Beginnings Guides Blog
This is the last in our series
using the SAM
pregnancy and parenting for low skilled readers who may be new
to the healthcare system.
For a good cultural fit
match readers’ LLE
Leonard and Cici Doak, authors
of the SAM,
concluded that most communication errors
in healthcare are caused
by cultural gaps
between patients and providers,particularly
gaps in Logic, Language &
Experience - LLE.
For anyone in health communications
-that’s everyone in healthcare, it’s an acronym
Logic refers to a way of
thinking about health, illness, treatment.
Because of their
specialized training, healthcare professionals have
a special way of thinking.
For example, to a clinician who sees 30
sick people per day, illness is normal,
another day at work, the usual
But to those 30 sick people, their illness is exceptional, a
major source of physical, emotional,
spiritual and financial stress for
a whole family, a reason to miss work and
suspend the usual routine.
The clinician’s routine challenge may be the
patient’s life changing
event. Consider, too differences between Western and
between medical specialties, between medicine and public health,
between medicine and
health promotion. A challenge for all health
communicators is to understand and
match the learner’s logic about
Language refers to a way
about health, illness, treatment
Of course, logic and language
To a professional the problem
may be hypertension exacerbated by
obesity; to the patient the problem is
bad blood making it hard to walk up the
stairs. In the West, we describe epilepsy
as a disease - abnormalities in brain
cells that cause seizures. Elsewhere,
epilepsy is described as blessing - a sign that the person may be
“the spirit catches you and you fall down”. Other language issues are
English is the language of the
If you are not proficient in English, you will struggle
every level. And even if you are, you may still
struggle when simple English
terms like stool and screen,
minor and routine take on a whole new medical meaning.
Or when simple concepts like walking and pus
or go home
on a whole new vocabulary like ambulation
Latin and Greek are the
language of medicine.
Terms are long and technical, so a natural short hand
emerges. As public relations director for a hospital that
specializes in heart
surgery, I encountered more than
one family who objected to hearing staff refer
their loved one as “the cabbage
in 206”. They were using shorthand for coronary
artery bypass, thinking and
talking about the patient as his procedure and
Experience refers to
participation in events as a basis of knowledge
A clinician lives in the
hospital or clinic. S/he is intimately familiar with
the technology. S/he is in
charge and in control. Everything is organized
for his or her convenience and
efficiency. His or her status comes from
specialized knowledge. In many cases, the patient has no
and very limited knowledge. That means no basis on which to judge
quality, weigh options, or interpret
instructions. At that same hospital,
two patients who had open heart surgery by
the same surgeon on the
same day were re-admitted two weeks later. Their doctor had
them to “take it easy.”
Both complied. One ran 3 miles instead of
his usual 5. The other never
got off the couch.
Who is responsible for
bridging the gap?
Federal, state and local laws,
Medicare and Medicaid regulations,
and accrediting bodies clearly state it is
the healthcare providers’
duty to communicate in a way the patient and family
SAM says Superior health education materials match the readers
and present images and examples that are realistic and and positive.
Beginnings Guides are intended for a broad
national audience. It’s
intent is to be as
culture-neutral as possible. We chose cover
art by Laurel Burch in which our testers saw
whatever was important to
Last words on SAM: Only
readers know for sure
SAM is an at-your-desk review. It cannot tell you that your
is easy to understand and use. Only the intended learners can tell you
that they learn
easily from your document. SAM helps you get your
materials to the point where
they are ready for Reader Verification
Interviews. More on that next time.
Adults learn to solve a
problem they have now
Motivation to learn depends in part on the
person’s skills, and more on the
information. Adults learn in order to solve a
problem they have now. Another
way to say it: literacy skills always are used
for a practical purpose.
the cognitive and
social skills that determine a person’s motivation
and ability to access, understand and use information is ways that maintain or
I’ll never forget a brochure titled How to Care for Your Son’s Penis, a topic
many a new mom has wondered
about and few have been willing to ask about.
So intended readers will be motivated to open the brochure.
