continuity in the presentation of ideas can be achieved through

Connecting Ideas Through Transitions

Writing that Establishes Relationships and Connections between Ideas

Introduction Common Kinds of Relationships Writers Establish between Ideas Cohesion Coherence Transition Words and Phrases

Introduction

According to poet and science writer Diane Ackerman, “one of the brain’s deepest needs [is] to fill the world with pathways and our lives with a design.” We naturally look for how things are related. In writing, this means that readers tend to assume that two side-by-side sentences or adjacent paragraphs relate to each other. If the pathways and design of your writing aren’t clear to readers, readers will either get confused or frustrated or try to mistakenly intuit their own connections. Both responses can be disastrous.

Good writing provides clear passages through all of your ideas so that readers don’t get lost or start to blaze their own conceptual trail. These connections between ideas occur at the sentence, paragraph, section, and (for longer works) even chapter level. As a writer, it is your responsibility to make sure that your readers follow this progression, that they understand how you arrive at your various ideas and how those ideas relate to each other. In this page, we explore how to make your connections between ideas understandable by using common relationship categories to compose sentences that are cohesive, paragraphs that are coherent, and transitions that clearly order and introduce ideas.

Common Kinds of Relationships Writers Establish between Ideas

Writers are always working to establish clear relationships between and within all of their ideas. Consider how Derek Thompson moves naturally between one concept to another in this short passage from his The Atlantic feature about the future of jobs entitled “A World Without Work”:

[1] One common objection to the idea that technology will permanently displace huge numbers of workers is that new gadgets, like self-checkout kiosks at drugstores, have failed to fully displace their human counterparts, like cashiers. [2] But employers typically take years to embrace new machines at the expense of workers. [3] The robotics revolution began in factories in the 1960s and ’70s, but manufacturing employment kept rising until 1980, and then collapsed during the subsequent recessions.

In the first sentence, Thompson begins with an idea that is familiar to readers at three different levels. The argument that machines haven’t replaced all retail employees and therefore won’t do so in the future is common to anyone who has thought much about workplace technology. This idea is also specifically familiar to the individuals who have been reading Thompson’s article. Finally, Thompson makes this idea even more familiar by connecting it to an example that his readers are familiar with: the effects of self-checkout kiosks. In his second sentence, Thompson uses the transition word “but” to establish a contrastive relationship; what he is about to say in some way opposes what he just said. He concludes this passage with a sentence providing chronologically organized evidence for the idea he raised through that contrast. In this example, he very quickly leads us from the 1960s to the late 20 th century and is able to cover a lot of ground clearly because he starts with happened earlier and concludes with what has happened more recently.

In just these three sentences, we can see Thompson establishing different kinds of relationships between concepts. He is:

• guiding us from familiar ideas into unfamiliar ones,
• comparing two unlike things,
• providing examples for his claims, and
• presenting information chronologically.

Familiarity, contrast, example, and chronology are four common ways that topics can be related, but there are several others. The following lists identifies key relationships that we tend to find naturally in the world around us when we ask questions like, “Why did that happen?” and, “How do these two things fit together?” If you can obviously situate any your ideas within these well-known structures, then readers will be able to more quickly understand the connections you are establishing between your ideas. In the list that follows we identify these common relationship categories, explain them, and provide examples of sentences that establish these kinds of relationships. (All off these sample sentences are about research in Lake Mendota—the body of water just north of the UW-Madison campus.)

Familiarity– Connecting what readers know to what they don’t known.

Learning often involves drawing from existing knowledge in order develop new knowledge. As a result, this is one of the most important relationships you can establish in your writing. Start with what your readers know (either because you can assume a common knowledge or because you’ve already told them about this earlier in your paper or even in the preceding sentence) in order to then take them to something they don’t know.

Example: When you dive into a lake for a quick swim, you’re actually entering a diverse limnology laboratory—the research field for the ecologists who study inland waters.

Causation– Connecting the instigator(s) to the consequence(s)

We are very familiar with thinking about ideas and processes in relationship to cause and effect. You can use the prevalence of this relationship to your advantage by relating your ideas to causation.

Example: In the mid-19 th century, the white sand beaches that used to line Lake Mendota were engulfed by the additional four feet of water that the Tenney Locks brought into the lake (Van Eyck).

Chronology– Connecting what issues in regard to when they occur.

This is particularly useful if you are describing a sequence of events or the steps of a process.

Example: In 1882, E.A. Birge was gathering data about the prevalence of blue-green algae in Lake Mendota (Van Eyck). By 1897, he was publishing about plankton (Birge). Even when he became president of UW-Madison several years later, his interest in freshwater lakes never waned (“Past presidents and chancellors”).

Combinations

Lists–connecting numerous elements..

You can think of this as a “this + this + this” model. You are saying that a collection of concepts or elements contribute equally or simultaneously to something. Within lists, it’s still important that you are being strategic about which elements you are identifying, describing, or analyzing first, second, and third.

Example: Across its studied history, Lake Mendota has been negatively affected by blue-green algae, Eurasian milfoil, spiny water fleas, and zebra mussels, among others (Van Enyck).

Part/Whole— Connecting numerous elements that make up something bigger.

This is a “this + this + this = that” model. You are showing how discrete elements form something else through their connections.

Example: Across generations, the damage Lake Mendota has sustained as a result of the unnaturally prolific prevalence of blue-green algae, Eurasian milfoil, spiny water fleas, and zebra mussels has irreparably altered these waters.

Contrast– Connecting two things by focusing on their differences.

This establishes a relationship of dis-similarity. It helps readers understand what something is by comparing it with something that it is not.

Example: But whereas boosting the population of walleye and northern perch in Lake Mendota effectively reduced the prevalence of Eurasian milfoil, scientists haven’t been able to develop a plan to respond to the damaging spiny water fleas (Van Eyck).

Example– Connecting a general idea to a particular instance of this idea.

Arguments are made more understandable and persuasive when you develop your overall claims in relationship to specific evidence that verifies or exemplifies those claims. Which examples will be the most persuasive (e.g., statistical data, historical precedent, anecdotes, etc.) will depend on the knowledge, interests, disposition, and expectations of your reader.

Example: “These new challenges demand new solutions, some behavioral (such as cleaning boats from lake to lake) and some research-driven (for example, identifying a natural predator for the invasive species)” (Van Eyck).

Importance– Connecting what is critical to what is more inconsequential.

This can also be thought of as connecting what is big to what is small. You may also choose to reverse these relationships by starting with what matters least or what is smallest and building to what is the most important or what is the most prominent. Just make sure that you are helping your reader understand which end of the spectrum you are starting with.

Example: Boaters were inconvenienced by the Eurasian milfoil clogging their propellers, but the plants’ real harm was dealt to the lake’s native flora and, consequently, its fish (Van Eyck).

Location– Connecting elements according to where they are placed in relationship to each other.

Even if you aren’t writing about geographical entities, you can still clarify how various ideas are positioned in relationship to each other.

Example: Whether or not the lake is pretty is peripheral to the issue of whether or not its natural ecosystems are in balance.

Similarity– Connecting two things by suggesting that they are in some way alike.

This highlights commonalities to show readers how elements or ideas are serving the same function.

Example: Just as invasive water flora (i.e., Eurasian milfoil) disrupted Lake Mendota’s ecosystem in the 1970s, in 2009 scientists discovered that the lake was being damaged by invasive water fauna (i.e., spiny water fleas) (Van Eyck).

While the examples provided above for each of these relationships is a sentence or short series of sentences where relationships are established through sequencing and transition words, you should also develop these kinds of common connections between ideas on a large scale through grammatical parallelism, paragraph placement, and your progression from one section to another.

Also, as can be seen in these examples, sometimes multiple different relationships are functioning simultaneously. For instance, consider again the example for the “Importance” item:

The ideas in this sentence work within the following relationship categories:

• Importance—Connecting what is more inconsequential (i.e., how boaters are bothered by Eurasian milfoil) to what is most critical (i.e., how the lake’s ecosystem is disrupted by Eurasian milfoil),
• Contrast—Connecting two things (i.e., boaters’ concerns and the lake’s wellbeing) by focusing on their differences,
• Causation—Connecting an instigator (i.e., Eurasian milfoil) to consequences (i.e., native plants’ destruction and, secondarily, the native animals’ destruction).

This collection of interwoven relational connections doesn’t mean that these ideas are jumbled; this is just an indication of how relationships can become interconnected.

Since clearly working within these relationship categories can be useful for organizing your key concepts as well as guiding readers through the structure of entire papers or particular paragraphs as well as sentences, different kinds of connections can be similarly layered across the whole structure of a paper. For example, if you are composing an argument about why it’s so hard for meteorologists to pin-point the severity and location of tornadoes, the overarching relationship of your ideas might be part/whole because you’re interested in how a range of factors contribute to a difficult prediction process. However, within your paragraphs, you might have to use chronological and causation relationships to describe the physical processes by which tornadoes are formed. And from sentence to sentence, you’ll need to make sure that you are starting with what’s familiar to your readers before moving into what’s new.

