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. I also produce and host this podcast series, Health Literacy Out Loud.

As many of you know, I’m often asked to translate complicated health information into plain language. The goal of doing so is to make the new version easier for average readers to be able to understand and use.

That takes more than just simpler words and shorter sentences. There are often a lot of issues to resolve and issues to consider. One of these has to do with dotted lists, or as many refer to them, bullet points.

Genevieve Walker and I are long-time plain language and health literacy colleagues. She has a wonderful newsletter called “The Health Writer,” and in a recent issue, she wrote about using bullet points. I knew right away that this was a great topic to discuss on Health Literacy Out Loud. I’m so glad she agreed to be a guest.

Genevieve Walker’s background includes courses in adult instruction and linguistics. Now with a PhD, Genevieve is a medical writer and editor who creates plain-language educational and marketing content for patients and other healthcare consumers.

Her business is Bridge Health Communications. Through this business, Genevieve helps organizations strategize, develop and execute communications with patients and the public.

Welcome to Health Literacy Out Loud.

Genevieve Walker: Thank you, Helen. It’s such an honor to be here with you. I consider you a mentor as well as a colleague and a friend.

Helen Osborne: That’s great. It’s reciprocal.

For all our listeners, let’s start at the beginning, bullet points. You wrote about it. I think about it. What are they? Please make it clear for all of us.

Genevieve Walker: Bullet points, as we probably know from business and specifically the PowerPoint universe, are those large dots that appear in front of items in, what we call in web development, an unordered list, a list where things don’t have to be done in sequence or to be in a specific order. It’s just a list of items, like symptoms.

Helen Osborne: We have some choices when we’re writing a document. We can either choose that with different points in different styles like squares, circles, or something like that. Or it can be a numbered list. You’re referring to those graphics that are on a non-numbered list, correct?

Genevieve Walker: Absolutely.

Helen Osborne: Why do people use them? People use them all the time. As you write in your article, sometimes people overuse them. Please tell us what the benefit is of these kinds of lists.

Genevieve Walker: There are a couple of ways that they do get used. The real world use that I see most often is when absolutely well-meaning folks that I work with decide to write for patients and the public.

There has been some awareness of health literacy and communication principles that’s made its way into the provider universe, which is a great thing, except what I see most is people simply putting everything in long lists with a dot in front of each item. A very long bulleted list.

Helen Osborne: You’re making me laugh. I think somebody goes to a health literacy conference somewhere, sometime and just wants to fix it, and fix it right away. They’ll find one thing to do, whether it’s shortening words in ways that sometimes are too short or, in this case as you’re describing, just making a list, making these short sentences or sentence fragments.

But lists can be helpful. How can they be helpful for the reader?

Genevieve Walker: If you have four to seven items . . . That number comes actually from your work in Health Literacy from A to Z. That’s the recommended length for these unordered lists. If you have a few things that don’t have to be in a particular order, but you want to put them in an easily scannable chunk or piece of information, these points are perfect.

Helen Osborne: Also, I just want to say I got that from somewhere else, that recommendation on four to seven. I’m not the guru of these points, but I certainly have learned that.

What I’ve learned in my practice is if you have a list of 10 different things, it’s almost too long a list. Make two lists. Maybe one has six things and one has four, but give it a header and a category. Give it some semblance.

In these bulleted or dotted lists, and I try to write this way, you’re always starting with the same part of speech. They’re all similar in certain ways.

They might start with a verb like “read,” “tell,” “go to” or something like that. They might start with a gerund like “doing,” “coming,” or “going.”

Are you finding that they should all be phrased in a similar way, each of those separate items in that list?

Genevieve Walker: That really is best, because it makes them easier to scan quickly by eye.

Helen Osborne: We talked about how they can be helpful. What is perhaps not so helpful about these unordered lists with little graphics in front of them?

Genevieve Walker: As you said, the very long lists. That is what inspired me to write this article that I call “Beyond Bullet Points.”

Even if it could be under its own subheading, off in a text box or called out in some other way, if everything is put in a “bullet point,” then nothing is, and you’re right back to where we have these large blocks of text with no differentiation. It’s just as confusing to the eye of the person who’s trying to read it.

Helen Osborne: Can you give an example, please?

Genevieve Walker: Sure. If you put everything related to a patient’s appointment in a list all together, so the date of your appointment, the address of your appointment, how long you will be at the clinic, whether you need to be wearing a mask or not, and how you’ll get test results all in one list, those are all different things.

