and important that I asked Rima to share it with you, the listeners of this podcast. I’m so glad she said yes.

Welcome, Rima.

Dr. Rima Rudd: Thank you, Helen. Good to be here.

Helen Osborne: I’m just delighted to have this opportunity that you can share this model. Tell us the gist. What is this expanded health literacy model, and why now?

Dr. Rima Rudd: I think we’ve focused a little bit too long on the skills and abilities of individuals, and I think it’s time for greater action. We can only bring about greater action if we think about skills and abilities, texts, tasks and context. I’ve just named the four components of this expanded model.

Helen Osborne: Skills, abilities, tasks and context. I think that’s what really resonated with me when I heard it. Those are chunks of this bigger world we talk about as communication. Tell us more.

Dr. Rima Rudd: I can focus on either of them. But I just want to point out that when we think about health literacy, we have to think about all four of these components interacting with each other. It’s almost the vision or visual of four overlapping circles where they all overlap each other in the middle. In that middle is where we find health literacy.

I can talk individually about skills, texts, tasks or context, but it’s the overlapping part that really intrigues me and that, I think, is the essence of health literacy.

Helen Osborne: Where do you want to start? Should we start with the different components, or should we talk about why it’s important that they overlap, the gist of it? I leave that to you. Where do you think a newcomer to this model should start?

Dr. Rima Rudd: Why don’t we start with the traditional, where we look at the skills of individuals and the important conversations that take place in the health field, either in the public arena, in the community or individually and intimately in the doctor’s office?

Helen Osborne: Okay.

Dr. Rima Rudd: The overlap there is the listening skills and knowledge of the individual patient, for example, and the skills of the professional. It’s that overlapping that’s the most important component.

Helen Osborne: When you use the word “patient,” is that a fill-in? It could be patient, public, caregivers or family. Is that a stand-in? Also, for professionals, it could be in the public health arena, a clinical context or community level. Is that correct?

Dr. Rima Rudd: All of those things, Helen. I don’t mean patient. I don’t mean that to be the focus of our attention at all. Maybe let’s talk about the layperson.

Helen Osborne: You’re talking about the skills on both sides. Tell us more.

Dr. Rima Rudd: We know what the skills are of the general public, the literacy-related skills in terms of reading, writing, speaking, listening and doing math. We know that from a wave of surveys that happened in the 1990s, at the beginning of this century and most recently. That is a given for us in the health field.

The education field wants to focus, and should focus, on that and improve those skills, because they’re not very good in our country amongst adults.

The skills of the individuals are the known factor. There’s nothing we in health can do about it.

Helen Osborne: Not in the short term, that’s for sure.

Dr. Rima Rudd: Right. Except we can hone our own skills and make that process of hearing each other and talking with each other easier.

Helen Osborne: Can you give an example?

Dr. Rima Rudd: Yes. Again, when I think about talking with each other, I also think about writing for each other.

Here’s an example. It reminds me in a sense of the Jim Crow era when literacy tests were used for voting. As you know, African Americans were given very difficult and demeaning texts to read out loud, so their literacy skills may have come across as rather poor.

If you give me a text in advanced physics and test my literacy skills with that text, I’m going to come out with very poor literacy skills.

We have to pay attention not just to my abilities. We have to pay attention to the complexity of the text. If I make that text easier, then that process becomes easier.

Helen Osborne: It’s also the context. For our listeners who aren’t necessarily US-based, a lot of the inequities of society had to do with seeing if someone could read. That’s the origin of Jim Crow.

In healthcare, we have inequities, too, because we have really hard information and we’re expecting someone, perhaps, who might be afraid of getting a disease, has a disease or is scared of an illness to be able to understand it on the spot. Is that equivalent?

Dr. Rima Rudd: You’re bringing in a more sophisticated and nuanced issue here, which is part of this new model. You’re bringing in the issue of context.

When we think about health, that context is very complex. When we talk about health and we’re making decisions, it’s very often a time of duress, worry, fear, pain or illness. That’s part of the broader context, which I think is very important as well.

But the text itself, the conversation, the written words are very often in a foreign language, a language of medicine. Very sophisticated words like “utilize” instead of “use.”

Helen Osborne: Why would we do that?

Dr. Rima Rudd: It makes us sound much more important or educated.