Joseph Williams and Joseph Bizup, in their handbook Style: Lessons in Clarity and Grace , identify the process of moving from what is known to what is unknown as “cohesion.” “Sentences are cohesive ,” they write, “when the last few words of one sentence set up the information that appears in the first few words of the next” (67). They relate this careful sequencing to the issue of “flow”—readers find that ideas follow each other naturally when one sentence begins where the previous sentence left off.

Consider another annotated example passage from Derek Thompson’s economic analysis of the effects of automation and technology on jobs. This paragraph comes after one about how horses (once primary forces for industrial production) were made obsolete by transportation technology.

[1] Humans can do much more than trot, carry, and pull. [2] But the skills required in most offices hardly elicit our full range of intelligence. [3] Most jobs are still boring, repetitive, and easily learned. [4] The most-common occupations in the United States are retail salesperson, cashier, food and beverage server, and office clerk. [5] Together, these four jobs employ 15.4 million people—nearly 10 percent of the labor force, or more workers than there are in Texas and Massachusetts combined. [6] Each is highly susceptible to automation, according to the Oxford study.

Thompson’s most obvious application of Williams and Bizup’s concept of cohesion happens at the end sentence 4 and the beginning of sentence 5 where he first lists four professions (salesperson, cashier, server, and clerk) then begins the next sentence with, “these four jobs.”

But even on a conceptual level, Thompson is continuously moving from old information to new information. Consider this analysis of the conceptual shifts within each of these six sentences where Thompson’s ideas have been stripped down and his key concepts have been highlighted in different colors:

[1] Humans have more skills than horses. [2] Humans’ full range of skills aren’t always utilized by many office jobs . [3] Many jobs don’t push us to our full potential. [4] Here are the most common jobs . [5] These jobs employ many people. [6] These jobs could be eliminated through automation .

Thompson begins this paragraph by connecting a new idea (i.e., humans’ present occupational relationship to technology) to an old idea from the previous paragraph (i.e., horse’s past relationship to technology). After introducing the human subject, he then uses it to bring in his next topic: workplace skills. Then, through skills he brings in the issue of jobs, and jobs eventually lead him to the issue of automation. This sequence holds together like a line of conceptual dominoes.

Connecting new ideas to old is a practice that you should implement across sentences, paragraphs, and even whole sections of your writing. However, be careful. If this practice becomes heavy-handed or overdone, your writing can become patronizing to your readers. Make sure that you are clearly and comprehensively connecting ideas and not just sequencing subjects.

In Style: Lessons in Clarity and Grace , Joseph Williams and Joseph Bizup also write about the importance of coherence. While “cohesion” and “coherence” sound similar, they are two different things. “Cohesion” is about ideas that connect to each other “the way two pieces of a jigsaw puzzle do,” whereas “coherence” “is when all the sentences in a piece of writing add up to a larger whole” (69). Sometimes this is also called “unity.” Coherence is achieved when the things you are writing about all clearly contribute to the same overarching topic. For example, let’s return to the domino example from above. The movement from humans to skills to jobs to automation works because Thompson’s larger article establishes a thematic connection between all of these topics: work changes in response to technological developments. Thompson is even able to start this paragraph with an otherwise unexpected reference to horses because in the previous paragraph he has shown his readers how horses also relate to this theme of work changing in response to technological development. Within your writing, it’s important to make sure that all of your smaller ideas are related to and pointed towards the same goal.

Williams and Bizup suggest one way of making sure that your writing is coherent or unified is to pay attention to what each of your sentences is about—its subject (the noun or pronoun that guides a sentence) and topic (the idea that is the focus of that sentence). In most sentences, your subject and topic should be the same thing. Also, most of the time your topic should be short and direct, and each paragraph should be primarily dedicated to one topic. As an example, consider again this paragraph from the Thompson article about human skills, jobs, and automation. The subjects/topics of each sentence have been highlighted.

1] Humans can do much more than trot, carry, and pull. [2] But the skills required in most offices hardly elicit our full range of intelligence. [3] Most jobs are still boring, repetitive, and easily learned. [4] The most-common occupations in the United States are retail salesperson, cashier, food and beverage server, and office clerk. [5] Together, these four jobs employ 15.4 million people—nearly 10 percent of the labor force, or more workers than there are in Texas and Massachusetts combined. [6] Each is highly susceptible to automation, according to the Oxford study.

Note that after setting up this paragraph in a way that connects back to the previous paragraph’s focus on horses, Thompson settles into the issue of jobs as his clear and primary focus. The final four sentences have some version of “jobs” as their subject and topic. This consistency allows him to develop coherent ideas about this one issue.

For more information about writing intentionally structured and unified paragraphs, check out our resource on paragraphing. Additionally, if you are trying to discern whether or not your paragraphs are functioning coherently across your entire paper, we recommend the practice of reverse outlining. You can find out more about this technique here.

Transition Words and Phrases

The best way to clearly communicate the logical pathways that connect your ideas is to make sure that you move smoothly from old information to new information (cohesion) and that your readers always understand how your primary topics contribute to the big picture of your overall argument (coherence). While we’ve considered ways that whole sentences and paragraphs can do this work, sometimes even individual words can help you establish clear, cohesive, and coherent relationships between your ideas. In writing these are often called “transition words.”

The following is a list of useful transition words and phrases. Following the list of common relationship categories provided above, these words are organized according to the kinds of relationships they frequently develop. Of course, establishing clear relationships between ideas requires much more than just dropping one of these into the start of a sentence, but used sparingly and carefully based on the logical associations they establish, these words can provide usefully obvious indications to your readers of the kind of connections you are trying to develop between your ideas.

Causation– Connecting instigator(s) to consequence(s).

accordingly as a result and so because

consequently for that reason hence on account of

since therefore thus

after afterwards always at length during earlier following immediately in the meantime

later never next now once simultaneously so far sometimes

soon subsequently then this time until now when whenever while

Combinations Lists– Connecting numerous events. Part/Whole– Connecting numerous elements that make up something bigger.

additionally again also and, or, not as a result besides even more

finally first, firstly further furthermore in addition in the first place in the second place

last, lastly moreover next second, secondly, etc. too

after all although and yet at the same time but

however in contrast nevertheless nonetheless notwithstanding

on the contrary on the other hand otherwise though yet

as an illustration e.g., (from a Latin abbreviation for “for example”)

for example for instance specifically that is

to demonstrate to illustrate

chiefly critically

foundationally most importantly

of less importance primarily

above adjacent to below beyond

centrally here nearby neighboring on

opposite to peripherally there wherever

Similarity– Connecting to things by suggesting that they are in some way alike.

by the same token in like manner

in similar fashion here in the same way

likewise wherever

Other kinds of transitional words and phrases Clarification

i.e., (from a Latin abbreviation for “that is”) in other words

that is that is to say to clarify to explain

to put it another way to rephrase it

granted it is true

naturally of course

finally lastly

in conclusion in the end

to conclude

Intensification

in fact indeed no

of course surely to repeat

undoubtedly without doubt yes

for this purpose in order that

so that to that end

to this end

in brief in sum

in summary in short

to sum up to summarize

Works Cited

Ackerman, Diane. “I Sing the Body’s Pattern Recognition Machine.” The New York Times , 15 June 2004. https://www.nytimes.com/2004/06/15/science/essay-i-sing-the-body-s-pattern-recognition-machine.html . Accessed 6 June 2018.

Birge, Edward Asahel. Plankton Studies on Lake Mendota . Harvard University Library of the Museum of Comparative Zoolog., 1897.

“Past presidents and chancellors.” Office of the Chancellor , University of Wisconsin-Madison, 2016. https://chancellor.wisc.edu/past-presidents-and-chancellors/ . Accessed 16 June 2018.

Thompson, Derek. “A World Without Work.” The Atlantic , July/August 2015, https://www.theatlantic.com/magazine/archive/2015/07/world-without-work/395294/. Accessed 14 June 2018.

Van Eyck, Masarah. “Lake Mendota: a scientific biography.” L&S News , College of Letters and Sciences University of Wisconsin-Madison, 29 Aug. 2016. http://ls.wisc.edu/news/lake-mendota-a-scientific-biography . Accessed 15 June 2018.

Williams, Joseph M. and Joseph Bizup. Style: Lessons in Clarity and Grace . 12 th ed., Pearson, 2017.

Improving Your Writing Style

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Clear, Concise Sentences

Use the active voice

Put the action in the verb

Tidy up wordy phrases

Reduce wordy verbs

Reduce prepositional phrases

Reduce expletive constructions

Avoid using vague nouns

Avoid unneccessarily inflated words

Avoid noun strings

Transitional Words and Phrases

Using Transitional Words and Phrases

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1.9: Transitions- Bridging Ideas for a Seamless Presentation

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Good transitions can make a speech more important to the audience because they feel they are being taken to a positive conclusion without having to travel a bumpy road. – Joe Griffith

Transitions

The difference between a novice speaker and an advanced speaker is in how they bridge the gap between ideas. Learning to use transitions effectively will help take your speaking to the advanced level. Transitions can be one word, a phrase, or a full sentence.

