1. Amy Behrens, MS Jaya Mathur, MA Writing for Behavior Change

2. Agenda Briefly review health education and behavior change theories Discuss key communication principles when writing for behavior change Explore how design and layout enhance (or detract) from your message Field testing 101

3. Health Education and Behavior Change Theories

4. Health Belief Model (Hochbaum, Becker, Rosenstock, Greene)  Explains health behaviors, and why you may adopt Self Efficacy (Bandura, Adams, Beyer)  More likely to adopt if you think you can do it Locus of Control Theory (Wollston)  More like to adopt if you believe you are in-control Cognitive Dissonance Theory (Festinger, Lewin)  High level of unhappiness more likely to lead to behavior change Theoretical Framework

5.  When was the last time you tried to make a change to improve your health?  Did you do it? If so, what motivated you?  Did you stick with it? If not, what got in the way? Neighbor Nudge

6. Health literacy is the ability to understand and use health information in everyday life. Hard to take action and change your behavior if you don’t know what to do or how to do it! Health Literacy: The short answer

7.  Approximately 1 in 2 adults struggle with literacy  Nearly 9 in 10 adults struggle with health literacy The Numbers Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.

8. Health Literacy affects people’s ability to:  Navigate the public health system, including locating information and services and filling out forms  Share personal and health information with professionals  Engage in self-care and disease management  Understand concepts like probability and risk Why is it important?

9.  Communication skills  Knowledge of health-related topics  Culture  Language  Literacy and numeracy skills  Age  Computer access and skills  Pain, illness, and stress Factors that affect HL and BC

10.  Most adults lack the skills needed to manage their health and prevent disease, such as: Understanding a drug label Using a body mass index (BMI) graph to find a healthy weight range The Bottom Line

11. Writing for Behavior Change

12.  Define the behavioral objective – what do you want the reader to do?  Organize this information into clearly defined action steps.

13. Will only be successful if you…  Use plain language.  Pay attention to layout and design.  Write for the web (when you’re putting content online).  Pre-test.

14. Neighbor Nudge What are some examples of actions/behaviors that you want people to do?

15. Crafting Your Message 1. Break the behavior down into small steps (this increases self-efficacy) 2. Include strategies / motivators to overcome barriers 3. Stay positive – emphasize the benefits of action 4. Reinforce / repeat action steps

16. Getting to Action Attitudes/Beliefs Action  Do people think they are at risk?  How do people perceive the benefits of the behavior? (Are the benefits relevant/important to them?)  Do they believe the action will reduce their risk?  What are people’s perceived barriers to taking action?  Do they think they can do it? (self efficacy)

17. Context counts Instead of : Reducing animal food products and substituting low-fat or nonfat for whole dairy products can lower the amount of cholesterol in your body. Try: You can lower the amount of cholesterol in your body by…

18. Using Plain Language Plain language is a strategy for making written and oral communication easier to understand. Key elements of plain language include: Use simple language and define technical terms. Use an active voice. Break complex information into short chunks. Put the most important information first.

19. Plain Language Warm-up What could we try instead of the following:  Indoor mold growth can and should be prevented or controlled by controlling moisture indoors.  Radon is a form of ionizing radiation and a proven carcinogenic.

20. Engage Readers with Interactive Content  Provide opportunities to answer questions Check which behavior you will try first The friend who will help me is ____  Invite users to customize content and provide feedback online Email information to a friend. Print out a recipe. Take a poll or rate the information on the site. Use a calorie or BMI calculator. Enter personal data like age or weight to get tailored tips.

21. Engage your readers: Q & A  Consumers come to your materials looking for answers to their questions.  Hint: Pose your questions carefully so that they match your patients’ personal interests. (If a question doesn’t appear relevant, readers will skip over it.)  Then give the answers right away.

22. Try a Quiz! True or False?  There is no co-payment when you go for your yearly physical exam. TrueFalse True. ABC Health Plan covers the cost of your annual physical exam. There is no co-payment.

23. Writing Tips: Basics Start with the behavioral recommendation. E.g. If you live in an older home, take steps to protect your family from lead poisoning. Describe the behavior. E.g. Keep kids and pregnant women away from chipping or peeling paint. Make the case without being overly negative. E.g. Preventing lead poisoning is important for young children because their bodies are still growing. They are more sensitive to the harmful effects of lead.

24. Writing Tips: Basics cont’d Address common concerns/questions. E.g. What if I rent my home? Describe risk factors/prevalence. E.g. 1 out of every 15 homes has a dangerous level of radon. Try not to sound “preachy” — avoid “should” and “don’t”

25. Writing Tips: Benefits Describe the long-term health benefits of the behavior. E.g. A few minutes now could save your child’s life. Describe “lifestyle” benefits. E.g. Making your own non-toxic cleaners will save you money.

26. Writing Tips: Take Action Break behavior into steps. Choose a simple first step. E.g. Check to see if there is a smoke alarm in each bedroom and on the ceiling outside bedroom doors. Address cost whenever possible. Include links to low- cost care.

27. Numeracy A study: Which disease is more dangerous? A.Kills 1,286 out of every 10,000 people B.Kills 24 out of every 100 people Source: Roller, C. presentation on 5/25/11 citing Yamagishi 1997.

28. Numeracy A study: Red bean = win prize A.100 beans, 7 of which are red B.10 beans, 1 of which is red Source: Roller, C. presentation on 5/25/11 citing Denes-Raj/Epstein - 1994.

29. Numeracy – Probability  The doctor said:  You have a 30% – 50% chance of developing a sexual problem  The patient heard:  In 30% – 50% of your sexual encounters, something will go wrong Source: Roller, C. presentation on 5/25/11 citing Gigerenzer/Edwards 2003.