Helen Osborne: Our texts are harder. When you use “text,” are you talking just about the written word? You made reference to the different modalities there.

Dr. Rima Rudd: I’ve sort of adopted the word text from the literacy field. There, people use the word text that means talk, writing, illustrations or something online or on mobile. It’s used for all parts of communication itself. The conveying of information is a text, written, spoken or visual.

Helen Osborne: The literacy field has their own language, too, and I’m learning it. You are well versed in it. That’s your background. I come from a clinical background, so we have to agree on our words here.

Dr. Rima Rudd: Yes. Thank you for calling me on jargon.

Helen Osborne: Maybe that’s a good example of health literacy. It’s hard for me to say that to you, a very well regarded guru of our field, and to say, “Really, what do you mean?” My assumption of what the word “text” is, is a little bit different than yours. Thank you for explaining what was really meant by texts.

You were talking about texts. I asked about contexts. You were also talking about abilities and tasks.

Dr. Rima Rudd: Yes. Again, the four components are skills, texts, tasks and context.

If we look at the word tasks, that encompasses what it is that we expect people to do with health information. It’s action. I could substitute the word “action” for that as easily. What action are people expected to take?

Then the challenge for us in the health field is how we make that action easier for people to take.

Helen Osborne: Are we trying to make that action easier, or the understanding of what they need to do for that action easier?

Dr. Rima Rudd: It’s not so much the understanding, because that falls into text. We have explanatory texts to help people understand. But taking action is often quite difficult.

For example, one of the action points is taking your medicine on time. It’s an action point. You may, from the text, understand why you have to take your medicine. But doing it is hard, because life is complicated.

Helen Osborne: What would be an example of how you could make that clearer?

Dr. Rima Rudd: I use an example from medicine of taking medicine. Again, people have come up with all sorts of ways to make that clearer. They’ve offered people material to post on their refrigerator to remind them when to take their medicine if their medicine has to be in the fridge. We have the pill bottles to help people with that taking action part.

In public health, we have different kinds of reminders. The fire department, for example, will post things twice a year about the time to change your batteries. We associate that with when we change our clock. It’s time to change the batteries for the smoke alarms.

We have a variety of ways of making tasks easier for people.

Helen Osborne: We make the tasks easier and we have a whole wide array of doing that. I’m intrigued by the thing about the fire department. Yes, I get those and I smile, and then I go change my batteries. You’re right. We make that easier.

When it comes to something like medicine, sometimes people have to do it exactly correctly and exactly on time and problem-solve if that action isn’t taken the right way. Again, it’s the complexities of health information.

Dr. Rima Rudd: Absolutely. Again, here’s the interplay of good texts to make tasks easier when it comes to medicine. We used to tell people, “Take your medicine on an empty stomach,” for example. Exactly when is my stomach empty?

Let’s say I wake up at 7:00 a.m., I have my breakfast at 7:30 a.m. and I know that I’m going to have lunch at 12:00 p.m. When is it that I’m going to take my medicine that morning? Do I take it at 7:15 a.m. before I eat breakfast? It’s certainly empty. I’ve been sleeping all those hours. Do I take it just before lunch?

Helen Osborne: That reminds me of a story of my father-in-law in his later years. He kept napping and every time he woke up he thought it was morning again. He ended up taking so much extra medicine because he thought he was starting fresh every day after every single nap.

Dr. Rima Rudd: Oh, good lord.

Helen Osborne: I know.

Dr. Rima Rudd: Let me just clarify this empty stomach bit, because I don’t want to leave people in the lurch there.

Yes, my stomach is empty at 7:00 a.m., but if I’m going to have breakfast at 7:30 a.m., I can’t take my medicine then. It’s two hours before eating and two hours after eating when my stomach is empty. Ten in the morning is when I have an empty stomach.

We don’t explain that. We don’t give that task to people in a clear way. How do we expect people to take their medicine properly when our texts are really not in good shape?

Helen Osborne: That falls on us as health communicators, correct?

Dr. Rima Rudd: Completely.

Helen Osborne: This expanded model, you said that where they all overlap is the essence of health literacy. Did we get to all the four important pieces of that?

Dr. Rima Rudd: We mentioned part of the context, the emotional part of the fear or trepidation when one is taking on health-related information. But there’s also the larger context of where we are and what the distractors might be.