The audience is dying to know the relationship between ideas. Their brains are hard-wired for that. It’s more important when you are speaking than when you are writing because the listeners can’t go back – they have to get it when it happens. If the brain is bored, or gets tired because it’s overwhelmed, or gets confused – it can’t stay in that place, so it daydreams, creating its own interest. Speech Coach Max Dixon, Westside Toastmasters.

So, let’s get started. I have included various transition types for you to consider. These do little good if you read them and do not use them. This list works best if you read it now and then revisit it every time you write a speech.

• Let’s begin with…
• First, I’d like to share with you…
• Now that you’re aware of the overview, let’s begin with…
• Our first stop is…
• I will first cover…
• My first point covers…
• To get started, let’s look at…

The Order of Things

• After that…
• Next…
• Second thing…
• Our next stop is…
• Let me tell you about your next step.

Steve Jobs Commencement to Standford University

Steve Jobs clearly previews his main points, “Today I want to tell you three stories from my life. That’s it. No big deal. Just three stories.” He flows smoothly between points with clear transitions.

• “The first story is about connecting the dots.”
• “My second story is about love and loss.”
• “My third story is about death.”

Between Similar Points

• In the same way…
• In addition…
• Likewise…
• Similarly…

Between Disagreeing Points

• Conversely…
• Despite this…
• The flip side of the issue…
• However…
• On the contrary…
• On the other hand…
• However …
• On the other side …
• Yet, we cannot ignore …
• The opposing argument …
• If we examine the opposite side, we see …

Introduce an example

• This is best illustrated by an example…
• For instance…
• Take the case of…
• For example…
• To understand this…
• Let me illustrate this by…

Introduce Research

• To make the point…
• As illustrated by…
• Case in point…
• To solidify this point…
• As researched by…

Cause and effect

• Therefore…
• Thus…
• Consequently…
• As a result…
• This is significant because…
• Hence…
• Resulting in…
• For that reason …
• The effect is…

Elaboration

• Also…
• Besides…
• What’s more…
• In addition/additionally…
• Moreover…
• Furthermore…

Transition to a Demonstration

• Let me show you how this works…
• Let me demonstrate this…
• Now that we’ve covered the theory, let’s see it in action …
• Next, I’d like to let you see this for yourselves…

Introducing Your Visual

• As you can see from this chart…
• I’d like you to notice that…
• The table indicates…

Questions as Transitions

• Now that you know the problem, what do you think will solve it?
• What do you think will solve this crisis?

Connective: A word or phrase that connects the ideas of a speech and indicates the relationship between them.

Transitions: A word or phrase that indicates when a speaker had finished one thought and it moving on to another.

Internal preview: A statement in the body of the speech that tells the audience what the speaker is going to discuss next.

Internal summary: A statement in the body of the speech that summarizes the speaker’s preceding point or points.

Signpost: A very brief statement that indicates where a speaker is in the speech or that focuses attention on key ideas.

From the Art of Public Speaking by Stephen Lucas

Thoughts from a Former Student

One thing I learned in class that made me a better speechwriter was to pay attention to the transitions. In our outlines, there was space for our main points, but also our transitions between them. At the beginning of the semester, I thought this was a waste of time planning out my transition for a speech and that I would just wing it the day of, but I soon realized how important they were. Transitions are like the finishing touches that make everything fall together in a speech.

You may have some interesting points or facts to give to your audience, but without transitions, you have nothing to connect your points and create a narrative. An audience is much more interested in a talk if there is a continuing idea or theme, and transitions help create this. I found this out by watching the other students in my class as they learned to use transitions as well. I loved the speeches that were clearly organized and had a common idea with transitions.

Zoe Lawless, Honors Public Speaking, University of Arkansas

Movement as Transition

Many people don’t think about movement as a type of transition, but it can be a very powerful way to help your audience transition between ideas.

• Setting out a visual or putting it away signals a change in ideas.
• Some speakers will imagine a baseball diamond laid out on the floor and move to each base throughout the speech. Their opening comment is at home plate. Point one is delivered on first, point two on second, and point three on third. They stand back on their home plate to deliver the final closing statements.
• One speaker that I met said he always has a special place that is his big idea place. He may move around during his speech but when he wants the audience to know it is an important point, he stands in the big idea place.

Silence as a Transition

John Chappelear, speech consultant, suggests that the use of silence can be powerful. It is powerful, but it is not easy. Being able to stand silently in front of a large audience for 15-45 seconds requires practice. Sometimes you can use silence as a way to let the audience catch up and think deeply about what you just said.

Transitioning Between Slides

• As the next slide shows…
• As you can see…
• Next, I will show you…

Transitioning to Visuals

• I’d like to direct your attention to…
• This diagram compares…
• Now, I’d like to illustrate this with…

Signaling the End is Near

• In conclusion…
• To sum it up…
• Lastly…
• In a nutshell…
• To recap…
• I’d like to leave you with…
• Finally, I’d like to say…
• The takeaway from all of this is…
• To summarise…

Moving to the Next Speaker

• I told you about the most credible theories about climate change, now John will share with you some examples of what you can do.
• I’m going to turn it over to Malachi, who will take you through the next few points.
• Next, Angie will come up and talk about…
• To help us understand this topic better, we have Beatrice, who will talk us through…
• Look to the next speaker and motion towards them as they walk to the podium, Twila will tell you more…

Problems with Transitions

These are some of the most common problems with transitions:

• Not planning out transitions and just “winging it.”
• Using fancy phrases inconsistent with the rest of the speech.
• Saying, “I have five points” and then having only four or miscounting the points.
• Overusing the same transitional phrase.
• Long pauses before transitions as the speaker tries to figure out what to say next.

Tricks on Smoothly Presenting Transitions

Now you have a list of ideas to use when you write your next speech, let’s talk about how to use transitions effectively. Speakers typically struggle as they end one point and seek to move to the next idea. This usually happens because of poor planning, not enough practice, and poor note management. Let’s talk about these one at a time. First, poor planning happens because a speaker does not put enough time and effort into writing the speech. Second, not enough practice happened because even when a speech is practiced, it is practiced with regards to getting through the main points and not about moving smoothly between points. Finally, poor note management. Let me give you some tricks.

• Make your notes large-larger than you think you need.
• Give ample space between main ideas so you can look down and see the gap and know another point is coming.
• On your notecards, make each main idea a different color.
• I usually have a “T” in a circle to remind me that this is a transition statement.
• Practice your speech twice by just reading the transition statements and the next sentence.
• The night before your speech, visualize how you will manage the transitions.

Key Takeaways

Remember This!

• Using transitions will help your speech flow smoothly.
• Practice using your transitions.
• Plan transitions for impact.

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Allgood, E., & Ebersole, T. (Eds.). (2017). C OMM 2100 public speaking: A workbook for student success . Fountainhead Press.

Beqiri, G. (2018). Speech transitions: Words and phrases to connect your ideas. https://virtualspeech.com/blog/speech-transitions-words-phrases

Dugan, A. (2013, August 26). Speech transitions: Magical words and phrases. http://sixminutes.dlugan.com/speech-transitions/

Effective speech transitions, how to make your speech flow. https://franticallyspeaking.com/effective-speech-transitions-how-to-make-your-speech-flow/

Jobs, S. (2005). Steve Jobs commencement address to Stanford University. [Video]. YouTube. https://news.stanford.edu/2005/06/14/jobs-061505/ Standard YouTube License.

Lawless, Z. (2020). Honors Public Speaking, University of Arkansas, Fayetteville. Used with permission.

Lucas, S.E. (2009). The art of public speaking. McGraw Hill.

Pace, P. (n.d). Bridge the gap–Speech transitions. https://westsidetoastmasters.com/article_reference/bridge_the_gap-speech_transitions.html#:~:text=%22I%20think%20body%20movement%20is,carries%20the%20audience%20with%20him.

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How Coherence in Writing Facilitates Manuscript Acceptance

Coherence is an essential quality for good academic writing . In academic writing, the flow of ideas from one sentence to the next should be smooth and logical. Without cohesion, the reader will not understand the main points that you are trying to make. It also hampers readability. Cohesion necessarily precedes coherence. There is a difference between cohesion and coherence: cohesion is achieved when sentences are connected at the sentence level, whereas as coherence is achieved when ideas are connected. In addition, cohesion focuses on the grammar and style of your paper.

What is Coherence in Writing?

Coherence also means “clarity of expression” and it is created when correct vocabulary and grammar are used. After all, the goal of writing is to benefit the readers. Without both coherence and cohesion, the readers may detect choppiness in the text and feel as if there are gaps in the ideas presented. Needless to say, texts without coherence are difficult to read and understand. It defeats the whole purpose of writing, which is to relay ideas in a clear and efficient manner. There are strategies that you can use to ensure coherence and cohesion in academic writing.

