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ABSTRACT 
The ability to use information easily and effectively is essential 

to medical communication. Yet who uses medical informa-

tion, when they use it, and how they use it has changed with 

the rise of personal medical technologies and increased reli-

ance on telehealth practices. As a result, a range of nonmedi-

cal professionals now regularly engage in different health care 

activities. This situation represents a challenge medical writers 

must address to ensure the health and wellness of individuals 

who use their content. Meeting usability expectations involves 

understanding both the cognitive models writers use to create 

content and those that readers rely on when using content to 

achieve a health care objective. Such mental models, however, 

vary from audience to audience on the basis of experiences. 

As a result, medical writers need to understand what mental 

models entail in order to create materials that meet an audi-

ence’s usability expectations. This article provides medical 

writers with an overview of what these mental models encom-

pass and how they affect an audience’s usability expectations. 

The article also presents a 5-step process medical writers 

can employ to identify and address such usability expecta-

tions when creating content for different groups. The related 

approach begins with researching and identifying the mental 

models upon which audiences base their usability expecta-

tions. The approach then focuses on applying the resulting 

findings to create draft content for the related audience. The 

approach then concludes with a process for testing (and revis-

ing, if needed) initial content via input from members of the 

related audience. Through this process, medical writers can 

more effectively identify and meet an audience’s usability 

expectations when creating medical content.

 Usability—the ability to use items easily and effectively—

has long been important to medical communication.1-6 The 

role of usability in health and medicine, however, has become 

more acutely important as the rise of wearable devices7-8 and 

the spread of telehealth practices9,10 increasingly place differ-

ent health care activities in the hands of patients. In these situa-

tions, failure to use content effectively can have adverse effects, 

including medical complications, injury, and even death.11 

Addressing these situations involves understanding the mental 

models guiding how audiences use health care content.12

 This article examines what these mental models entail 

and how they affect an audience’s usability expectations for 

health care. The article also presents an approach for research-

ing such expectations and applying related findings to develop 

usable health care content for different groups. The article’s 

objective is to provide medical writers with an approach for 

creating usable health care materials for different audiences.

MENTAL MODELS AND CONTENT 
CONSIDERATIONS
When we write, we use a cognitive model—a mental picture or 

representation—to guide the process.13,14 If we wish to explain 

how to use a blood pressure cuff, for example, we access the 

mental model we have for that process (eg, what it “looks like”) 

and produce content/text that describes the activities depicted 

in this representation.14,15 Our goal is to provide individuals 

with information they can use to mentally re-create the same 

depiction in order to perform that process. An audience’s 

ability to perform the related activity thus becomes a matter of 

how effectively individuals can re-create and follow a mental 

model as described in the content we provide. This ability to 

re-create mental representations guides how effectively audi-

ences can use content to perform tasks.

 These mental models are not innate; we learn them 

through our experiences over time.15-17 The more we notice an 

activity occurring a certain way in a particular location, the 

more we perceive these situations as “standard” representa-

tions that become our mental models for activities.17,18 We 

Kirk St.Amant / Louisiana Tech University, Ruston, LA; University of Limerick, Limerick, Ireland

A Cognitive Model Approach to Creating 
Usable Health Care Content



102 AMWA Journal / V36 N3 / 2021 / amwa.org 

then use these models to conceptualize processes when creat-

ing related content. Additionally, the more often we encounter 

a process occurring in a specific setting, the more that loca-

tion—and everything and everyone in it—becomes central to 

the metal model we use to conceptualize the activity.19-21 So, 

the more we observe individuals checking their blood pressure 

a certain way in their kitchen, the more we associate “dynamics 

of kitchen setting” with where, when, and how to perform that 

process. As a result, mental models contain more than depic-

tions of how to perform activities. They also include expecta-

tions regarding the individuals involved, the objects used, and 

the processes for using them in a particular setting.19-21

 Because experiences can vary, audiences and authors 

could use different mental models to conceptualize a situa-

tion. Such variations can have implications for how individuals 

create or use content.15-17,21 In medical communication, such 

differences often involve aspects associated with performing 

health care activities (e.g., using a device to check one’s blood 

pressure).1,2,12 These differences generally reflect expectations 

associated with a context of care—or the location where indi-

viduals expect to perform a health care process and what that 

processes entails in that setting.1,12 These variations can affect 

how audiences perceive and understand content describing 

health care activities,15-18 and such factors can affect the usabil-

ity of health care content.1,2,15-18

CONTEXT AND CONCEPTUALIZATION
In terms of usability in health care contexts, 2 major problems 

can arise when the mental model of authors/content creators 

and the readers/content users diverge.

