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.

Health communication is all about words. That includes the words we use when we speak and when we write. But sometimes those on the receiving end of our words do not always understand them in ways that we intended or expected. This certainly can affect health understanding and health acceptance.

Dr. Elena Carbone knows a lot about this topic. She is Professor of Nutrition and Associate Dean for Curriculum & Academic Oversight in the Honors College at the University of Massachusetts Amherst.

Elena has over 25 years of experience in health education, health literacy and nutrition communication. Her research engages multi-ethnic communities with low health literacy skills and integrates behavioral interventions to promote health and prevent chronic disease complications.

In all her teaching and research, Elena knows deep inside that our choice of words matters.

Welcome to Health Literacy Out Loud.

Dr. Elena Carbone: Thank you for having me.

Helen Osborne: Our words do matter, but I want to know more. I know you’ve studied this a bit. Please start us off with how can our word choice affect health understanding and health acceptance?

Dr. Elena Carbone: Do you know the expression “it’s not what you say, it’s how you say it”?

Helen Osborne: Yes.

Dr. Elena Carbone: I would take that a step further and say, “It’s not what you say. It’s what people hear.”

Helen Osborne: Oh, okay. You’re going in a different direction than I expected. It doesn’t matter what words come out. It’s how the other person hears those words.

Dr. Elena Carbone: It’s both, really. People process information through their own lens, their own worldview, and that includes experiences, cultural contexts and language. Really, to make matters worse and more complicated, there’s more than one way to interpret words and phrases.

Think about it. I love crossword puzzles.

Helen Osborne: So do I.

Dr. Elena Carbone: Stay with me here for a minute. I was looking at a crossword puzzle just this weekend. The clue was “a four-letter word for fat.”

Helen Osborne: For fat?

Dr. Elena Carbone: Yes, fat. What’s the first thing that comes to mind when you hear that?

Helen Osborne: Diet.

Dr. Elena Carbone: I didn’t even think of that one. I can’t believe it. As a dietitian, I can’t believe I didn’t even think of that.

Helen Osborne: What did you think of?

Dr. Elena Carbone: I came up with five different words. If you’re thinking about a package or perhaps a person, you could say heft or bulk. If you’re thinking about cooking, which I love to do, it could be lard or even ghee. I was looking out my window and I thought, “There’s another way of looking at this. How about suet?” That’s the fat you feed to birds.

Helen Osborne: Oh my goodness. Do either your words or mine have anything to do with what the crossword puzzle constructor meant?

Dr. Elena Carbone: Suet was the one.

Helen Osborne: One out of five. You got it. That’s really an interesting view, but that’s more like a puzzle. There are many ways to say the same things. Some were about actions. Maybe “diet” is an action. You were talking about forms of fat. There are all kinds of ways.

How can our word choice really affect someone’s understanding of it? You’re a dietician. Let’s say you’re writing a booklet about fat. What kinds of words might you choose, and what might be some problems?

Dr. Elena Carbone: Let’s start with some of the problems, and then we’ll think about some solutions.

If you’re asking people questions and they interpret your meaning differently in a research setting, then your data will be meaningless, because you’re not getting at the concept in the way that you want to study it.

If you’re interacting with someone else, a patient-provider interaction, if you’re asking somebody a question and they interpret your meaning differently than what you intend, that can lead to confusion or frustration, and  even lack of compliance on some advice you may give.

Helen Osborne: I’m thinking of the term fat, which certainly we hear and read about a lot. I wonder how people understand that term. Is that a judgment call? “I’m fat” or “I’m obese” or “You’re telling me I’m fat”? Is there a spectrum of this?

That sounds like a really laden term right there, just that one-syllable, three-letter word. Are you finding that in your work, that that is a problematic word?

Dr. Elena Carbone: It can be. I’ll tell you that one of the studies I did years ago was with parents who had a child with excessive weight. Actually, the child was in a program, so I was working with a pediatrician.