Examples of Cohesive and Non-Cohesive Paragraphs

Paragraph coherence and cohesion results in paragraph unity . To ensure that your paragraphs have unity, there are two things to keep in mind: it must have a single topic (found in the topic sentence) and sentences provide more detail than the topic sentence, while maintaining the focus on the idea presented. The paragraph below shows a lack of unity:

Non-cohesive sample: Dogs are canines that people domesticated a long time ago. Wolves are predecessors of dogs and they help people in a variety of ways. There are various reasons for owning a dog, and the most important is companionship.

Cohesive sample: Dogs are canines that people domesticated a long time ago, primarily for practical reasons. Even though dogs descended from wolves, they are tame and can be kept in households. Since they are tame, people have various reasons for owning a dog, such as companionship.

Notice that the ideas in the non-cohesive sample are not arranged logically. The sentences are not connected by transitions and give the readers new ideas that are not found in the topic sentence. Thus, the paragraph is hard to read, leaving readers confused about the topic. On the other hand, the cohesive sample has ideas arranged logically. All ideas in this sample flow from the topic sentence. In addition, they give more details about the topic while maintaining their focus on the topic sentence.

Establishing Coherence

It is important to focus on coherence when writing at the sentence level. However, cohesion smoothens the flow of writing and should be established. There are various ways to ensure coherent writing :

• Write sentences that flow by varying the lengths and structures, the use of correct punctuation, and broadening your word choices
• Use simple transitions, such as “in addition, additionally, furthermore, therefore, thus, on the contrary, by the same token, at the same time, in other words, etc.”
• Repeat your keywords but be careful of excessive repetition
• Repeat sentence structures, which is used as a rhetorical technique rather than cohesion to highlight parallelism between sentences
• Ensure thematic consistency
• Start every sentence or paragraph with information that hints at the content of the next sentence

Academic writing is improved by coherence and cohesion. Without coherence and cohesion, readers will become confused and eventually disinterested in the article.  Your ideas then become lost and the primary objective of writing is not achieved.

Tips and Strategies

There are six ways for creating coherence, which you will find useful while polishing your manuscript. Creating coherence is not as difficult as it seems, but you will need the right tools and strategies to achieve it.

• >Lexis creates cohesion using synonyms, hyponyms, and superordinates. The use of lexical chains creates variety in writing and avoids monotony.
• Reference creates cohesion by using possessive pronouns (e.g. your, their, etc.), pronouns (e.g. she, me, etc.), and determiners (e.g. those, these, etc.).
• Substitution, which is the use of a different word in place of a previously mentioned word (e.g. “I bought a designer bag today. She did the same.”)
• Ellipsis is the removal or omission of words because their meaning is implied through context (e.g. “He goes to yoga classes in the afternoon. I hope I can too.”)
• Cohesive nouns are also called umbrella nouns because they summarize many words in one.
• Conjunctions include words that list ideas (e.g. first, next, then, lastly, etc.)

Academic writing should be concise, coherent, and cohesive. Maintaining these three qualities involves using a number of strategies to impart ideas to the reader. After all, that is the whole point of any type of writing.

Thanks for this nice post. It is very useful.

rich info, thank you.

Thanks for the well explained meaning of cohesion and coherence, how ever, I rated this post with 5 🌟 to show my appreciation, once again thanks 😂😀😀

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The ancient Egyptians were masters of preserving dead people's bodies by making mummies of them. Mummies several thousand years old have been discovered nearly intact. The skin, hair, teeth, fingernails and toenails, and facial features of the mummies were evident. It is possible to diagnose the disease they suffered in life, such as smallpox, arthritis, and nutritional deficiencies. The process was remarkably effective. Sometimes apparent were the fatal afflictions of the dead people: a middle-aged king died from a blow on the head, and polio killed a child king. Mummification consisted of removing the internal organs, applying natural preservatives inside and out, and then wrapping the body in layers of bandages.

The ancient Egyptians were masters of preserving dead people's bodies by making mummies of them. In short , mummification consisted of removing the internal organs, applying natural preservatives inside and out, and then wrapping the body in layers of bandages. And the process was remarkably effective. Indeed , mummies several thousand years old have been discovered nearly intact. Their skin, hair, teeth, fingernails and toenails, and facial features are still evident. Their diseases in life, such as smallpox, arthritis, and nutritional deficiencies, are still diagnosable . Even their fatal afflictions are still apparent : a middle-aged king died from a blow on the head; a child king died from polio.

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3 Ways to Keep Your Audience Focused During a Presentation

• Matt Abrahams

Fight back against their tendency to zone out or multitask.

Grabbing and keeping your audience’s focus is critical to communication success. What you have to say is important, so give yourself the best chance to convey your message to your audience by first gaining attention, but then, more importantly, sustaining it. In this piece, the author outlines three techniques — physical, mental, and linguistic — to engage your audience.

Attention is our most precious commodity. In today’s fast-paced world of always-on digital devices and round-the-clock media cycles, getting our audience’s attention is critical to our communication success. With so many distractions vying for our time, we must actively seek and gain our audience’s attention first.

• Matt Abrahams is a lecturer in organizational behavior at Stanford Graduate School of Business. He hosts Think Fast, Talk Smart: The Podcast and is the author of Think Faster, Talk Smarter: How to Speak Successfully When You’re Put on the Spot .

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15 Interactive Presentation Ideas to Elevate Engagement

By Krystle Wong , Aug 04, 2023

As attention spans continue to shrink, the challenge of engaging audiences in a short timeframe has never been more significant. Let’s face it — grabbing and keeping your audience’s attention can be quite the challenge, especially when time is ticking away. But fear not, I’ve got the perfect solution: interactive presentations!

Believe it or not, creating an interactive presentation is easier than you might think. In this guide, I’ll show you how to effortlessly turn ordinary slides into captivating experiences with 15 interactive presentation ideas that will leave your audience begging for more. From quirky polls and fun games to storytelling adventures and multimedia magic, these ideas will take your presentation game to the next level.

Venngage is a game-changer when it comes to empowering interactive presentations. With just a few clicks, users can customize their favorite presentation templates , add multimedia content and create immersive experiences that leave a lasting impact. Whether you’re a seasoned presenter or a newcomer, get started with Venngage to elevate your presentation game to new heights of engagement and creativity.

Click to jump ahead:

What is an interactive presentation?

15 ways to make a presentation interactive, 7 best interactive presentation software, what are some common mistakes to avoid when creating interactive presentations, interactive presentation faqs, how to create an interactive presentation with venngage.

An interactive presentation is a dynamic and engaging communication format that involves active participation and collaboration between the presenter and the audience. Unlike traditional presentations where information is delivered in a one-way manner, interactive presentations invite the audience to interact, respond and contribute throughout the session.

Think of it as a two-way street where you and your audience have a friendly chat. It’s like playing a fun game where you ask questions, get live feedback and encourage people to share their thoughts. 

To make a good presentation , you can utilize various tools and techniques such as clickable buttons, polls, quizzes, discussions and multimedia elements to transform your slides into an interactive presentation. Whether you’re presenting in-person or giving a virtual presentation — when people are actively participating, they’re more likely to remember the stuff you’re talking about.

Interactive presentations leave a lasting impression on the audience. By encouraging active participation and feedback, interactive presentations facilitate better understanding and knowledge retention. Here are 15 innovative 5-minute interactive presentation ideas to captivate your audience from start to finish:

1. Ice-breaker questions

Start your presentation with intriguing and thought-provoking questions or a fun icebreaker game. These questions should be designed to pique the audience’s curiosity and encourage them to think about the topic you’ll be covering. By doing so, you create an immediate connection with your audience and set the stage for a more engaged and attentive audience.

For example, if you’re giving a business presentation about management and leadership training, you could ask audience questions such as “What’s the best business advice you’ve ever received, and how has it impacted your career?”

2. Live polling

Incorporate live polls during your presentation using audience response systems or polling apps. This allows you to collect real-time feedback, opinions and insights from active participants. Live polling encourages active participation and involvement, making your presentation feel like a collaborative and interactive experience.

3. Q&A sessions

Encourage the audience to ask questions throughout your presentation, especially for pitch deck presentations . Address these questions in real-time, which fosters a more interactive and dynamic atmosphere. This approach shows that you value the audience’s input and promotes a two-way communication flow.

4. Clickable buttons

Add clickable buttons to your slides, allowing the audience to navigate to specific sections or external resources at their own pace. For example, you could include links to your social media accounts or extra reading materials in your education presentation to give further information about the topic and get your students engaged. By providing this autonomy, you empower the audience to explore areas of particular interest, creating a more personalized and engaging experience through your interactive slideshow.

5. Storytelling

Incorporate anecdotes or personal stories related to your topic. Storytelling is a powerful way to emotionally connect with your audience, making your presentation more relatable and memorable. A little storytelling along with a set of creative slides draws the audience in and keeps them engaged as they follow the narrative.