Misalignment
Misalignment occurs when author and audience have different 

mental models for the same situation.12,21 In these cases, the 

audience might perceive an author’s content as

• explaining an experience or process in a way that differs 

from what audience members expect,

• describing a process that conflicts with an audience’s 

expectations and is therefore considered incorrect, and

• missing essential elements as per the audience’s 

mental model.

These factors could lead audiences to doubt the credibility of 

content or try to supplement seemingly incomplete content 

with information based on the audience’s own experiences. 

Such situations can affect if and how audiences use health care 

materials.

Comprehension
Occasionally, an audience might have no prior mental model 

to guide expectations.16-18 In these cases, content based on the 

author’s mental model might not provide audience members 

with the information needed to effectively re-create a mental 

representation for a process. This situation could leave indi-

viduals wondering what to do or leave them unable to compre-

hend and use content. As a result, audiences might

• avoid using content they cannot understand,

• guess what a writer means to convey, but use inaccurate 

assumptions to guide actions, and/or

• misconceptualize information and perform an activity 

incorrectly.

Such situations could prompt audiences to perform a process 

in a way that results in adverse consequences, ranging from 

making a condition worse to causing permanent injury.

 Such situations reveal how successful medical commu-

nication requires an understanding of the mental models 

audiences use to conceptualize health care information.15,16 

Medical writers can benefit from strategies that help identify 

such models (or the lack thereof) and the associated dynam-

ics of where a process occurs, what it entails, and who it 

involves.12,21 Such approaches should focus on collecting the 

model-specific information an audience relies on to guide the 

use of content.

MAPPING MENTAL MODELS
Understanding an audience’s mental models involves iden-

tifying the dynamics associated with a context of care—the 

location audiences associate with a health care activity.1,2,12,21 

These dynamics include determining who the members of an 

audience are, how their experiences have shaped their health 

care expectations, and what aspects they associate with health 

care processes. To better understand such factors, researchers 

with Louisiana Tech University’s Center for Health and Medical 

Communication reviewed the literature on cognition, usability, 

and design in health care contexts. This review led to the devel-

opment of an approach for researching an audience’s context-

of-care expectations. The researchers then conducted pilot 

studies to assess this approach and used the resulting feedback 

to revise the process.

 These activities resulted in a 5-step method for research-

ing, designing, and testing communication materials for differ-

ent audiences. Called “mapping contexts of care,” the objective 

of this approach is to help medical writers identify and address 

the mental models that shape audience expectations of health 

care activities. This mapping approach works as follows.

Step 1: Identify the Audience for Health Care Content
Medical writers must first identify the audience for which they 

will create content. This process entails gathering information 



AMWA Journal / V36 N3 / 2021 / amwa.org    103

on a group’s background (i.e., who individuals are and what 

they know about a topic) as well as on

• geographic information on the health care options (eg, 

clinics, hospitals, pharmacies, etc.) that are available based 

on where individuals live and what transportation options 

they can use and

• insurance information affecting the health care options 

available to patients (ie, treatment patients can afford) and 

where individuals can access care (eg, a local physician’s 

office vs a free clinic).

Such factors are essential to understanding location-based 

experiences that shape an audience’s mental models for health 

care activities.

Step 2: Select a Method for Collecting Data
After identifying an audience, medical writers need to collect 

data on the mental models that shape expectations of health 

care activities. To do so, medical writers can use the following 

tools:

• individual interviews asking individual members of an 

audience questions about their expectations, assumptions, 

and associations for where and how certain care is provided;

• Focus groups assembling 5-10 members of an audience and 

asking them to answer questions as a group, as such situa-

tions might help individuals remember details or provide 

clarification; and/or

• Mixed methods that use both interviews and focus groups to

collect data and compare individual and group responses to 

better understand audience expectations for a context of care.