What we did was we said, “What are the most preferred and least preferred words in relation to the child’s weight?”

The most preferred words were referring to weight, weight problem or unhealthy weight, because that put it into more of a context of almost a medical terminology.

The least preferred words were fat, obese and extremely obese. What people told us was it felt like it was a more emotional reaction, that there was a value-laden approach versus a more medical approach. That was really interesting.

Helen Osborne: I have another take on this. I do a lot of plain language writing and editing, and I’m trying to be very aware of words that might sound the same way but have different meanings.

You talked about weight and weight problems. But there’s another way for weight. I know it if we’re talking about how many pounds a person weighs, but it can also be “you need to wait a while” or “going into a waiting room.”

Boy, these can be really a source of concern if people don’t understand it the best way. Meanwhile, the word fat is a three-letter common word, but that, you’re saying, can lead to a lot of feelings about value judgments.

Is this a problem always, or is this something coming up now? I’m thinking of how we communicate these days. It’s usually in brief little tidbits, whether we text something, do it on social media or whatever. We don’t have many words to explain. Is that a factor in our understanding of words?

Dr. Elena Carbone: You brought up a number of different things. First of all, as complicated as, as you said, the word “weight” can be for the English language, think about if English is not your first language. You’re adding a whole other layer to the challenge of clear communication.

When you’re talking about communication, miscommunication and missed communication have long been a problem. It’s getting even more challenging because of social media.

This is just another example of very quick messaging back and forth that we’re texting each other. But now we’re almost taking it to the extreme of being so brief that we think we are clear, but in fact, that’s not always the case.

Helen Osborne: I’m thinking of this expression “what’s clear to you is clear to you.”

Dr. Elena Carbone: Exactly.

Helen Osborne: Elena, you’re talking about how our words matter, and sometimes they’re understood, sometimes they’re not understood so well. What happens if someone doesn’t understand our words in the way we intended?

Dr. Elena Carbone: There are a number of things that can happen. Certainly, in a healthcare setting, people who don’t understand may not adhere to health advice. They may not have as positive outcomes, and certainly their satisfaction with the whole healthcare experience may be less positive than one would want it to be.

From a non-medical perspective, miscommunicating can lead to frustration, confusion or an emotional reaction that was not intended.

I think in either sense, whether it’s in a healthcare setting or in an informal setting, there are consequences when we don’t take the time to clearly communicate with others.

Helen Osborne: Thank you for sharing that. You sure made that clear.

We’ve talked about some of these problems. It’s daunting. We have a few minutes left. Our listeners, wherever they’re working, whatever they’re doing, we all want to communicate a bit better today than we did yesterday. What tips and strategies do you have for us?

Dr. Elena Carbone: I think being aware of the fact that what may be clear to you is not clear to others, and we need to be willing and flexible to be aware that that’s the case.

Instead of thinking, “This is the way I speak. This is the way I communicate. Therefore, it should be clear to others,” I challenge folks to ask themselves, “What can I do to ensure that others are understanding what I’m saying?”

It’s really our responsibility to meet people where they’re at versus expecting them to see things the way that we do.

Helen Osborne: Be clear. Be self-effacing. That’s a big term, but, “Did I do my best to make sure that somebody else understands?” Be aware that there are problems. Those are all big concepts and it’s kind of hard to do. Can you give an example?

Dr. Elena Carbone: If we give somebody some advice in a healthcare setting, we would say, “Do you understand?” Let’s think about that. It’s very easy for folks to just nod and have really no understanding.

There is a question that can be asked in a different way, or an approach. We call it teach-back. It’s a way of checking people’s understanding.

We can ask them, “Tell me in your own words what we talked about today.” That really confirms what they’re thinking versus what we think they’re thinking.

Helen Osborne: I know that the teach-back is a tried and true health literacy tenet and important thing to be doing. I’m so glad you shared it again with us. I don’t think we can hear that too often.

I’m wondering about our communication. When you talk about word choice, are you talking about the words we’re saying to someone or the words we’re writing?