6. Interactive charts and graphs

Use interactive charts and graphs that respond to user input to make your presentation interactive. For instance, allow the audience to click on data points to view more detailed information or to change the displayed data series. Creating charts with interactive visuals help the audience interact with the data, fostering better understanding and engagement.

7. Animated infographics

Add animations to your infographics, making them visually dynamic and progressive. Animated infographics reveal information gradually, keeping the audience curious and attentive. This transforms complex data into an easily digestible and engaging format.

Venngage’s extensive library of infographic templates is a powerful tool to visualize data and elevate the interactivity of your presentations. Personalizing the visuals ensures a cohesive and professional look throughout your interactive presentation. The templates are highly customizable, allowing you to adjust colors, fonts, and styles to match your presentation’s theme and branding. 

8. Gamification

Introduce an interactive quiz, puzzles, or challenges related to your presentation content. Gamification adds an element of fun and competition, motivating the audience to participate actively and boosting their learning experience. Here are some gaming presentation templates you could use. 

9. Virtual reality (VR) or augmented reality (AR)

If applicable, leverage VR or AR technologies to provide immersive experiences. These interactive presentation tools transport the audience into a virtual or augmented environment, making your presentation more captivating and memorable.

10. Collaborative whiteboarding

Get your audience involved in your presentation by utilizing digital whiteboards or collaborative tools to brainstorm ideas collectively. This fosters teamwork and creativity, enabling the audience to actively contribute and feel a sense of involvement in the presentation.

11. Hyperlinked text

Keep the information in your slides minimal with a simple presentation and incorporate hyperlinks to direct viewers to relevant websites or blogs , resources, or additional information. This encourages self-exploration and gives the audience the opportunity to delve deeper into topics of interest.

12. Role-playing

Engage the audience in role-playing scenarios to explore different perspectives. Role-playing promotes active learning and helps the audience relate the content to real-life situations, enhancing their understanding and retention.

13. Embedded videos

Include video clips in your slides to provide visual explanations, demonstrations, or interviews. Videos add a dynamic element to your presentation, enriching the content and keeping the audience engaged.

14. Audience-generated content

Encourage the audience to contribute ideas, stories or examples related to your professional presentation . Audience-generated content fosters a sense of ownership and involvement, making the presentation more interactive and personalized.

15. Slide transitions

Use slide transitions to create smooth animations between slides. Well-planned transitions maintain the audience’s interest and keep the presentation slides flowing seamlessly.

Interactive elements aside, enhance your presentation with these guides on how to summarize information for a captivating presentation and how to make a persuasive presentation to captivate your audience. 

If you’re looking to create engaging and interactive presentation slides that captivate your audience, these presentation software options are sure to elevate your game:

Prezi is renowned for its dynamic and non-linear presentation style, enabling users to craft visually stunning and interactive presentations. With an array of templates and animation effects, Prezi enhances audience engagement, making your presentations more captivating and memorable.

2. Mentimeter

Mentimeter serves as an audience response system, empowering real-time interaction during presentations. Users can create interactive polls, quizzes, word clouds and more, allowing the audience to respond using their smartphones or other devices. This fosters active participation and provides valuable feedback instantly.

3. Google Slides

Google Slides is a free cloud-based presentation software that not only offers collaboration features but also enables real-time interactions. It includes add-ons and third-party integrations to further enhance interactivity, making it an excellent choice for collaborative and engaging presentations.

4. Microsoft PowerPoint

PowerPoint, a classic presentation software, has evolved to incorporate more interactive features like live captions, real-time collaboration and interactive elements such as quizzes and forms. With its familiar interface and versatile functionalities, PowerPoint remains a reliable choice for interactive presentations.

5. Prezentor

Prezentor caters to sales-oriented presentations focusing on interactive storytelling and data-driven content. It offers analytics to track audience engagement and behavior during presentations, allowing you to fine-tune your approach and keep your audience hooked.

6. Opinion Stage

Opinion Stage is a visual and interactive data collection tool designed to engage and excite audiences whether sitting in a lecture hall, participating in a live Zoom, or watching an on-demand webinar. The Opinion Stage tools are simple and intuitive, making it easy to create attention-grabbing quizzes, surveys, and polls in minutes. A great way to spice up any presentation, encourage audience participation, and collect authentic feedback.

7 . Venngage

Venngage stands out as a versatile design tool that facilitates the creation of interactive infographics, data visualizations and presentations with ease. Offering various interactive elements and animations, Venngage empowers you to craft visually appealing and engaging presentations effortlessly.

With these interactive presentation software options at your disposal, you can unleash your creativity and deliver presentations that leave a lasting impact on your audience. So, go ahead and make your presentations interactive, captivating and memorable!

For more presentation software options, check out this blog on the 12 best presentation software for 2023.

Creating interactive presentations can be a game-changer for engaging your audience and enhancing your presentation skills, but steering clear of common pitfalls is essential. Here are some key mistakes to avoid when crafting your interactive presentations:

1. Overloading with interactivity

While interactivity is fantastic, bombarding your audience with too many interactive elements can backfire. Strive for a balanced approach that enhances engagement without overwhelming your listeners.

2. Ignoring audience relevance

Failing to tailor interactive elements to your audience’s interests and preferences can lead to disconnection. Make sure your interactions resonate with your specific audience for a more meaningful experience.

3. Not testing interactive elements

Skipping thorough testing of interactive features before showtime can spell disaster. Avoid technical glitches by diligently testing all interactive components in advance.

4. Poor timing and pace

Timing is everything, especially with interactive activities. Ensure seamless integration by planning your key points and the timing of your interactive elements carefully.

5. Lack of clear purpose

Every interactive element should serve a purpose and contribute to your presentation’s objectives. Don’t add interactions just for the sake of it — ensure they add value and align with your message.

6. Failing to engage beyond interactivity

While interactive elements are powerful tools, remember that content is king. Combine your interactive features with compelling storytelling and valuable insights to create an immersive and impactful presentation.

Incorporating animated slides into your interactive presentations enhances the overall appeal and interaction, turning an ordinary presentation into an engaging experience. Try it out with one of our animated presentation templates to get started. 

How do you start an interactive presentation?

Begin by grabbing the audience’s attention with an intriguing question or a surprising fact, setting the tone for a dynamic and engaging session.

Which type of presentation is the most interactive?

Workshops and seminars are often the most interactive types of presentations as they encourage active participation, discussions and hands-on activities.

How can interactive presentations enhance audience engagement?

Interactive presentations foster a two-way communication flow, involving the audience through polls, quizzes, discussions and multimedia elements, leading to increased interest, attentiveness and better retention of information.

What are some common interactive elements to include in a presentation?

Common interactive elements include clickable buttons, hyperlinked text, polls, quizzes, interactive charts, multimedia content and audience participation activities.

Can interactive presentations be used for educational purposes?

Absolutely! Interactive presentations are highly effective for educational purposes as they promote active learning, encourage critical thinking, and provide real-time feedback and knowledge exchange opportunities.

Need inspiration on how to give an engaging presentation ? Here are 120+ presentation ideas you could use. 

Venngage makes it easy for anyone to infuse interactivity into their presentations. From clickable buttons and hyperlinked text to interactive infographics and dynamic charts, Venngage offers a diverse range of interactive elements to captivate and engage the audience. Here’s how you can make your presentation more fun and interesting with Venngage:

• Sign up or log in to Venngage to access the platform.
• Choose a presentation template or start with a blank canvas to begin designing your interactive presentation.
• Add and edit slides in the Venngage editor to structure your presentation content effectively.
• Customize the design by selecting themes, fonts, colors and backgrounds to match your style and branding.
• Use interactive elements like buttons, links, pop-ups and hover effects to engage the audience during the presentation.
• Enhance engagement by incorporating interactive media such as videos and audio clips.
• Preview and test your entire presentation to ensure everything works smoothly before presenting it to your audience.
• Save your interactive presentation on Venngage and share it online or download it in various formats for presenting purposes.

Well, I hope these 15 5-minute interactive presentation examples can help unlock a new level of audience engagement for your next presentation. From fun quizzes and interactive storytelling to multimedia magic and gamified challenges, the possibilities are endless. So, don’t be afraid to experiment, tailor the ideas to suit your audience members and let your creativity shine.  

That said, remember to strike a balance and keep the interactivity purposeful and relevant. Some common mistakes to avoid when creating interactive slides include overloading the presentation with too many interactive elements and failing to align the interactive elements with the overall presentation goals and content. 

Got it? Great. Now let’s turn that boring presentation around!

• Best in Class

19 Ideas for More Compelling and Effective Presentations

Presentations play an important role in marketing and business development. Whether speaking at a conference, making a new business pitch, meeting with a client, or hosting a webinar, presentations can be a true differentiator — for better or worse.

But as important as presentations are, they can often be treated as an afterthought. And many marketers and business leaders settle for mediocre presentations at best and dreadful presentations at worst. The fact is, even though we’re not all capable of making inspiring presentations like Steve Jobs, most presentations could be  better ! So here are some simple ideas to help you create more compelling and effective presentations.