These approaches would all use the same questions, and the 

number of interviews and focus groups conducted would 

depend on the time and funds allocated for a project. In each 

case, the resulting information can provide insights on an 

audience’s mental models for health care. Medical writers can 

use such information to develop content according to an audi-

ence’s context-of-care expectations.

Step 3: Craft Questions for Collecting Information
Audiences could use different mental models for a context 

depending on when they perform an activity. Such timing 

dynamics, however, can be significant, for who is in a location 

and what is in a location at a particular time can affect what 

audiences expect to do in a setting.22 For this reason, research-

ing mental models requires audience members to identify both 

the location where they perform an activity and the time when 

they perform the activity in that context.

 To account for these factors, medical writers need to ask 

certain questions in a particular sequence. The objective is to 

prompt audience members to access the correct mental model 

for a health care activity in terms of time (when) and place 

(where). Doing so involves asking the following questions in 

the following order.

Question 1: When Do You Do X (eg, Check Your Blood Pressure)? 

The dynamics of a location can change at different points in 

time, and individuals could have different expectations for a 

location based on when they use items in a setting.22 Asking 

audience members “where” they perform a health care activity 

might, therefore, prompt individuals to access a mental model 

for a location at the wrong point in time (i.e., one other than 

when they engage in health care). As a result, audience mem-

bers might describe a mental model that does not reflect the 

persons, items, situations, etc., in a location when they perform 

a health care activity. Medical writers should therefor begin their 

questioning by asking audience members when they perform 

an activity to prompt individuals to access the correct mental 

model they associate with performing an activity in a location.23

Question 2: Where Do You Do X (eg, Check Your Blood 

Pressure)? Can You Describe That Location?  Once time is 

established, the medical writer can ask audience members 

where they perform the related process. Knowing the place, 

however, does not inherently clarify what an audience expects 

to encounter and use in that location. Medical writers there-

fore need to ask individuals to also describe that setting in 

order to provide more complete information on model-related 

expectations. To this end, medical writers might ask individu-

als to sketch that space and identify/label items as they go. 

Alternatively, medical writers could sketch the location as 

audience members describe it and ask for modifications,  

additions, etc., to such sketches during this process.

Question 3: Who Helps With Doing X (eg, Process of Checking 

Your Blood Pressure)?  Various individuals (eg, patients, 

patients’ family members, caregivers, etc.) could participate  in 

different activities (eg, checking blood pressure) and use 

certain items (eg, a blood pressure cuff). Medical writers need 

to identify such factors and craft content that addresses associ-

ated expectations. Such content can better convey what  

audience members expect to do themselves compared with 

what audience members expect to rely on others to do for 

them in a context of care (eg, create instructions telling indi-

viduals how to let a caregiver use a sphygmomanometer to 

take their blood pressure).

Question 4: Can You Describe the Process to Me? Who Does 

What?  Mental models for health care generally encompass all 

activities occurring during a care-related process. By having 



104 AMWA Journal / V36 N3 / 2021 / amwa.org 

audience members provide step-by-step descriptions of a  

process, medical writers can identify the activities audiences 

associate with a health care activity. These specifics include 

what tasks are involved, who performs them, and what is used 

(and by whom).

Question 5: What Do You (or Others) Use to Perform This 

Process? Can You Describe That Item? Many health care activi-

ties involve different items used to perform certain tasks. What 

those items are—and what characteristics they must have for 

audiences to recognize and use them—can vary from audi-

ence to audience.24 Medical writers need to identify such fac-

tors to create content that reflects expectations audiences use 

to identify the items and individuals associated with a health 

care process.

Step 4: Apply Information to Create Initial Materials
After completing all interviews and/or focus groups, medical 

writers would compare responses to identify common expec-

tations audiences have for health care activities in a location. 

Medical writers could use this information to create

• a depiction (eg, an image) of the audience’s mental model 

for where a process occurs, what items individuals use, 

who uses them, and how; and/or

• a checklist of location-related factors, individuals, items, 

and tasks to address when creating content for members of 

that audience.

Such items would constitute a draft representation of the 

mental models an audience uses to conceptualize a particular 

health care process in a context of care. Medical writers could 

use such tools to guide content creation when developing 

health care materials for a particular audience.