The busyness of a hospital setting, the time pressure within a doctor’s office, the distractors within the community, the demands of a work setting. The context is both emotional and physical.

We have to think about the environments within which we’re making decisions, the time constraints, the noise and the pressure on us. The context is extraordinarily important. I wanted to focus on that just a bit, as we have just done.

Helen Osborne: Thank you. Whoa. No wonder health communication is so hard. When you break it down into all its components, and each component has so many factors to it, it can feel overwhelming.

You and I have a long-term commitment to health literacy, as probably many of our listeners do. We just want to make it better today than it was yesterday.

You talked about this overlap, those interlocking circles, how they come together at the essence of health literacy. How can we do that going forward and how can we put into place this expanded model? What would you love to see?

Dr. Rima Rudd: I’d like to talk about both the research and practitioner perspectives on this.

For the researcher, I’ve really grown out of patience with the researchers who will talk about measuring one’s health literacy skills without paying any attention to what the demand was.

I’ve seen article after article talk about someone’s health literacy skills, but no one ever talked about how they measured it, what the demand was and whether the communication was good or not.

We need to make sure that researchers talk about these various component parts and look at them as different variables that have to all be measured.

Helen Osborne: Researchers need to do this. My world is not the research world. Yours is much closer and part of the research world. Are people starting to get that message?

Dr. Rima Rudd: Very slowly. I’m not seeing that reflected in a lot of articles yet.

Helen Osborne: Keep doing what you’re doing and keep championing it. I’m with you on this one.

Who else does this have meaning for and how can we start applying it?

Dr. Rima Rudd: For all of us who are practitioners as well. Maybe we want to focus on, perhaps, one of these component parts. Maybe, for example, we want to improve skills.

When we talk about skills, we’re talking about skills of individuals, but we’re also talking about skills of professionals. That’s an area of practice that’s extraordinarily exciting, of honing our own skills.

Helen Osborne: An example would be just doing what you talked about earlier. Instead of just saying, “Take this on an empty stomach,” you might make clear what that means. That’s our skill and our responsibility.

Dr. Rima Rudd: Exactly. For example, now is the time to work very closely with pharmacists, with everyone who is going to be involved in the vaccination for COVID.

Helen Osborne: We are recording this when the COVID vaccine is just about coming out. We’ve got a huge communication challenge ahead of us.

Dr. Rima Rudd: Absolutely. Now is the time to really focus on good, clear communication for people who are going to be taking that vaccine. That’s a very exciting action opportunity for everyone in practice right now, focusing on professional communication skills around this issue.

Helen Osborne: I hear an optimism from you. I heard you talk about an exciting opportunity. I think other people might say, “This is overwhelming.” But you feel deep down that this is doable and we can get better?

Dr. Rima Rudd: Absolutely.

Helen Osborne: Good.

Dr. Rima Rudd: I think that it’s a wonderful opportunity for action in health literacy. We can ease tasks that people are facing. We can look at them, we can deconstruct an activity into its different component parts and say, “How can we make that a little bit easier for the mother of a school-aged child to make that decision? What is needed? What more can we do? How can we simplify both the language and the taking action?”

We can look at different contexts, too, and we can say, “What is the environment like here? How can we make this a better environment for people to feel empowered and engaged so that people can ask questions and can take the time to think something over?”

Helen Osborne: That’s the essence of health literacy. Rima, I have to put a semicolon on this, only because most of these podcasts are under a half an hour. That’s always a challenge. How to communicate efficiently.

What I’m taking from this, and what I also took from your presentation at that conference a while ago, is a sense of optimism, that sense of breaking it down and that it is possible. We can all communicate better, and that’s the essence of health literacy.

Rima, thank you so much for making our work clearer, for deconstructing that big puzzle of health literacy and starting to teach us all about it on Health Literacy Out Loud.

Dr. Rima Rudd: Thanks for the invitation, Helen. I really appreciate it.

Helen Osborne: As we just heard from Dr. Rima Rudd, it is important to consider all aspects involved in how we communicate health messages: the context, the timing, the expectations, our words and our modalities. But doing so is not always easy.

For help clearly communicating your health message, please take a look at my book Health Literacy from A to Z. It covers many different ways of communicating health information.

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

New Health Literacy Out Loud interviews come out every few weeks. Get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

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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