1 Consider the setting upfront

A critical factor to consider before developing a presentation is to take into account the setting of the presentation. Is it in-person or virtual? A keynote address or a breakout session? Small room or large room? Casual environment or formal? Whatever the setting, your approach to developing and giving the presentation should factor in the unique setting and respond with an appropriate approach.

2 Spend time developing great content

This should go without saying, but content is the core of your presentation. While all the other ideas below will help to make your content more impactful, a great presentation starts and ends with great content. So don’t shortchange your audience by shortchanging the effort you spend on developing compelling content. You’ll need to invest many hours researching, writing and brainstorming if you aim to create a presentation that your audience will appreciate.

3 Start with an outline

Don’t start with PowerPoint or Keynote! Many people start their presentations by getting right to creating slides.  But you need to remember that your presentation is not your slides; your slides only support your presentation. So it’s best to start by creating a simple outline of the main points you want to make in each act and go from there.

The key is to get your main ideas on paper and organize your thoughts before you start creating slides. You’ll gain a better understanding of the flow of your presentation and what content needs to be added, omitted or reordered.

4 Follow the 3-act structure

While not every presentation can easily fit into the 3-act structure, it’s generally a good method to follow.

Act 1  – The first act is the introduction, the setup of your presentation. This is where you grab the audience’s attention early on, giving them an expectation of what they are going to get out of it and a reason to keep listening. A compelling story or illustration can serve as a powerful opener.

Additional thoughts on the opening: You’ve got mere seconds to hook your audience, so open with a bang! Absolutely, positively, DO NOT be salesy or self-deprecating in your opening (or at any point in your presentation for that matter). And unless you want to lose the audience’s attention and respect out of the gate, don’t open with those token and boring slides that talk about you, your firm and all those accolades. Jump right into the real content!

Act 2  – The middle act is where you sustain their interest. Typically you are detailing a problem and offering a solution, while educating and informing along the way. It’s here where you really build your case and sell the benefits. This is where you’ll want to provide compelling examples, data, statistics, etc. to support your points.

Act 3  – The final act is where you resolve the problem, recap and remind the audience of the high points of your presentation. Then leave the audience with a call-to-action. What is the audience supposed to take away from your presentation? That should be clearly defined in your closing act. Also, a final story or illustration and questions from the audience are a great way to draw the presentation to a close.

5 Have one main point for each slide

It’s best to make only one main point for each slide. Be concise and coherent and don’t try to cover too much ground on a single slide. Instead, keep your slide (and your words) focused on hammering home the main point. But always use brevity; once you have made your point, move on. You don’t want to lose the audience by belaboring a point once it has been made.

6 Avoid using bullets

Nothing gets abused in presentations more than bullets. A slide full of bullets will undoubtedly ensure that your audience will stop listening to you and instead read what’s on the slide. The fact is, they can read faster than you can make your points. So remember, they are there to listen to you, not to read your slides. Bullets might be helpful as notes, but there’s little reason to include them on your slides.

7 Less is more

Keep in mind, your slides are there to support your presentation, not BE your presentation. So it’s best to always keep things as simple as they can be, because your slides are slides, not Word documents! Many presenters have entirely too much text on a slide and include way too many visuals, leaving audience members dizzy wondering what they’re looking at. And don’t design your PowerPoint presentation to be a leave behind. If you want to give your audience a substantive leave-behind, that should be treated as an entirely different document altogether.

8 Use large text

Since you are simplifying your slides, avoiding the use of bullets and only making one major point for each slide, amplify your points by using large text. Using a larger font size will not only make it easier for your audience to read the slide, it will also help them retain the information. And depending on the screen and room, your audience is probably going to have a hard time reading the text if you use a font size any smaller than 24pt. Ideally, each slide will only contain a few words that underscore your point.

9 Include captivating visuals

It’s been documented that messages accompanied by pictures are retained at a much more significant rate than words alone. This is called the “picture superiority effect” and studies indicate that including powerful visuals can increase information retention by 55% – 65% or more. Avoid using cheesy clip art or overly generic stock art. And absolutely, positively don’t use watermarked or copyrighted images that you found online! Similar to including one main point on each slide, one large and powerful photo is preferred over several smaller photos. The key is to choose images or graphics that convey the message you’re trying to make, in the most compelling way possible.

10 Utilize data wisely

Data can be a good thing or a bad thing in a presentation, depending on how wisely it’s used. Try to avoid the use of excel charts and graphs, as these are nearly impossible to make sense of on a screen and will surely distract your audience from listening to you. If you’re going to use complex data, try to find a way to simplify the numbers, using more of an infographic style than a typical Excel chart style.

Also, while statistics can certainly add to your presentation, be sure you always source your stats and find the most recent information possible. Using a 10-year-old statistic or quoting statistics without a source will detract from your credibility.

11 Have a solid, professionally designed slide deck

Regardless of how great the quality of your content may be, a poor slide deck design can be distracting and erode credibility — even if your firm is not in a “creative” industry. Design still matters and can help or hurt your presentation, so your slide deck design should be professional.

The template you use should be custom (don’t use the templates included with PowerPoint or Keynote), branded (but not over branded), and have a clean and organized layout. Avoid the temptation to overuse animation for transitions.

If your firm doesn’t have design capabilities, consider hiring someone to design a custom presentation and establish a design system for the various components of your presentation.

12 Don’t read it

If you don’t use bullets and have only one major point on each slide, you aren’t going to be able to turn around and read the slides like many often do during a typical presentation. But if you use notes, be sure you know the presentation well enough to avoid being glued to them. Not only is listening to someone read their way through a presentation boring, it gives the impression that you aren’t as knowledgeable on the subject as you should be.  Instead, use your notes for cues, not as the narrative for your presentation.

13 Engage with the audience

If you want to make a connection with your audience and have them pay attention to what you are telling them, you need to be engaging.  Here are some tips:

• Do you best to be and stay relaxed
• Show your personality, passion and enthusiasm about the topic
• Make eye contact with specific members of the audience, even in virtual meetings
• Project your voice; a notch more than you think you should
• Move around the stage and interact with the audience
• Don’t talk too fast, but don’t talk too slow either
• Take a brief pause after making a substantial statement

Following these tips will help you appear confident and comfortable to the audience, making you seem more knowledgeable.

14 Treat it like a conversation

Nothing is more annoying (and boring) than a presenter that simply recites facts and information in a pontificating way. You don’t want to talk down to your audience, but you don’t want to treat the presentation like a 9th grade oral book report either. Instead,  act like you are having a conversation with your audience .

The best presentations I’ve ever sat through are the ones that made me feel like the presenter was talking with me and to me, not at  me. So try to speak as though you are speaking to only one person at a time. A good way to set the right conversational tone is by starting with open-ended questions to engage the audience at the beginning.

15 Tell compelling stories

The best presenters in the world are also incredible storytellers.  One of the best ways to engage an audience and make a lasting impression is to use stories and illustrations as a way to bring context and clarity to your points. Stories are usually much more engaging than raw information.  So look for stories, examples, illustrations, case studies, etc. to help bring your points to life.

16 Make them laugh (a little)

Not surprisingly, the best presenters, in addition to being great storytellers, are also generally funny people.  So look for ways to inject some (clean and safe) humor into your presentation. Making your audience occasionally laugh will keep them alert, entertained and more likely to keep listening to your message.

Now I’m not in any way insinuating that you should be a part-time stand-up comedian.  But at the same time, in addition to educating your audience, it’s always good to make them laugh every once in a while.

17 Don’t under OR over prepare

Don’t go into a presentation under-prepared! You should know your topic backwards and forwards and be able to present without an over dependence on notes.  Similarly, don’t over-prepare either. Remember, you are having a conversation with the audience, not reciting a speech.

So while you should spend a lot of time in preparation, don’t rehearse too much or memorize what you are going to say. You want your presentation to sound natural and organic, not like a canned political speech.

18 Get the technology right

All the hard work that goes into a creating a great presentation can be derailed by technological glitches. Don’t let yourself be a victim! Here are some things to consider:

• Bring your own laptop to run the presentation
• Come with every possible adapter/cable you may need for A/V
• Invest in a quality remote and frequently change batteries
• Have a spare power cord and/or extension cord handy
• Avoid overusing animations, audio and video
• Don’t depend on web-based content; embed directly from your laptop
• Get there early, click through your deck and test the microphone

19 Adapt to the virtual environment (when required)

The Coronavirus (COVID-19) pandemic has ushered in a new era of virtual meetings , conferences, workshops and interviews. Virtual presentations are a completely different dynamic and require a different strategy, approach, pace and delivery. Here are some of the things you need to think about:

• Slide deck – Keep in mind that your slides will be seen on much smaller screens than what you typically find at in-person presentations.
• Equipment and technology – Be sure you have a high-quality camera and microphone, as well as sufficient internet bandwidth to stream the presentation.
• On-camera appearance – Being on camera means your audience is going to get a much more “up close and personal” view of you. Be sure to look directly into the camera and position yourself so that only your upper chest and face are visible. Make sure the room is well lit and eliminate any background distractions.
• Energy and Enthusiasm – Just like on-screen personalities exude energy and enthusiasm, it’s important for you to as well. Amp it up a bit more than normal and remember to keep up the enthusiasm until you’ve logged off.
• Engagement – The virtual audience is much more difficult to read and keep attentive. While the specifics will depend on your particular situation, building in engagement activities such as live polling, interactive Q&A, and audience input can be helpful for engagement.

