Making plain language an organisation's practice

An organisation makes plain language a matter of routine practice by building it into how it plans, connects its units, trains its staff, produces and clears its documents, measures its progress and reports on it. The work takes a large investment of resources, its reported returns include more accessible health information and higher consumer ratings, and in 2013 one writer saw the pharmaceutical industry accepting the need to do more, and better, for patients and prescribers.

Why an organisation takes on clear communication

Both the mission of the US Centers for Disease Control and Prevention (CDC) to protect and promote people's health and the 2010 federal Plain Writing Act require CDC to write clearly so that people can understand and act on the health information it provides, and the Act places the same requirement on all US federal agencies. ^{1, 2} CDC's information is often unfamiliar, complex and technical, and dependent on quantitative risk calculations that reflect population rather than individual estimates. ²

The Plain Writing Act, the public's limited health literacy skills and the increasing recognition of organisations' responsibility in responding to the health literacy needs of their audiences together prompted CDC's Office of the Associate Director for Communication to promote an organisational culture that values clear communication as a matter of routine practice. ²

What clear communication covers

Plain language is one of several techniques CDC uses to make its information clear to different audiences. ² Besides language and document organisation, the factors that affect the clarity of its health information include the types of actions and recommended health behaviours involved, the novelty and technical complexity of the information, the amount of information presented, the status of scientific knowledge about the topic, how numbers are used, and the ways statements of risk are included and explained. ² CDC applies insights from health literacy, health communication, numeracy, science literacy, risk communication, visual communication and design to address these elements of clarity. ²

Writing is only one way CDC communicates with the public: its staff also present information in community meetings, interview people exposed to infectious diseases or harmful substances, and produce radio interviews, podcasts and videos. ² CDC has committed to use plain language in all its communication formats, not just writing. ²

Building clear communication into routine practice

In 2013 CDC's implementation of the Plain Writing Act consisted of training its staff to use plain language, applying those skills to public communication, and tracking and reporting on plain language use. ³ By 2015 CDC was taking six steps to promote a culture of clear communication, so that its health information and services are accessible and understandable to the different audiences it serves: plan, connect, train, produce, measure and report. ^{1, 2, 4, 5, 6, 7, 8, 9}

Planning

The significance of clear communication for US national health goals is visible in the Healthy People 2020 health communication and health information technology objectives, the National Prevention Strategy, the National Stakeholder Strategy for Achieving Health Equity and the Institute of Medicine's Roundtable on Health Literacy; the Patient Protection and Affordable Care Act includes some health literacy requirements, and writing government documents in plain language is federal law under the Plain Writing Act. ⁴ In 2010 the US Department of Health and Human Services (HHS), of which CDC is a part, published the National Action Plan to Improve Health Literacy, which calls on health organisations to respond with their own strategic plans and whose first and second goals include strategies on plain language. ⁴ CDC responded with its own health literacy action plan, which cascades from the national plan. ⁴ The CDC Health Literacy Council, with representatives from across the agency's organisational units, drafted the high-level strategic action plan in November 2011 using agency-wide staff input; it guides the agency's approach to using clear communication and health literacy methods, and is organised around three health literacy goals and 18 supporting strategies. ⁴ The three goals are:

1. To develop and disseminate health and safety information that is accurate, accessible and actionable.
2. To integrate clear communication and health literacy in public health planning, funding, policy development, research and evaluation.
3. To incorporate accurate, standards-based and developmentally appropriate health and science information and curricula in educational settings from childcare through university.

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Goals one and two include using clear communication for CDC materials and encouraging the organisations CDC interacts with to use clear communication. ⁴ The plan also aligns with the HHS Plain Writing Act implementation plan. ^{4, 2}

Connecting units and leadership

The National Action Plan to Improve Health Literacy observes that improving access to accurate and actionable health information and usable health services will take everyone working together in a linked and coordinated manner. ¹⁰ The success of any plan to create and sustain a new organisational culture requires opinion leaders and gatekeepers to implement a strategic plan and persevere through the process. ⁵ The Council is the primary connection between the agency's high-level plan and on-the-ground implementation, and its members work with their organisational units to:

• Apply the action plan's goals to their missions and audience.
• Provide technical assistance so that units can tailor operational plans to align with the action plan.
• Assist units by developing guidance, proposing procedures, standards and measures, and coordinating the planning and reporting processes.
• Provide a list of resources to help units develop and implement their operational plans.

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CDC's health literacy website is a major channel connecting its staff, grantees, contractors, partner organisations and other stakeholders with health literacy information and resources, and in September 2014 it was refreshed and expanded to include new online training courses, information on culture and health literacy, and more resources for developing materials. ⁵ Senior agency officials reinforce plain writing by sponsoring and releasing staff for training, requesting briefings and inviting presentations at staff meetings. ⁵ CDC's basic plain language training slides quote the CDC Director on the importance of clear communication, and the agency's leadership continually reinforces the importance of complying with the Plain Writing Act through the intranet, newsletters and agency-wide announcements. ⁵

Another important connection for creating and sustaining a new organisational culture is an organisational champion to inspire, coordinate and provide vision for the agency. ⁵ CDC's Office of the Associate Director for Communication strives to maintain the agency's momentum by leading clear communication activities throughout the year, and in 2013 it coordinated an agency-wide clear communication challenge to incentivise the use of plain writing and clear communication. ⁵ In the challenge, units' activities included training staff in plain language, developing a clear writing checklist and guidance material, creating a clear writing thesaurus widget, and requesting that reviewers consistently require plain language in the materials they review. ⁵