Helen Osborne: Even though it was just maybe five things, they’re still not quite the same. Right? They’re just information.

From all your writing experience, what do you recommend that writers do instead?

Genevieve Walker: I like to see people put things in lists only if a list is really needed, if you have a number of similar things, like symptoms of an infection. Redness, swelling, fever over such and such degrees, put all those together. Group like items together.

I like to see people using subheads. “About coming to your appointment” might be one subhead. “What to expect at your appointment” might be another subhead. “Getting results from your tests” could be another one.

It’s hard to break information into paragraphs if you aren’t trained to write. This is no knock on anyone, because I always tell my clients, “Hey, I’ll handle the writing. You go do the things I could never do,” like saving actual lives, doing surgery and caring for wounds. I haven’t got that, but I can take this off your hands so that you can do other things.

Helen Osborne: Do they breathe a sigh of relief, like, “Whew”?

Genevieve Walker: They do. Writing is hard, and sitting and organizing ideas for patients when you have already had an 8-, 10- or 12-hour day caring for those patients is extremely challenging.

Helen Osborne: If I can add, it’s also a skill. It’s a learned skill. Just because somebody is good at something else does not mean that they’re great or intuitive at putting it in simpler wording or using the formatting or lists that work. There really is an art to it. I love to hear when it’s a real partnership.

I expect that all the listeners of this podcast are somehow interested in communicating clearly about health. Many of them might be writers. Some might be charged with putting information in plain language, writing lists or coming up formatting. I want to address some issues for them. I’ll also tell you some of my emerging questions.

Genevieve, you talked about writing about symptoms, let’s say. Maybe there are five or six different symptoms for wound care, or whatever you’re writing about. How do you go about organizing?

I know you said this is a rather unordered list. My way is, “Which one do you do first? Which do you do second? Which one do you do in last place?” What is your thinking on how you put that information in that list?

Genevieve Walker: Great question. I would then use a numbered list. You can also use cue words like, “Here’s what to do to take care of your cut or burn. First, wash your hands.”

Adding pictures is a great strategy if you have the capacity to get photos of all the supplies laid out on a clean towel on your kitchen counter.

Use cuing words like first, second, third, last, before you, etc., but keep them simple.

Don’t make that numbered list be 20 items. Those lists should be short. There should be a break to the next part of the process.

Helen Osborne: I can add my experience on this, too, and my preference. If I’m doing something about the symptoms of a wound or an infection, I often ask my clients who are the health professionals and scientists, “Do it in some order.”

I don’t care what order it is. It might be the most common to the least common, the most risky to the least risky, the easiest to the hardest, or opposite. I don’t always have to say it, but I want to have a sense of how that list is organized.

I have a feeling that people pay most attention in a list to the first item and the last item.

Genevieve Walker: I totally agree. In fact, I think that we know from readability research that people abandon things that they’re looking at in print, even digitally, pretty quickly. Our attention spans are very short.

I would say put the most important item first. Have your subheads tell a story so it’s flagged for the user what they’re going to be looking at in that section. Is that a section they want to look at?

Attention is very short, so that’s such a great point, Helen.

Helen Osborne: When you say subhead, and let’s go with this going to an appointment at a new provider or something, a subhead might be, as you had said, “Getting ready for your appointment” and “Things you need to do.”

Then would another subhead be “Meeting with your healthcare provider,” and then “After the appointment,” or something like that?

I want listeners to have a sense of what you mean by subheads.

Genevieve Walker: Absolutely. Say the handout is called “Coming to your child’s first appointment.” You would have, then, subheads. I usually use bold and a slightly smaller font than for the title. It would be something like “Appointment information,” “Where to find us,” “How long is my child’s appointment?” “If you are late,” “Do I need to wear a mask?” and things like that.

Helen Osborne: Thanks for those examples, Genevieve. What are your thoughts about lists within lists? I sometimes see those. You’re sighing.

Genevieve Walker: I am.

Helen Osborne: Maybe we’re likeminded. Put it in words. What do you think about lists within lists?

Genevieve Walker: I think that they confuse people. I think that the more complexity you introduce in a document someone most likely would not choose to read if they were feeling healthy and everything was okay, the more likely you are going to lose people. My greatest concern is people just abandoning the information.

Helen Osborne: You want it visually simple and appealing to look at, too. Correct?

Genevieve Walker: Yes.

Helen Osborne: It really has to do with layout, because you were talking about font size or bold.