Step 5: Test, Revise, and Finalize Materials
The materials created through this process (i.e., depictions 

and/or checklists) are not final. Rather, medical writers should 

use them to create draft content—text, visuals, online materi-

als, etc.—to assess how effectively such items match an audi-

ence’s mental models. For this testing, medical writers would 

recruit new members of the intended audience (i.e., persons 

not involved in earlier interviews and focus groups) to avoid 

biased responses based on prior familiarity with the project.25 

Medical writers would then ask these individuals to use  

draft content to perform a health care process in the related 

context of care.

 For this testing, medical writers could use the following 

tools:

• Talk-aloud protocols: These are processes in which medical 

writers meet with members of the intended audience and 

observe these individuals as they use draft materials to per-

form a health care activity in the related context of care.26

Individuals are asked to “talk aloud” during this process and 

note what they are doing, why, and their impressions as they 

perform the process. After individuals complete the task, 

medical writers could ask questions about what aspects of 

the draft content need revision (and how to revise materials) 

to enhance usability. Medical writers could also ask if any-

thing should be removed from or added to the draft content 

to make it more usable.

and/or

• Focus groups and/or interviews: Medical writers would first 

request that members of the intended audience use draft con-

tent to perform a health care activity in the associated context 

of care. Medical writers would then conduct follow-up focus 

groups and/or interviews to ask individuals for suggestions 

on revisions needed to enhance the usability of that content.27 

Medical writers could also ask if anything should be removed 

or added to enhance the usability of that content.

 Medical writers would use information resulting from this 

testing to revise both draft content and associated materials 

used to create it. They would then test this revised content with 

new members of the intended audience to determine if addi-

tional revisions are needed. This process of testing, collecting 

comments, revising, and testing revised materials would con-

tinue until a final version is confirmed or until time and funds 

for such activities run out. In either case, the objective is to 

create usable materials that best reflect the mental models an 

audience uses to engage in health care activities.

CHALLENGES AND CONSIDERATIONS
Major challenges related to this approach include identifying 

and recruiting individuals for the data collection and the test-

ing done to map mental models and create related materials. 

Attracting enough members of an audience for the interviews, 

focus groups, and testing sessions involved can be difficult 

depending on the availability and willingness of individuals. 

Similarly, effectively identifying and using channels for dissem-

inating calls for participation can create challenges that affect 

the size and representativeness of groups participating in  

these activities.

 Additionally, context-related dynamics often change over 

time. As a result, medical writers need to regularly test and 

re-assess materials used to guide content creation in order to 

determine if they still reflect the experiences and expectations 



AMWA Journal / V36 N3 / 2021 / amwa.org    105

of an audience. If not, then medical writers need to review and 

even redefine who the audience for content is. They then need 

to engage in new data collection, content creation, and test-

ing to address expectations based on new or changed mental 

models for health care processes.

 Finally, responses to questions 3-5 in the previous section 

could reveal the need to create content for a different audi-

ence—such as caregivers, friends, or family members—who 

perform essential activities during a health care process. Such 

individuals become a new and necessary audience for health 

care content associated with a process. As these audiences use 

mental models to guide their activities, creating such content 

would mean identifying the mental models this audience has 

for a process. Doing so would mean mapping such models via 

the same approach to research, drafting, testing, and revising 

content described previously.

CONCLUSION
An understanding of mental models can help medical writers 

create content that meets an audience’s usability expectations. 

The result can be content audiences can easily and effectively 

use in the contexts where they engage in a health care activ-

ity. The approach described in this article can help medical 

writers identify the dynamics of such models and create con-

tent that meets audience expectations. Through a combina-

tion of researching expectations and testing materials, medical 

writers can develop content audiences can use to effectively 

engage in health care. Such approaches can be important to 

addressing new situations that might arise as societies emerge 

from COVID-19 restrictions. They can also help medical writ-

ers respond effectively to different social changes, economic 

changes, and other changes that might affect health care prac-

tices and processes in the future.

Author declaration and disclosures: The author notes no commercial 
associations that may pose a conflict of interest in relation to this article.

Author contact: kirk.stamant@gmail.com

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