So far so good.
do not motivate
The brochure would fail a SAM
on many counts discussed earlier in
, each of which puts a damper on
readers’ motivation to read and
learn and take action. But here’s the big sin: the six-panel
five and a half panels to describe and illustrate the details of
it structure, functions and properly named parts.
None of it tells the mom what she
wants to know.
None of the dense narrative of facts
motivates her to adopt the desired behavior
-which is yet to be mentioned. In
fact, this information is discouraging and
disempowering. It overwhelms the reader with the author’s
her feeling like she can never learn what she needs to know
to take care of her
child. It makes her unnecessarily dependent on The One Who
Knows. It takes up
her time and leaves her with nothing she can use, no action
she can decide to
take or not.
The last sentence on the back
panel of the brochure says, “The
best course is
to leave it alone.”
There is no need for the rest of the
brochure. That’s all she needs to know.
A clinician could tell her that in less time than it takes to hand her
and a lot less time than it would take her to wade through the
We are motivated to read and learn from information that is
clearly and immediately
relevant; AND that describes in specific familiar
concrete terms the actions that will
solve the problem that motivated us to
seek information in the first place.
As long as the desired behavior feels
doable. On this point, the offending brochure
gets a high score. “Leave it
alone” is specific and doable.
that describe and show
specific behaviors and skills and that subdivide complex
topics so readers feel
confident and ready to take action step by step.
that the posting and the included excerpt from Beginnings Parents Guide is
because the text does not address fathers and it does not use the
neurtral “he or she” in referring to the baby.
These are two sticky issues for
editors and reviewers of health education
materials. Decisions need to be
driven by consideration of the intended
readers and ease of reading and
Guides and the Center for Health Literacy Promotion we
to what degree to include fathers in parent education
and programs that intend
to support child development. My
editor is based on data from home visitation and parent eduction
We have two databases now, totaling
2675 parent child dyads. The data are
reported by the practitioners on the families
in their case loads (we have
no access to identifying information). In each
database, fathers /male
caregivers make up less than 1% of the parents. That
does not indicate
fathers are not active and important in the children’s lives.
But the data
do show clearly that it is still mothers who are the primary
I can understand our unhappy reader’s
objection about the excerpt that
refers to the baby using the male pronoun he. If she or he were more
familiar with Beginnings, she or he would see that the
convention is to
alternate the use of he
and she in logical ‘chunks’ of
text. This avoids
the page, slowing reading, and interfering with comprehension
by repeating the
awkward and unfamiliar he or she or s/he, as I have done
illustration. Another way around the pronouns is to use Baby
capital B as you would use a name.
I’m sad to loose a reader, and I appreciate
his or her passion for equality,
and that she or he brought these issues to the forefront for
is a literacy skill that is used to personalize information. We
with the information and with others (family, friends, professionals)
meaning from it and decide how it applies to us in our situation,
resources and our challenges.
also is a parenting skill used to engage a child and stimulate
physically changes brain chemistry
Brain imaging shows how interacting
with information stimulates learning.
It produces a measurable chemical change
in the brain that takes the
information into long term memory. No interaction,
no long term memory.
No recall. No ability to use the information for health
questions, spark thinking and action
You can work interaction into print
materials, face-to-face teaching and
any media format. By now you may not be
surprised to read here that
that requires the learner to think. In
printed matter, our subject here,
interaction usually looks like blanks to fill
in, boxes to check, pictures or
words to circle, choices to make, alternatives
example, In the Beginnings Parents
Guide, running text about lead
testing for infants is replaced by a set of
five short personal statements
and check boxes to choose [ ] Yes or [ ] No. This follows guidelines we’ve
discussed previously in this
space: no more than 5 items are “chunked
under one subhead; a 10% cyan
(blue) screen behind the text draws the
the upper left where reading starts, using the principles of reading
to further ensure the reader does not miss it. The headline engages
reader with a reflective question that requires thinking: Does your baby
need a lead test?
Thinking through each question and
physically checking the box is the
that stimulates the chemical change that fosters long term
memory and converts
information to knowledge that can be used again later.
text is easy to read, understand and forget. Read the next sentence
when you finish reading the rest of this post, see what you recall.
