BUILDING THE BUSINESS

IHA Helps with Children’s Health: 3,400,000 Copies and Counting

by Linda Carlson

Numbers spell success for the Institute for Healthcare Advancement’s publishing program, but the numbers this nonprofit cares most about don’t show up on its bottom line.

Created to help keep people healthy and out of hospital emergency rooms, IHA books are credited with reducing children’s visits to the ER by almost two-thirds and with cutting visits to doctors almost in half. And those numbers do show up on the bottom lines of health insurance companies and hospitals serving the uninsured and the underinsured.

IHA, a La Habra, CA–based program launched in 1993 to provide pediatric health care, will have more than 20,000 patient visits this year in its medical clinics. For the past decade, the 75-person nonprofit has run an annual conference on health care literacy that attracts hundreds of health educators and health care providers from all over the United States. It also offers a health care literacy consulting service, a fee-based program that serves health insurers and similar clients who need their patient materials rewritten in simple conversational English.

The organization’s publishing arm has printed more than 3.4 million copies of its 18 titles since 2000, when the handful of people then running the startup recognized that many parents of young children didn’t know which illnesses and injuries they could handle at home and which required medical attention. IHA co-founder and CEO Gloria Gilbert Mayer wrote What to Do When Your Child Gets Sick to answer these questions in language that makes sense even to those who read at a third-grade level.

“Estimates are that approximately one-third of the U.S. population is functionally illiterate, not able to read beyond a fifth-grade reading level,” Warren Hand, vice president for sales and marketing, explains. The American Medical Association, which began sponsoring Health Literacy Month events in 2004, provides similar numbers: it estimates that almost half of adults in the United States read at below an eighth-grade level, and it points out that low literacy is a serious issue, especially for people dealing with chronic conditions. AMA research shows that poor reading skills can create problems with even such basics as cough medicine.

The careful attention given to people who don’t read English well—or at all—is what has made IHA publications so popular, says Hand, who has run the publishing operation pretty much as a one-man show since he joined the organization in 2000 with a background in book sales and distribution to the grocery industry.

He makes sure the book drafts meet readability standards established by Rudolf Flesch, who used word length and sentence length to assess how complicated content is. Material that meets the required Flesch level then goes out to readability consultants for a second review, which can result in significant revisions: IHA’s new What to Do for Kids with Asthma needed several rewrites to get the text appropriately easy to read.

In the early years, IHA also used focus groups to test the language, which led to finding substitutes for such words as obtain. Today, informal feedback, including comments at conferences, ensures that content stays easy to understand.

Noteworthy Numbers

The payoff is documented in a four-year study of 9,400 families with children enrolled in Head Start child care programs, which the business school at the University of California–Los Angeles concluded in 2005. Provided with copies of What to Do When Your Child Gets Sick and taught how to use the book, these families and their 23,000 children sharply reduced their visits to emergency rooms (by 58 percent) and to doctors’ offices and pediatric clinics (by 48 percent). It’s these results that convince companies, government agencies, and nonprofits to buy the books in bulk and give them away, Hand says.

To ensure that people who speak no English can get the same information, each IHA title is available in Spanish, and several are also available in Chinese, Korean, and Vietnamese. Because most readers of the Spanish editions have come from Mexico, IHA specifies a conversational Spanish as it is spoken there. Similarly, because California state agencies are the major customers for the Chinese editions, they are written in Mandarin, as recommended by a University of California at Berkeley study.

So that the books will be easy to use, they are all designed in 14-point type, in a question-and-answer, bullet-point format that walks parents and caregivers through what to do before they call a doctor. The same freelancer does the design and the preproduction work on the books, which run 160 to 256 pages.

Print runs are large, even though the goal is only a six-month supply. IHA typically orders 100,000 copies of its bestseller What to Do When Your Child Gets Sick—unless it has received an order from a state agency, in which case it may print as many as 300,000, some of them second-covered with the name of the sponsoring agency. Other titles are ordered in quantities of 5,000 to 20,000.

“Things in pediatric medicine can change rapidly,” Hand notes, “and we don’t want to be stuck with books we can’t distribute.” (That did happen a few years ago with What to Do When You’re Having a Baby, which originally mentioned using crib bumpers. When the American Academy of Pediatrics determined that bumpers can cause suffocation or strangulation, IHA had to discard 10,000 copies of the book.)

The organization hasn’t had too many publishing disasters, Hand says, although in 2008 he got calls from a Head Start program conducting a class for the parents of children enrolled in the child care program. Some parents had duplicate pages in their copies of What to Do When Your Child Gets Sick—and some didn’t.