30. Scientific Literacy  How long does it take for the Earth to go around the Sun: one day, one month, or one year? (one year) 55% of all adults answered correctly  Antibiotics kill viruses as well as bacteria. (false) 56% of all adults answered correctly Source: National Science Foundation Science and Engineering Indicators 2008

31. Limitations of Readability Formulas  Readability formulas do not measure how well people understand your material.  Grade level scores for the same text differ greatly depending on the formula you use.  Editing text to reduce the number of syllables may not make it easier to read.  The important thing is that the words are familiar — not necessarily shorter.

32. Universal Precautions Approach Use plain, everyday language for all communication.

33. Layout and Design

34. Research tells us that information design is neither decoration nor artifice. Rather, good information design supports readers’ cognitive and emotional interactions with content.* *Karen Schriver, Knowing About Information Design, in publication 2011

35. The Basics  Make your content look easy-to-read.  Actionable health content written in plain language will still look overwhelming without good use of whitespace, layout, font, and color.

36. What makes materials usable (or not)?  Attractive design  Intuitive (can be figured out easily)  Good labels  Little/no background “noise”  Tailored to the audience  Feedback

37. Actions at a Glance  Limit paragraph size. Use headers, bullets, and lists.  Use meaningful headings.  Use familiar font in at least 12 points.  Use white space and avoid clutter.  Use images to facilitate learning.  Use bold colors with contrast.  Use bold face instead of CAPITALS and italics.

38. Examples

39. Text:

40. Breaking up blocks of text Q. What are Pulmonary Function Tests (PFT’s)? A. Pulmonary Function Tests tell us how well you breathe. Testing measures how much air you can breath in and out, how well your breathing muscles work to move your lungs (like a pump), and how well your lungs exchange gas (move air from the small air sacs in the lungs to the bloodstream). Your doctor uses these tests to check you for health problems, to check progress on your current condition, and/or to begin or change your treatment. A single test or a series of tests over time may be done. Q. What are Pulmonary Function Tests (PFT’s)? A.Pulmonary Function Tests are done to see how well you breathe. A single test or a series of tests over time may be done. A test measures: How much air you can breath in and out. How well your breathing muscles work to move your lungs (like a pump). How well your lungs exchange gas (move air from the small air sacs in the lungs to the bloodstream). Excerpted from AHMC Pulmonary Function Test Brochure

41. Whenever possible, use bulleted lists and short sentences. Limit text to 3 lines. Use clear stand-alone headings and sections that function independently.

42. Create an obvious path for the eye Start Move on Place text and visuals in a way that fits with this pattern. Visuals can guide readers through a document – and help them notice key text.

43. Prominent Legend Upper left corner is reader’s natural point of entry Avoid Cross-referencing

44. Tables and Charts

45. Forms  Easy (don’t have to think)  Hard (not intuitive – less accurate) Your first name: Middle name : Last name: DouglasJohnHunter Name (last, middle, first) HunterJohnDouglas

46. Place visuals in context

47. Nielson Norman Group Typical F pattern

48. Web users with limited literacy skills… 1. Skip instead of scanning 2. Have difficulty searching 3. Keep a narrow field of view 4. Are easily overwhelmed 5. Have a limited working memory 6. Prefer simple navigation Source: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, DC: Author.

49. Recommendations?

50. Give it a try!

51. Field Testing

52. It’s not really a test…

53. It’s co-creation  Work with your target audience to develop or improve your materials.  If you are evaluating existing materials, think of it as quality assurance.  Field testing is an evaluation of your materials — NOT your users.

54. Why should I field test my materials?  All materials have problems. (Some more than others.)  They may not obvious to you. But your users will almost always find them.  Watching people read/use your materials makes you a better health educator.

55. Who do I test with?  Almost anyone.  Try to find users who reflect your audience (a.k.a. “real users”)  Demographics  Knowledge and context  Culture and language

56. Where do I test?  Hospitals and health clinic waiting room  WIC waiting room  Senior centers  Adult education classes or literacy centers  Libraries and community centers

57. Getting started  “Do you have a few minutes to take a look at this? Can you tell me what you think this is trying to say / what this is for?”  “I’m helping the clinic with a new factsheet. We want it to be interesting and easy-to-use. Do you have a minute to look at it and tell me your opinion?”

58. How many people do I need to test?  It depends.  1 is better than none.  Between 3 and 8 is great.

59. Sample Questions  What catches your eye? Who do you think this factsheet is for? (first impression)  Tell me in your own words what this is trying to say. What does this list tell you to do? (comprehension)  What do you think of the pictures? Do these people look like anyone you know? (graphics/ cultural acceptability)  Do you see any words that you think some people might have a hard time understanding? The word “sample” means different things to different people – what does it mean to you? (individual word choice)

60. Getting at self-efficacy  Do you think you could do what this brochure suggests?  After reading this factsheet, do you feel prepared to child-proof your home?  After reading something like this, do you think you would try any of these exercises in the next month?  Did this brochure give you specific ideas of what you can do to control your blood pressure? Do you think people will take any of these steps after reading the brochure?

61. The fine print  If you are in an academic or government setting, you may need to get approval from an IRB (Institutional Review Board).  Test plan  Informed consent form  Informal tests are often exempt.

62. Iterative Design  Test. Revise. Repeat.  Don’t wait until you have already developed your materials to test them with your target audience. You can test a draft!  Periodically test existing materials and improve them.

63. Get Started: What will you do?

64. Thank You!! Amy Behrens amy@communicatehealth.com Jaya Mathur jaya@communicatehealth.com www.communicatehealth.com/healthlit