Your baby needs a lead test if you live in a home built before 1960 or
home has lead pipes. Also, If you live near a highway, lead smelter or
plant, or you live with someone who works with lead, your child needs
a lead test.
A question-answer format is more
engaging than straight text, but it is passive,
rather than interactive.
can build interaction into audio and video taped information by including
question for each important point. Ask listeners a direct question and include
a pause. After the pause, give the answer. In face-to-face teaching, use the
“teach back method”. Ask the learner to tell you in their own words what they
are going to do at home, and what
problems they might encounter. Use their
words in this conversation.
education materials present problems or questions for reader response.
Information that does not offer interaction does not stimulate learning and
not suitable for health education. Information that improves health literacy
Now, close you eyes and say out loud
the ways you know that does a baby
needs a lead test.
To see how you did and check out the
example, take a look at the lead
Did you ever play the party game where
multiple items are displayed on a tray;
everyone gets to look at the tray for
one minute, then the tray is removed and
you write down as many items as you
one remembers more than seven items
That is because of the way the brain
processes information. Earlier in this series
we said the purpose of the cover
is to attract the readers’ attention. When it
does, the reader’s mind very
rapidly decides to activate memory and process
the information. Or not.
Assuming the reader decides to pay
attention - the information goes to short
term memory. If you’ve played the
“What’s-on- the- tray?” game, you probably
noticed that short-term memory has
very limited capacity and short storage time.
In a bright mind on a good day,
short term memory holds seven items. It lasts
less than 1 minute. For many,
especially those with low literacy and high stress,
it holds less. And here’s
the thing: the more items on the tray, the less you
remember. When short-term
memory hits capacity, it dumps everything.
prevents over-taxing short term memory
The parlor game is easier when the
items on the tray are organized -- ”chunked”
into groups of related items.
Chunking helps the mind associate the items with
something it already knows.
Association gives the brain a place in to put the
information in long-term
memory, so you can recall it.
Maybe the tray contained
kitchen utensils (spoon, can opener, peeler),
bathroom items (toothbrush, comb,
soap) and writing implements (pencil, pen,
marker). These chunks are easier to
think about than a bunch of stuff.
It’s the same with printed
information: use subheads to chunk a list of items into
logical groups that
link the information to something the reader already knows.
says that in Superior health education materials, lists are grouped under
descriptive subheadings with no group having more than five items.
Beginnings Parent’s Guide’s
Home Safety Checklist for infants up to 12
is divided into four chunks: fire safety,
sleep safety, burn safety and air safety.
Each chunk covers one to three items.
In addition to increasing comprehension,
this chunking makes the checklist look
and feel do-able.
Doak C, Doak L & Root J. (1996).Teaching
Patients with Low Literacy
Skills. 2nd edition. Philadelphia,
Lippincott. NB: Find it free
online thanks to
Harvard School of Public Health
In this Part 10 of our series using
the SAM - Suitability Assessment of Materials
- to evaluate Beginnings Guides, we address layout,
the architecture of the page.
Like the architecture of a building, layout makes
a page inviting or intimidating,
easy or physically demanding to navigate,
memorable or nondescript. SAM
eight factors that substantially influence the suitability of health
materials by making the process of reading painless or not. We will
take them in
order. But first, I will add one essential item that SAM leaves
out and that all page
design should respect
gravity rules layout
Reading demands physical skill,
concentration and time, all of which may be in
short supply. The information
architect must ensure that none of the reader’s
effort and time are wasted, or
worse, sacrificed to design.
We read from the top left corner of
the page and work our way across and down;
left to right and back again to the
bottom right corner. Page design
this efficient pattern and avoid disturbing reading
rhythm. In testing, on average
percent of readers showed good comprehension of information that complied
reading gravity compared to 32 percent of readers of the same information
pages that required them to work against reading gravity. Learn more and see
Reading gravity explains many of the
suitability factors for layout.
illustrations adjacent to related text.