“We had ordered 25,000 books, and the printer said there could only be a few hundred books that contained the duped pages because its quality control would have caught the mistake,” Hand recalls. “OK, but which cartons held the problem books? Had we shipped the cartons? Were they in our office stock? Our warehouse stock? Or were there problem books already distributed and yet to be found? “

The solution: the printer sent employees to IHA to inspect each of the 700-plus cartons. The 15 agencies that reported a total of 56 problem copies were each sent a complimentary case of 32 books—in all, 480 replacement units.

Sales from Mailings and More

IHA self-distributes, working with Baker & Taylor, library distributors, and Amazon.com. Many of its sales are direct, prompted by twice-annual mailings of about 65,000 each. Each mailing results in a sales spike, says Hand, both direct and through Amazon.

The mailings and exhibits at a dozen conferences a year (for example, the national and California Head Start events, the National Conference on Family Literacy, and conferences sponsored by Zero to Three, the American Library Association, and the American Public Health Association) also result in requests for sample copies, which Hand distributes liberally. He estimates that 80 to 90 percent of the sample copies spawn sales, usually in bulk quantities.

To serve nonprofits that have tight budgets, IHA developed a Nonprofit Grant Book Program in 2001 with the financial backing of a medical industry source that remains anonymous.

“This is a source that funds the difference between the $12.95 list price and the $5 nonprofit price, for as many as 500 copies of books per year per nonprofit. There’s a simple application, and we review requests every week,” Hand explains.

Some agencies are so small that they buy only a few hundred books each year; others buy the 500 they are allowed at the $5 price and then buy the balance they need at the regular quantity discount. Although IHA has never exhausted the funds available through its anonymous source, it uses the 500-book limit to ensure that it can offer the nonprofit pricing to as many organizations as possible.

Like many publishers, IHA sometimes struggles to determine appropriate inventory levels. “My greatest challenge is to keep all the titles, in all their different languages, in stock, given how they all sell at different volumes and rates,” Hand reports.

Another issue: what he calls a “fluid” market. Head Start programs are a major customer, and those contacts often change as funding and contracting providers change. Although IHA buys mailing lists, many of its prospects are locally based organizations such as literacy programs and child development coalitions that may not show up on nationally produced lists, and/or organizations where contracts may change, especially when budgets are tight.

Although word-of-mouth is one of IHA’s most important promotional tools, Hand still recommends the carefully written sales letter and prompt follow-up calls to those who have received samples.

He takes the results from the UCLA and other studies and uses them in every letter he writes to prospective clients and in each brochure. “When I get questions, I have the backup regarding who’s using the books, how the studies showed reduced use of the ERs and clinics,” he says. “I call after I send out samples, and keep calling. Even when a prospect won’t answer your calls, you can’t take it personally. Somewhere out there is someone who does want your book!”

Linda Carlson writes for the Independent from Seattle. She was introduced to Rudolf Flesch’s readability assessments and the Fog Index by her high school journalism instructor.

Quantifying Readability of Your Text

The concept of counting syllables per word and words per sentence as a measure of readability was introduced in the post–World War II era by Rudolf Flesch, who created the Flesch Reading Ease test and co-authored the Flesch-Kincaid Readability Test. A calculator for both is included in some Microsoft Word programs; for information, go to office.microsoft.com and select Support and then Word, or go directly to office.microsoft.com/en-us/word-help/test-your-document-s-readability-HP010148506.aspx#BM2.

About the same time, Robert Gunning developed the Fog Index, which is similar, but uses only a 100-word sample. The Fog Index assumes that all long multisyllable words are “complex,” and thus hard to understand, and that all short words are easy to understand.

The formulas each use a sample of at least 100 words, average sentence length in words, and average number of syllables per word.

The Flesch Reading Ease test uses a 100-point scale, with a higher score meaning your content is easier to read. The Flesch-Kincaid Grade Level test, which was developed for the U.S. Navy and later introduced for school texts, rates content by U.S. school grades. So a score of 8 means an 8th-grader should be able to understand the material.

A Fog Index score of 6 is comparable to a 6th-grade reading level, and an index score of 12 is comparable to a 12th-grade reading level.

Dozens of Web sites offer detailed information about these readability gauges, and many promote software that uses the work of Flesch or Gunning. More objective information is available from Wikipedia and from a University of Texas at Austin site (utexas.edu/disability/ai/resource/readability/manual/forcast-versus-flesch-English.html), where differences between the Forcast, Flesch-Kincaid, and Flesch Reading Ease Formulas are analyzed.