Dr. Elena Carbone: It can be both, absolutely. If we are producing a written or printed educational pamphlet, how is that going to be interpreted by your intended audience?

One of the ways we can address that is by pilot testing. Go to your audience and ask them. Be prepared for what they say. Then revise in keeping with what their cultural norms are, what their language is, what their food choices are, what examples we give.

That takes a little bit longer, but in the end, we shouldn’t be walking away thinking, “We’re so smart. This looks wonderful.” We should be walking away saying, “These are the best ways to communicate with our intended audience.”

I want to mention one thing. That does not mean dummying things down.

Helen Osborne: Oh, I hate that term.

Dr. Elena Carbone: It really means that we’re making an additional effort to work with our audience in a way that’s respectful to them, to their concept of understanding, to their culture, to their background, and then we’re doing our job because we’re making that extra effort. Again, it’s showing respect for that process.

Helen Osborne: I’ve got a few other questions building on that. You talk about the teach-back, pilot groups and studying our communication. What about just informal conversation?

You seem to be talking more about those “here I am writing something and I am teaching you something,” but what about just that more casual back-and-forth you might be having with another person? Words can still be misunderstood.

Dr. Elena Carbone: Maybe you’re just getting to know someone and you can ask them, “Do you like to exercise?” That doesn’t seem like a very complicated question. I have found that the word “exercise” means something different than “physical activity.”

What I found out from some of the folks that I’ve worked with is that exercise means you need to have special equipment or you need to be going to a gym. Physical activity is walking your dog or just gardening.

Even in a casual conversation, you can have misunderstandings. Asking the questions and being aware of this doesn’t mean that we always have to be checking everything that we say. But we can learn from our experiences, learn from our mistakes and do better next time.

Helen Osborne: I love your stories and examples. Have you ever come across a situation, and I’m sure I have in my life, when communication does not go well?

Dr. Elena Carbone: More often than I would probably like to admit. This is also in a professional context. Sometimes things are misunderstood.

Again, miscommunication is bound to happen with the complexity of printed word, text messaging and all of the different approaches.

We should also be very aware of people’s body language and reactions. I know that’s going into another area, but I’ve been very aware in the community work that I do. Body language really tells us a lot of how they are emotionally responding to the words they’re reading or hearing.

It’s just another piece of the puzzle of awareness and respect and just taking the time to reflect upon how we are communicating with other people.

Helen Osborne: Thank you. You’ve given so many tips and strategies there. Being aware, being flexible and thinking about the recipient of our message. This applies to how we write and speak, and just being respectful even of culture and words.

I’m also putting on my plain language hat about words that sound alike and have different meanings, and now you’re introducing body language.

It sounds like so much that we have to be able to take care of, but I appreciate what you said that we are making progress on that. That keeps me hopeful about it.

We could be feeling like, “Oh my goodness, there’s so much to consider. I’m afraid to ever put anything into words.” But it sounds like there’s a hopeful element, too. We’re doing pretty well. Is that true?

Dr. Elena Carbone: Absolutely. There are a lot of tools out there. There are a lot of people who have done work in this area, who have given us data to show just how important this is.

Again, small steps. Being aware that this is the first step. Try it with your partner, best friend or neighbor. It doesn’t have to be a scientific process. It can just be as casual as a conversation.

Everybody is in this, and if we’re in it together and we have patience and flexibility, we can make some progress together.

Helen Osborne: Thank you. That’s what I think of these podcasts. It’s a conversation, and we are all in it together. Hearing from folks like you who have researched and focused on a specific angle and putting that together with other topics that we know about, we are making a difference.

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

Dr. Elena Carbone: Thanks so much for having me. I’ve enjoyed it.

Helen Osborne: As we just heard from Dr. Elena Carbone, it’s important to consider not only the words we say and write, but also how people understand and can act on our words. Doing this is not always easy.

For help clearly communicating your health message, 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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