Ask Build Check
ABC for better health literacy
Ask Build Check is a New Zealand-developed three-step model that can be used to build health literacy.
Step 1: Ask
In this most important step, you ask people what they know, think, believe or do.
Step 2: Build
In this step, you build new information on to what people already know.
Step 3: Check
In this step, you check how clearly and effectively you communicated.
Ask: This is the most important step and easiest to do.
“Tell me what you know/think/ believe/do …”
Build: You are already doing some of this.
Build new information on to what people already know. At the end of this step, ask “Most people have lots of questions. What are your questions?”
Check: This is the hardest step and needs lots of practice.
“I want to check I’ve been clear. What are you going to do when you get home?”
“I want to check I’ve been clear. What are you going to say to your partner?”
Step 1: Ask
This is the most important part of the three-step model. Every person you work with has existing knowledge and beliefs, even if those beliefs and knowledge are incorrect.
Step 1 helps:
you uncover what people already know, think, do and believe
you plan how much information you will give people and in what order in Step 2
people recall what they already know so they can make connections to the new information you give them.
When you are talking to people, listen to what the person tells you and acknowledge what they know.
Also listen to the words the person is using. For example, if they say they have “runny poos” this shows they either don't know or are not confident to use the word diarrhoea. So, use the words they used, "You said you have runny poos”, and later you can say, “Have you ever heard the word diarrhoea? It's a hard word to say and even harder to spell. Well, it means just what you said – runny poos".
Sometimes people will have incorrect knowledge or beliefs about their health condition. To add new correct information, you are going to have to deal with that incorrect knowledge in a way that recognises the person may have held these beliefs for a long time and that there are very valid reasons for those beliefs. If you just add new information without addressing the incorrect beliefs, the person may reject the new information because it doesn’t fit with what they already know.
So, if someone says to you, “I get gout because I eat too much seafood,” you could say:
“A lot of people think when they eat seafood they get a gout attack. We have a lot more information now that gout is about how your kidneys get rid of uric acid and this is often affected by your genes. Some people have genes that mean their body produces too much uric acid and some people have genes that mean their kidneys don't get rid of enough uric acid."
For more information about Step 1: Ask, see the Ask Build Check handout.
Step 2: Build
Health professionals are already using Step 2 with people. Remember it's key to link all new information back to what the person knows at Step 1. Use the words the person used and build on these words.
“So, you said when you eat seafood you get gout. This is because eating seafood makes a lot of uric acid in your body. If you have too much uric acid in your body your kidneys can't get rid of it and so the uric acid turns into very painful crystals in your joints.”
Building new skills and knowledge involves the co-construction of knowledge between you and the other person.
"Is it okay if we talk about the fact that you haven’t had a smear for the past 10 years?" And if it isn't, say, "That's okay, I will make a note of it here and will ask you again next year in case you have changed your mind.”
Always explain why
People need to know why they have to do something. Knowing why means people are more likely to carry out the action because they understand its importance.
Welcome different points of view
It is okay if people want to do something different from what you think is best for them. Listen really carefully to understand their reasons for doing something different.
Trying to persuade the person to make the change you think is best will only work while the person is with you. Afterwards they will not be able to recall your reasons for wanting them to make a change.
Understand people make their own decisions about changing behaviour
This is linked to the previous point. You want people to have an honest relationship with you rather than pretending that they are doing something. Accept that it is okay if sometimes people don’t feel motivated to change their behaviour or else they have other more pressing things going on in their lives. Ask them what is important to them.
Acknowledge where people are at
Sometimes, just telling you their story is enough for the person. They are not at the stage where they can’t make any changes.
Acknowledge that and say you will follow up. “It sounds like you have got too much on at the moment. How about I ring you in two weeks and see how you are going?” Or “I understand you don’t want to make a change at this time. Is it okay if I check with you from time to time in case you have changed your mind?”
Follow up in a few days when the person may have had time to think about what they want to do. Be prepared to follow up again if they are still not sure.
Believe people can create their own solutions
Asking people what they think will work for them is the best approach. They know their own situation and what they can manage at this time. Always resist telling people what they need to do – it doesn’t work.
This is linked to cultural competence and your biases. People have their own reasons for doing things. These reasons can be seen as illogical and unreasonable from your perspective.
People are very quick to pick up when you don’t think they are doing the right thing. Being non-judgmental means finding out the reasons why the person wants to do something so you can understand their perspective and what they want to do as a result. Remember you are not questioning whether the reasons are valid for that person.
For more information about Step 2: Build, see the Ask Build Check handout.
Step 3: Check
This step is about checking how clearly and effectively you communicated.
This is the step that gets overlooked because you run out of time. Or else you use questions such as “Do you have any questions?”, “Does that make sense?” or “Do you understand?” as a way of checking people have understood.
Asking closed questions is not effective to find out whether you have been clear. People are most likely to say they don’t have any questions and they do understand, even when they don’t.
The responsibility for effective communication is on you as the person giving the information. So, Step 3 isn’t a test of how well the person has understood you. Instead, Step 3 is about how clearly and effectively you communicated.
Checking you have been clear is about getting feedback from the person you have been talking to about how clear your communication was.
If you do not check you have been clear, the only indication that the person did not understand may be a medicine error or failure to follow up. Relying on spoken, non-spoken and non-verbal cues such as the person saying “yes” or nodding is not accurate.
If you use Step 3 and find that you weren’t clear and the person does not recall information given previously, think about what you said that wasn’t clear. Was there a problem with the language you used or did you give too much information the first time? Or perhaps the person was stressed or feeling unwell.
If you weren’t clear the first time, simply repeating what you said won’t work. Instead find another way of rephrasing or restating the information, maybe using visual reminders to help the person. For example:
“How about I write it down as 1, 2, 3.”
“Would it help if I wrote it down for you?”
“I think this diagram/picture will help explain what is going on in your body."
In the USA, checking to understand is called ‘teach-back’ or ‘teach to goal’ because you are asking the person to ‘teach-back’ to you what you have just discussed with them.
Some health coaches find Step 3 difficult to use at first so try using it at the beginning or the end of the day.
Practice with a colleague.
Once you have used Step 3, think about what you did well and what you could improve next time.
Develop a script that works for you.
Talk to colleagues about things they are finding useful.
Tell the person you are working with that you are trying something new.
Ask the person to repeat, in their own words, what they now know or need to do. For example:
“I want to check I have been clear, so can you tell me what you have to do and I will listen to make sure I explained it properly.”
“Just to be sure I haven’t missed something, can you tell me what I have told you about how to take this medicine?"
Take responsibility for not being clear, eg, “Sorry I haven’t been clear – what do you think would help you to remember this information?”
Use prompts if the person has only missed out a small piece of information, eg, “Do you remember what we said about weighing yourself to check if you are retaining fluid?”
Use pictures and diagrams when people haven’t understood spoken information or instructions. Link it back to what the person knows, eg, "You told me you sometimes feel you are retaining fluid because your shoes get too tight. We want to find out about it before that happens so ...."
Make sure it is obvious to the person that you are taking responsibility for being clear.
For more information about Step 3 Check, see the Ask Build Check handout.