SAM says photos or other graphics
should be placed adjacent to the text that they
explain. Ideally the text is to
the left of the graphic (so you read it, then see the
explanatory graphic) and a caption
below the graphic. Otherwise,
the illustration becomes a distraction and
it easy to predict the flow of information
That means the content follows a
logical sequence and is presented consistently.
and the usual progress of pregnancy. Each of the six booklets uses
the same section
heads and text addresses similar subjects in consistent order
(e.g. Your Baby’s
Growth and Development). Warning Signs are always located on
the back cover;
they change by stage of pregnancy; no searching is required.
visual cues to direct attention to key content
For example, Beginnings Guides highlight key messages by displaying them in bold
in a box with 10% cyan( light blue) screen. Research suggests the light
screen attracts the eye
without interfering with comprehension. A cell phone
icon alerts the reader to a condition that
warrants a call to the doctor.
the page clean
Simple design works best for readers.
A cluttered page looks hard to read, and
most likely is. Testers may say the over-designed page
is more attractive, but
color in a supporting role
Color attracts the eye. Use it to lead
the reader to key content. Or to lure the
eye up to the “fallow corner” at the
upper right. Check to make sure the color
does not pull the eye against reading
gravity like it does below.
lines short - 30 to 50 characters and spaces
Remember the reading eye moves from
left to right
and back again. At the end of the line, the eye returns
starting place and drops down to the next line.
Unless something is in the way.
Then it has to search
for what is next,and be lost to the distraction.
high contrast between type and paper.
contrast is low, reading is difficult. For comprehension, black type on
says use non-gloss (matte) finish. Glossy paper carries a reflection which
can be distracting. However, other testing showed no difference in
A coated stock repels fingerprints and is more durable.
Beginnings Guides get a Superior rating for
complying with all these factors most
Material with fewer than three factors present or
that just looks uninviting or hard to
read is Inadequate.
instrument. It will
complete the review of graphic elements begun in
Today we consider lists, tables, charts and forms.
can facilitate learning if they engage the reader to interact with the
information, make choices, and take action. To meet this goal, the purpose
of the list must be made
immediately clear through a headline or subhead
(see Road Signs
brief instructions, as needed.
Example: Beginnings Pregnancy Guide (Page 65) includes a list of what to
take to the hospital or birthing center for childbirth. This is important
content to increase confidence and reduce anxiety, especially for the
many women for whom childbirth is their
first hospital experience.
“Pack you bag” is a clear simple
headline that clarifies the purpose of the
list. Two short introductory
sentences tell when to pack and indicate the
list includes “all you will
need.” Check boxes are included to
interaction. The list is
broken up with a subhead: “Pack for
indicating the next
Explanations and directions are
essential. When presenting how-to
information, a bulleted list is easier and quicker to read and use than
paragraph. An example clarifies
the instruction and instills confidence.
When preparing instructions, think
through who will use the information
and how will they use it. Where are they
likely to be when the want and
need the information. What might they be doing?
Who might be with
them? What might get in the way? What might be confusing? What format
will be most accessible?
Focus on what-to-do. Be specific. Omit all
reference to what not to do (it is equivalent to static).
Example: Every pregnant woman
wonders how she will know she is in labor
and what to do when labor begins. Beginnings Pregnancy
Guide (page 72-73 )
presents step-by-step instructions under the headline “Are you in labor? Walk
to find out.” Steps are numbered and presented in
logical order: 1.Notice
contractions. 2. Walk 3. Time your contractions. 4. Call your doctor. Key
information is highlighted: “True labor
contractions get longer, stronger
and closer together” . Instructions for
calling include who to call, when to
call, what questions to anticipate, what
to say, what if you get an answering
service, what if you cannot call; and
finally, what to expect at the hospital.
shows a woman walking with hands on pregnant belly, noticing her
essential instructions with a few representative learners with no prior
experience and little knowledge of your topic. Invite them to read your
instructions and tell, or better show you what they would do. You will find
out quickly if the
directions are too brief to use the graphic or follow the
independently in likely circumstances. For Beginnings,our standard
is that the learner can find and follow the
necessary instructions in the middle
of the night while throwing up.
gets a Superior rating on the SAM for providing step-by-step
with examples that build self-efficacy. Graphics--lists, charts,
forms-- presented without explanations are not suitable in health
NEXT: Typography: type sizes, fonts,
The Nation & World section of
my morning newspaper reports, right next
he story re civil war in
Syria, on a doll that is making TV
The Breast Milk Baby makes suckling sounds when it
touches sensors sewn into a
halter top that comes with the doll. A Fox news
commentator thinks we “don’t
this kind of stuff”. It’s hard to
say what “stuff” he’s worried about. A father
says it’s “creepy”; maybe his daughter
could play with the doll at home, but not
on a play date or in public.