I’m not a fan of lists within lists. There is a rare time I might have ever done that. It’s really an exception. It was so many years ago that I can’t even remember what that was. I would rather have a couple of lists within it, or sometimes do without the lists and break it up so it’s not always the same.

Our listeners might be dealing with the spoken word, too. Is there some way we can translate what you’ve learned about bulleted lists to how we present information in the spoken word?

Genevieve Walker: That’s a great question. Is this in a face-to-face conference, or are we in a teaching presentation? What are you thinking?

Helen Osborne: I’m also thinking about slides.

Genevieve Walker: Exactly.

Helen Osborne: Where I think these dotted lists are used a lot.

The rigor of writing something and putting it in a list, and not having too many items and subheads, I think that is a great tool that all of us can apply for all our communication. But I’d like your opinion on that, too.

Genevieve Walker: I totally agree. My principle is the more you write or say, the less they will remember. The longer you talk, the more likely people are to just tune out. We’re all busy, so keep it short and keep it to the need-to-know.

Helen Osborne: On this need-to-know about these dotted lists, I have one question I really want to know. Then I just want to leave it to what else you want to tell listeners.

My ongoing question about these lists is why in the world do we call them bullet lists?

Genevieve Walker: That’s a great question. I actually did a little research, because you and I talked about this before.

We have real concerns today about words that make some people upset. With my background in English and my studies of linguistics, I know that the word is not the thing, but it’s still an odd little phrase. It appears to have originated sometime in the ’80s.

Helen Osborne: The term bullet list?

Genevieve Walker: The term bullet list or bullet point. There’s some discussion that the point that we see as round points, because software can make nice graphics, used to be asterisks on the typewriter, if you remember that ancient device. We didn’t have the graphics capability.

The origins are a bit obscure. It’s kind of biz school speak to me. It goes along with PowerPoint and terms like “prezo.” Prezo is for presentation.

It’s not really a term that I use with the public at all. You always have to think of your audience. If you’re giving a talk to a bunch of administrators, I think it’s okay to refer to bullet points unless someone objects.

You could, though, just say, “This list here.” For patients and families, I would always just say, “The list below,” or, “Here is a list.”

Be very simple. Don’t use any jargon. Really, the term “bullet points” appears to be business jargon.

Helen Osborne: Thank you. Thank you for clearing that up.

When I was teaching about writing in bullet points years ago, and this was to a group of people who were running centers for victims of domestic violence, someone raised her hand and said, “Could you please use another word?” It took my breath away. I said, “Of course.”

Ever since, I’ve been looking for other words that don’t have this violent connotation in certain circumstances. I sometimes call them dotted lists. But I love your solution. Why not just call them lists? Thank you for doing the research on that.

Genevieve, you had said people only want to know what they need to know. Time, brevity and clarity are important. What’s a takeaway that you want listeners of this podcast to know that we haven’t already discussed about these lists?

Genevieve Walker: I think this takeaway applies to everything we share with patients, families and caregivers. These are folks who aren’t necessarily there in the document or using the app because they love health and medicine the way we do. They are there because they or someone they love and care about is very ill, might be very ill or has something else worrisome going on, like an injury. They have a lot distracting them.

They may be an expert car mechanic, or they may be expert at shoeing horses or running a boat. But they don’t have to come into your specialty world any more than you have to become an expert at what they know.

Always be audience aware, be simple and remember where the people, our users, the people we write for, are actually coming from.

Helen Osborne: Thank you. So well said. In that way, to be audience aware, maybe you can help out our audience. How can people learn more or contact you?

Genevieve Walker: They can learn more from my website, which is www.BridgeHealthComm.com. They’re welcome to email me at genevieve@bridgehealthcomm.com, or feel free to call me. The number is on the website.

I’m also a member of the American Medical Writers Association, and they can find me in the freelance directory there, especially if they search for “patient education.”

Helen Osborne: Genevieve, you are great. Our paths have crossed in person, I think, years ago. We’re both members of AMWA. We’re both advocates of plain language. We both do so much work in health literacy. I am delighted that now our paths are crossing virtually in this podcast. Thank you so much for being a guest on Health Literacy Out Loud.

Genevieve Walker: Thank you. Thank you for all that you do, Helen.

Helen Osborne: As we just heard from Genevieve Walker, it’s important to consider the many ways we communicate, including those lists that we use when we organize information or put similar information together, whether in order of priority or any other way that we think makes sense. But communicating clearly and using formats like this is not always so easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. 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 the first of every month. 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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