Don’t wing it!

There are many other ways to create more compelling presentations and we’ve only scratched the surface with these 19. But the takeaway is, don’t treat presentations like an afterthought. Instead, adequately prepare and follow these simple tips to make your presentations more impactful.

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• Int J Integr Care
• v.23(1); Jan-Mar 2023

Continuity of Care and Coordination of Care: Can they Be Differentiated?

Chi-chen chen.

1 Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan

Yi-Chen Chiang

2 School of Public Health, Xiamen University, Xiamen, China

Yi-Chieh Lin

3 Department of Public health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan

Shou-Hsia Cheng

4 Institute of Health Policy & Management, College of Public Health and Population Health Research Center, National Taiwan University, Taipei, Taiwan

Associated Data

Introduction:.

Both care continuity and coordination are considered essential elements of health care system. However, little is known about the relationship between care continuity and coordination. This study aimed to differentiate the concepts of care continuity and coordination by developing and testing the reliability and validity of the Combined Outpatient Care Continuity and Coordination Assessment (COCCCA) questionnaire under the universal coverage health care system in Taiwan from a patient perspective.

Face-to-face interviews were conducted nationwide with community-dwelling older adults selected via stratified multistage systematic sampling with probability-proportional-to-size process. A total of 2,144 subjects completed the questionnaire, with a response rate of 44.67%.

The 16 items of the COCCCA questionnaire were identified via item analysis and principal component analysis (PCA). The PCA generated five dimensions: three continuity-oriented (interpersonal, information sharing and longitudinal between patients and physicians) and two coordination-oriented (information exchange and communication/cooperation among multiple physicians). The second-order confirmatory factor analysis supported the factor structure and indicated that distinct constructs of care continuity and coordination can be identified.

Conclusion:

The COCCCA instrument can differentiate the concepts of care continuity and care coordination and has been demonstrated to be valid and reliable in outpatient care settings from a patient perspective.

Introduction

Care continuity and care coordination are important features of a health care system. Many countries have introduced strategies to improve care continuity and coordination [ 1 , 2 ], for example, the patient-centered medical home, accountable care organization programs under the Affordable Care Act in the United States [ 1 ]. To investigate the impacts of these programs, good measurement tools for care continuity and care coordination are critical. Several studies have argued that the two concepts have distinct features [ 3 , 4 , 5 , 6 , 7 ]. However, the concepts of care coordination and care continuity are sometimes used interchangeably [ 8 , 9 , 10 ].

WHO (2018) provided the definition of care continuity as “the extent to which a series of discrete health care events is experienced by people as coherent and interconnected over time and consistent with their health needs and preferences.” [ 7 ] Before the year 2000, the concept of care continuity focused on the relationship between patients and their physicians [ 4 , 11 , 12 , 13 , 14 , 15 ] or uninterrupted health care [ 8 ]. Few studies adopted a multidimensional concept of continuity of care [ 16 ]. However, after 2000, the concept of care continuity was treated as multidimensional [ 17 , 18 , 19 , 20 ]. Three types of care continuity have been identified: longitudinal continuity [ 7 , 16 , 17 , 19 ], informational continuity [ 7 , 17 , 19 ] and interpersonal/relational continuity [ 16 , 17 , 18 , 19 ] between patients and their physicians. Longitudinal continuity is characterized by a regular source of care whereby patients receive most care from a provider or a team of providers for a long period of time [ 19 ]. This ongoing relationship existing between patients and health care providers allows physicians to be familiar with the medical history and current condition of patients. Informational continuity is defined as the transfer of a patient’s information across episodes of care, both between the patient and providers and among providers, through the organized collection of medical records as well as the memory of the physicians who establish a relationship with the patient (such as knowledge of the patient’s preferences) [ 19 , 20 ]. Interpersonal continuity represents patients’ trust that is established with their usual care providers from a personal perspective, as well as physicians’ view of themselves as having personal responsibility for patient care [ 19 , 20 ].

However, the growth of the elderly population with an increasing prevalence of chronic conditions and the increase in specialization among health care professionals have challenged the concept of care continuity. People are more likely to receive specialty care from various health care providers in different settings [ 21 , 22 , 23 ]. Researchers have suggested that when patients see multiple providers, the concept of care continuity should focus not only on the ongoing interpersonal continuity between patients and their physicians but also on care coordination among multiple physicians in different care settings, such as cross-boundary continuity [ 17 ] and managerial continuity [ 18 ]. The concepts of cross-boundary continuity and managerial continuity are similar to the concept of care coordination.

On the other hand, WHO (2018) provided the definition of care coordination as “a proactive approach to bringing together care professionals and providers to meet the needs of service users, to ensure that they receive integrated, person-focused care across various setting.” [ 7 ] In the early years, the concept of care coordination focused on primary care settings. It was defined as a provider’s recognition of information concerning a patient from one visit to another [ 24 ], other providers’ awareness of the involvement of the primary care physician [ 3 ] and the advanced coordination of patient care by the primary care physician [ 25 ]. Later, care coordination began to be considered a multidimensional concept and to frequently include information transfers among providers [ 26 , 27 ], communication among providers [ 7 , 26 , 27 , 28 , 29 , 30 ] and cooperation among providers to create a care plan for a patient [ 7 , 18 , 26 , 27 ]. Gradually, the concept of care coordination has been extended to the entire health care system instead of focusing only on primary care settings [ 31 ].

Measurements of care continuity and coordination were constructed by using medical records, claim data and patient- or provider-reported surveys. Freeman and colleagues (2001) proposed the evaluation of patients’ experiences of coordinated and smooth progression of care [ 17 ]; since then, measuring care continuity and coordination from a patient perspective has attracted attention [ 32 ]. After reviewing the literature, we categorized instruments measuring patients’ experiences of care continuity and care coordination into three categories. Instruments in the first category aim to evaluate the performance of primary care services from a patient perspective [ 28 , 33 , 34 , 35 ]. Some instruments in this category contain subscales to measure specific dimensions of care continuity and coordination, such as longitudinality [ 28 , 33 , 34 , 35 ], interpersonal communications [ 28 ] and coordination of care [ 28 , 33 , 34 , 35 ].

Instruments in the second category measure patient-reported care continuity. The majority of the instruments in this category aim to capture the multidimensional concept of care continuity proposed by Saultz (2003) [ 19 ] and Haggerty et al. (2003) [ 18 ], with different focuses [ 36 , 37 , 38 , 39 , 40 , 41 ]. For example, the Cuestionario Continuidad Asistencial Entre Niveles de Atencion (CCAENA) questionnaire aims to assess care continuity across different health care levels, including primary and secondary care providers [ 40 ]. Haggerty and colleagues (2012) developed a generic measure of multidimensional care continuity to be used when patients encounter several physicians [ 39 ]. In general, most of the care continuity instruments include both items concerning the “ongoing relationship between patients and specific physicians (e.g., longitudinal, interpersonal, and self-management information, etc.)” and items concerning “care coordination among different physicians (e.g., information gap, management, and cross-boundary continuity, etc.)” [ 36 , 37 , 38 , 39 , 40 ].

The third category of instruments aims to measure patient-reported care coordination, which is relatively new in this research field. McGuiness and Sibthiorpe (2003) developed the measurement tool specifically for care coordination [ 42 ]. The Agency for Healthcare Research and Quality (AHRQ) in the United States introduced a standardized definition of care coordination and later published the “Care Coordination Measures Atlas”. This atlas provides an overview of care coordination measurements as well as a framework of key dimensions that are important for measuring care coordination [ 43 ]. Afterward, based on the AHRQ atlas, Schultz et al. (2013) reviewed the existing care coordination measures of 96 instruments and found that the majority of the measures used survey data (88%) and focused on primary care settings (58%) [ 27 ].

In recent years, each care coordination measurement tool has had individual features, such as being patient centered [ 44 ], including patient and provider perspectives [ 45 ], and being applicable across different settings [ 46 ]. Similarly, some instruments for care coordination have included subscales of care continuity, such as information [ 44 ], interpersonal communication [ 42 , 44 , 45 , 46 ] and the longitudinal relationship between patients and their physicians [ 46 ].