Somehow these men think breastfeeding has
something to do with sex. So the
doll’s suckling sounds are “too
mature” for little girls who want to grow up to
be mommies. Apparently,
dressing up the buxom Barbie doll in a cocktail dress
and heels for a date with
hunky Ken is a better way for “kids to be kids” and for
little girls to
envision their future and understand the purpose of breasts.
a health literacy standpoint
Critics of Breast Milk Baby are
showing a very limited ability to
use information for health. Breastfeeding, exclusively in the
baby’s first six months,
way to feed a baby with benefits to both mother and child over their
Breastfeeding is only X-rated in the
minds of some adults. Let’s think about what
we want to teach our daughters and
what we want to protect them from. What is
it we want to protect ourselves from
by banning a breastfeeding baby doll.
milk is made for your baby. It contains the right amount of all the nutrients
Baby needs. As the baby’s needs
change, your milk changes, too. Mother’s milk is
easy to digest. It is always
ready, clean and just warm enough. Breastfeeding creates
a special bond between
mother and baby. Breast fed babies have fewer infections
and allergies than
bottle-fed babies. And their brains develop faster.
Pregnancy Guide p 62
If you are not ‘creeped out’ by the
thought of little girls learning that breastfeeding
is normal, healthy and
health-promoting; if you believe breasts are engineered
primarily for feeding
babies, and if the sound of suckling does not distract you beyond
thought, you can order Breast Feeding Baby online at half-price. She is more
culturally competent than some of
her critics; choose a doll with one of eight names,
skin tones and facial
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012
This continues our discussion of what makes materials easier or
harder to read,
We are using the instrument to assess the suitability ofBeginnings
Road signs reduce anxiety,
Working through information on a tough subject is like driving a
rental car in unfamiliar
territory. You need road signs to know where you are
now, and what’s ahead. Without
them, it’s easy to feel anxious, get confused
and go a long way in the wrong direction.
Road signs enable drivers and readers
to more easily find what they are looking for, and
arrive there focused and
Road signs in information -- on paper or on screen -- are
headlines and subheads. They
alert the reader to expect what’s coming next and
prepare her to think about (process
and understand) the announced topic.
Without good subheads, the reader is likely to
bypass the information or
miss the point.
Subheads break up a sea of
A text-heavy page
can be intimidating and discouraging to anyone, and especially those
unaccustomed to reading by learning. Judicious use of subheads, in bold type,
more readable, an essential first step toward being read.
A good easy-to-read sentences contain one thought. An easy to
read paragraph contains
two or three thoughts about the same topic. A subhead
announces what is coming in
the next one to three paragraphs.
Put a verb in it. A
good subhead is more than a label. It should be a short basic sentence.
You can tell your subheads are useful
if, when the reader takes in only
and subheads on a page, she gets the most important points.
Sometimes you will need
levels of heads and subheads. Note that this section
starts with a subhead, in bold type,
on its own line, with no punctuation. Then
this paragraph starts with a secondary subhead.
The topic is still subheads, but now we are talking about a different aspect of
The second-level subhead
is in bold type, but inline with the text and using a period to
from the text.
Be consistent. On the
road, drivers expect freeway signs to look different from state
and local street signs. If
they were inconsistent they would be distracting,
less informative, harder to
learn from. Navigating through a page is equally aided by
SAM says at least half of
topics must have a road sign
rating since nearly all topics are announced just before the reader
gets to them.