Training staff

The first goal of both the HHS Plain Writing Act implementation plan and CDC's action plan focuses on strategies for training staff in clear communication. ⁶ These plans recognise that clear communication benefits everyone and that, to be most efficient, staff should use clear communication methods at the beginning of the document or message development process. ⁶ Some audiences, such as scientists and researchers, benefit from more general use of clear communication methods such as plain language, while for a lay audience staff may need to pay close attention to health literacy issues and must address conceptual and cultural differences, clearly explain scientific processes, and carefully express numbers and statements about threats or harm. ⁶

Council members identify staff with regular duties in writing, editing, designing and clearing documents for the public, as well as web developers, and train them in plain language. ⁶ They also contact new employees to find out whether they will write, edit, design, review or approve materials for the public, and if so refer them to the training options. ⁶ The options include in-person small-group classes, on-demand online training from CDC and the US National Institutes of Health, and self-study with the plain language training slides and the Federal Plain Language Guidelines. ⁶ CDC University, the in-house training unit, offers health literacy, clear communication, plain language and web development courses periodically, and consults with individual units to schedule training based on need. ⁶ Course instructors encourage staff to post CDC's plain language checklist at their workstation as a convenient reference to the Federal Plain Language Guidelines. ⁶

CDC also trains staff to recognise and address health literacy issues for different audiences. ⁶ In 2014 it released four intermediate-level online health literacy courses, which apply health literacy research to writing, to using numbers and expressing risk information, to creating easier-to-understand lists, charts and graphs, and to speaking with the public. ⁶ They supplement an introductory course, Health Literacy for Public Health Professionals, offered on CDC's health literacy website. ^{6, 3}

Producing and clearing documents

The Plain Writing Act requires plain writing in the documents CDC produces for the public, and the Council has identified the categories of documents intended for public audiences, including brochures, campaign messages, fact sheets, federal register notices, funding opportunity announcements, infographics, media advisories, mobile apps, press releases, social media messages and webpages. ⁷ CDC includes clear communication review, including plain language principles, in the clearance process before documents are publicly released, and several units incorporate plain language requirements in the electronic systems that track documents through clearance. ⁷ Staff apply the Clear Communication Index, a research-based tool CDC implemented in 2013, to the development of new materials, and some units require minimum Index scores before documents are released. ^{6, 7} Some staff use software to analyse documents for plain language elements such as sentence length, passive voice and jargon, so that they can revise them in accordance with the Federal Plain Language Guidelines. ⁷ Some communication offices test their materials with the intended audiences and ask for feedback on the language, organisation and amount of information. ⁷

In the UK in 2013, editors at the National Institute for Health and Care Excellence (NICE) ensured that the institute's guidance documents were clear and easy to understand for the people who use them, even though they often contain complex and technical information. ¹¹ To that end, all NICE guidance was written according to its principles of effective writing, such as:

• Write in plain English.
• Avoid repetition.
• Vary sentence length, but keep sentences as short as possible.
• Avoid jargon.
• Use short rather than long words.
• Do not use two words when one will do.
• Avoid nominalisations, turning verbs into nouns: "for treating" rather than "for the treatment of".

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Measuring and reporting progress

CDC's success in creating a culture of clear communication depends on identifying where positive changes happen, creating feedback loops so that people perceive cultural shifts, and correcting the course when necessary. ⁸ Measuring and tracking progress are critical to initiating, improving and sustaining the effort. ⁸ Once a quarter, Council members report activities through an electronic data form whose items align directly with the Plain Writing Act requirements and the action plan's goals and strategies. ⁸ The Council makes a considerable effort to enter all training offerings into an electronic learning management system, which confirms participants, assigns credit and lets each unit run reports on its own staff training data. ⁸ Council members report the number of documents produced and cleared in plain language across more than 30 communication product categories, such as fact sheets, web pages and reports, and also report audience testing methods, efforts to meet the information needs of people whose native language is not English, sharing of clear communication guidance and tools with funded partners and grantees, and other strategies from the action plan. ⁸

An annual report card summarises the quarterly data for CDC staff, rating progress on each of the 18 strategies on a four-point scale of no, little, some and substantial progress. ⁹ CDC also submits these data annually to HHS for its annual Plain Writing Act report. ⁹

The cost and the return

At CDC, training thousands of staff, creating and revising materials to meet clear communication criteria and tracking health literacy activities is a large investment of agency resources, and these activities require staff commitment at all levels and an organisational champion to inspire, coordinate and persevere through challenges. ¹⁰ The agency holds that the impact of the investment is greater accessibility of the health information it provides to its audiences. ¹⁰

In a project a health communication firm reported in 2018, thousands of a health insurer's letters were revised and tested. ^{12, 13} The firm reports finding that the plain language increased transparency, which increased perceptions of trustworthiness, which in turn increased consumer satisfaction with the brand overall, and that the company's J.D. Power consumer ratings were up 18 points after the project. ¹³ It concludes that there is a very strong business case for using plain language. ¹³

Acceptance in the pharmaceutical industry

At the 2013 DIA Euro meeting in Amsterdam, many presentations addressed writing for patients and the lay audience and how risk and benefit should best be communicated to them, and a whole session addressed how poorly the information sent to doctors and put inside package leaflets is written. ¹⁴ Some of these sessions were scheduled in the main auditorium, were extremely well attended and generated lively debates. ¹⁴ To one medical communications writer who attended, this showed a real acceptance in the industry of the need to do more, and better, for patients and prescribers, and that the pharmaceutical industry was very keen to do so. ¹⁴