Starting on p 86, the text leads the parent/reader through an exploration of
new baby’s body. The
previous paragraphs’ subheads are “Get to know your baby” and
“Do not give Baby
your cold”. So now the reader understands why she would explore the
and, we hope, she has washed her hands, and is ready for the next section:
“Explore Baby’s body”.
Then, uh-oh, a label for a subhead. In this case the label
functions on its own to tell
parents where they are in the exploration. Body
parts are labeled consistently and
the discussion moves logically from head to toe. Second level subheads
that highlight things to notice. Under “Eyes”, the second level subheads are “Baby
have blood spots”, “Baby might look cross-eyed”, “Baby may cry without tears”
and “Yellowish discharge from the corner of the eyes is normal”. Each of these
information about something that mothers said they worry or wonder
To make information easier to read, lead your reader through the
text with good
Next: A new section on
graphics starts with the Cover
Today we are continuing with our Suitability Assessment of Materials using the SAM
in US mothers, including those with limited resources and limited literacy.
We’ve already discussed factors related to content. Now we are considering factors
that determine literacy demand, that is the number and difficulty of literacy tasks
required to make meaning from the information. The literacy demand of any health
related information is unavoidably high; the health communications challenge is to
reduce the literacy demand and facilitate meaning making and application in real
So far in the category of literacy demand, we have considered readability,
writing style and sentence construction. Today’s topic is vocabulary.
Choose common, explicit words
Almost always, the need for health information emerges due to something painful,
scary, “weird” or otherwise stressful, so that learning capacity is reduced. Health
information should not be a vocabulary test. Parents and patients cannot be
expected to know the specialized vocabulary of medicine. Health professionals must
be expected to use plain ordinary short words in conversation with the rest of us.
Plain talk is empowering to patients, and may be challenging to those whose power
comes from status.
What’s clear to you is clear to you
To check that you are using plain language, note the mental picture your words
create. Watch out for categories like poultry (chicken, turkey, goose, duck,
pigeon, dove, pheasant...). One mother told me, “I eat chicken; the doctor said
to stay away from poultry.”
Watch out for concepts that require a judgement.
Two men had heart surgery. On discharge, the surgeon told each of them to
“take it easy”. But the doctor’s mental picture of taking it easy was not the same
as the images his words created in the patients’ minds. Two weeks later both men
arrived at the ER by ambulance and were readmitted. The first man was a runner;
he ran two miles instead of five. The other man was a couch-potato; he had not
been vertical in weeks, his systems were shutting down. What question (s) could
you have asked these men to learn how to frame take it easy’ in way that would
facilitate their making meaning and taking recovery-promoting action?
My favorite: familiar words that mean something else
In a medical context, common familiar words often take on a new meaning. Stool
is one that often baffles new mothers. While the nurse is talking about what’s in
Baby’s diaper, the mother is wondering what a 3-legged thing to sit on has to do
He is complying to the letter. And he is
about to overdose. “Cap”
brings to his mind his hat; experience
tells him he can drink out of it in a pinch.
But in the writer’s mind, a “cap” goes
on a medicine bottle and measures a dose.
Photo Credit: "Life According to Carp"
From Smith S. (2000) Patient Education and Literacy in Laubus and Lauber (Eds)
Preventive Medicine and Patient Education. Philadelphia, Saunders, 266-290
When you cannot avoid a technical or judgement term...
Instead of excess mucus, which requires a judgement of what is excess and
interpretation of medical jargon (mucus), say it the regular way: runny nose.
Sometimes there is no plain term. In those cases explanation, example and
illustration reduce literacy demand and facilitate meaning-making.
Culture matters In testing the Beginnings Pregnancy Guide, we asked mothers
how to talk about urination, since no one actually says urinate. English speaking
moms wanted to say “go to the bathroom”. Spanish speakers seemed surprised
by the question; they said, “We know what orino means.”
Final note: no one says healthcare provider. Mothers said a provider is one who
puts a roof over your head. While they know there are physicians and nurses and
therapists and receptionists, most used the term doctor to refer to anyone they met
in the medical encounter.
Bottom line: Short plain words that create an unambiguous mental picture
Next: Road Signs