In summary, we considered the concept of continuity of care to refer primarily to the interpersonal and longitudinal relationship and information sharing between patients and their physicians, which is similar to the definition of Saultz (2003) [ 19 ]. On the other hand, the concept of care coordination refers mainly to coordination among multiple health care providers, including information exchange and communication/cooperation. However, the existing instruments measuring care continuity include subscales of managerial continuity (similar to the concept of care coordination) [ 36 , 37 , 38 , 39 ], while some of the care coordination measures include subscales of care continuity, such as interpersonal/relational continuity [ 27 , 42 , 44 , 45 , 46 ]. It is academically valuable to distinguish between the constructs of care continuity and care coordination and identify the different dimensions of care continuity and care coordination described in the literature. To the best of our knowledge, no existing instrument measures both care continuity and care coordination as separate concepts and incorporates the corresponding dimensions under each concept. This study aims to differentiate the two concepts and to develop and validate a generic questionnaire of both care continuity and coordination from a patient perspective, namely, the Combined Outpatient Care Continuity and Coordination Assessment (COCCCA) questionnaire, by using a nationally representative random sample of community-dwelling older adults.

Taiwan’s health care system

There is no formal referral requirement or primary care system in Taiwan’s health care system. Patients are free to visit specialists at community clinics or hospital outpatient departments based on their preferences [ 47 ]. In addition, Taiwan implemented a compulsory National Health Insurance (NHI) program in 1995 to provide health care coverage for all residents. Patients in Taiwan are often criticized for “doctor-hopping” behavior [ 48 ] and are likely to receive fragmented care from various health care providers. Therefore, we considered Taiwan’s universal health care system to be an ideal setting for measuring patient experiences of care continuity and care coordination.

Research methods

In the development process, we referred to the development measures tutorial recommended by HinKin (2011) [ 49 ], which provides a straightforward guide for the development of scales.

Item generation and development

We developed the COCCCA questionnaire in the following steps. First, we conducted a review of the relevant literature regarding the concepts of care continuity and coordination. We considered the concept of care continuity to consist of three dimensions: longitudinal continuity, information continuity and interpersonal continuity between patients and their physicians [ 18 , 19 ]. The considered the concept of care coordination to consist of two dimensions: information transfer and communication/cooperation among multiple physicians [ 18 , 26 , 27 , 28 , 29 , 30 ]. Second, after identifying the dimensions of both constructs, we reviewed the existing instruments to identify and select potential candidate items [ 28 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 42 , 44 , 45 ]. Third, we developed certain new items that we considered appropriate and necessary for inclusion in the COCCCA questionnaire. Finally, a total of 32 candidate items were generated and mapped to the corresponding dimensions in this study.

After the initial development of the draft COCCCA questionnaire, a pilot survey was conducted by face-to-face interviews with community-dwelling residents aged 50 years or older (N = 179 subjects). The pilot COCCCA questionnaire was found to be a reliable and valid instrument [ 50 ]. Based on the results of the pilot study, we held an expert meeting with eleven professionals in related fields. They provided comments on whether each item had the appropriate content to unambiguously assess the corresponding dimension and provided suggestions for rewording question items to improve their clarity. We also calculated an item-level content validity index by using a four-point scale (1 = very inappropriate; 2 = inappropriate; 3 = appropriate; 4 = very appropriate) for the experts’ assessment. Then, for each item, the content validity index at the item level was calculated as the number of experts giving a rating of either appropriate or very appropriate divided by the total number of experts [ 51 ]. In this study, the item-level CVI ranged from 0.7 to 1.0. According to the results of the pilot survey and the opinions of the experts, we then selected and modified the items for the questionnaire.

The final question items for the first version are shown in Supplementary Table 1 . The questions concerning the experiences of care continuity and coordination were confined to the previous 12 months. The respondent experience referred to the health care services provided by their most frequently seen physicians in either community clinics or hospital outpatient departments. In this study, the majority of the respondents (76.54%) had a most frequently seen physician (or usual provider). If the subjects did not have the most frequently seen physician, they were asked about their overall experience in the previous year. The responses to each item were scored using a Likert scale with five response options.

Characteristics of the total respondents and the respondents who visited at least two physicians.

Sampling and questionnaire administration

The target population for the survey was community-dwelling residents aged 60 years or older with a household registration in Taiwan. We employed a stratified three-stage systematic sampling method in this study, similar to population-based national surveys in Taiwan [ 52 , 53 ]. In this study, all townships/districts of Taiwan were stratified into 19 strata according to demographic structure, ecological economics and geographic location. In the first stage, for each stratum, townships/districts were the primary sampling units and were chosen with probability proportional to their population sizes (PPS). In the second stage, for each selected township/district, lins and villages (the smallest administrative units in Taiwan) were the secondary sampling units and were also sampled with PPS. Finally, in the third stage, community-dwelling residents were the basic sampling units and were selected from each selected lin and village. A systematic sampling method was used in each of the sampling stages.

This study was approved by the Research Ethics Committee of National Taiwan University Hospital in Taiwan (No. 201603076RINA). The randomly selected subjects were invited to participate in the survey via exclusively face-to-face interviews conducted at their homes by trained interviewers. Informed consent was obtained from each participant prior to the questionnaire interview. Because this study aimed to understand the experience of care continuity and care coordination from a patient perspective, patients who had no physician visits in the 12 months prior to the survey were excluded from the sample.

Statistical analyses

To examine the psychometric properties of the COCCCA questionnaire, we conducted a variety of analyses using SAS statistics software package version 9.3 and Mplus version 7. We conducted item reduction and refined the questionnaire by using item analysis and principal component analysis (PCA) (Supplementary Table 1 and Supplementary Table 2). After the item reduction process, a final model was built for the items and their corresponding dimensions. A PCA with varimax rotation was again employed. The latent constructs of care continuity and coordination were simultaneously included in the confirmatory factor analysis (CFA) for the final model. Furthermore, we employed a second-order CFA that consisted of three levels: the secondary factor (i.e., the two latent constructs of care continuity and coordination) and the primary factor (i.e., the dimensions of interpersonal continuity, information sharing continuity and longitudinal continuity under the continuity construct and the dimensions of information exchange and communication/cooperation under the coordination construct). This CFA analysis tested the model as hypothesized for care continuity and coordination and demonstrated the distinctiveness of the constructs measured in this study. Several goodness-of-fit indexes of the second-order CFA were evaluated. For the comparative fit index (CFI) and Tucker-Lewis index (TLI), values >0.90 represented a good model fit. For the root mean square error of approximation (RMSEA), a value <0.05 indicated an excellent model fit, and a value <0.08 indicated an acceptable model fit. For standardized root mean square residual (SRMR), a value <0.05 indicated a good model fit [ 54 ].

In addition, the criterion-related validity of the care continuity and coordination constructs was examined based on the relationship between the constructs and their criterion measure. For care continuity, we assessed whether the patients had a usual provider of care as the criterion measure [ 55 ]. For care coordination, we employed a single item from the overall assessment of care coordination, i.e., “whether the patients perceive lack of care coordination”, as the criterion measure. Independent Student’s t-test (equal variances not assumed) was employed to determine whether significant associations existed between the items for each dimension and their criteria. Finally, the internal consistency of the three dimensions of care continuity and two dimensions of care coordination that emerged from the final model was then assessed by Cronbach’s alpha. A Cronbach’s alpha value ranging from 0.70 to 0.95 was considered acceptable [ 56 ].

Sensitivity analyses

In this study, we conducted two sensitivity analyses to improve the robustness of our results. First, in addition to PCA with orthogonal varimax rotation, we employed PCA with direct oblimin or promax oblique rotation to allow for correlation among the dimensions. Second, we drew a sample of 500 subjects by using a simple random sampling scheme (i.e., the first group), and the remaining sample (1,023 respondents) served as the second group. Data from the first group were used for model building by conducting item reduction and PCA. Then, the second group was used for model confirmation through a second-order CFA model.

Demographic characteristics and health status of the participants

A total of 2,144 subjects completed the questionnaire, for a response rate of 44.67% from November 19, 2018, to January 25, 2019. Respondents who had seen at least two physicians in the previous 12 months were included in the analysis (N = 1,730) because this study aimed to explore patients’ experience of care coordination among multiple physicians. The basic characteristics of the target population, the total number of respondents to the survey (N = 2,144) and the number of respondents who had visited at least two physicians (n = 1,730) are shown in Supplementary Table 3. Table 1 shows the demographic characteristics and health status of the total respondents (n = 2,144) and the respondents who had visited at least two physicians (n = 1,730). Among the total respondents, 49.63% were male, the mean age was approximately 72 years old. Half of respondents (49.16%) had graduated from junior high school or higher, while approximately 11% of respondents had no formal education. With regard to health status, 22.81% of respondents reported that their health status was very poor or poor, and 40.58% of the respondents reported having two or more chronic conditions ( Table 1 ). Furthermore, we found no significant differences in demographic characteristics or health status measures between the total sample of respondents and those who had visited at least two physicians. However, slightly higher proportions of the respondents who had visited at least two physicians had a poor/very poor health status (24.86% vs. 22.81%) and had two or more chronic conditions (43.76% vs. 40.58%).

Item reduction: item analysis and PCA

Supplementary Table 1 shows the excluded items and the criteria applied for item reduction. After the item reduction process, we performed PCA and found that the sample data were adequate for PCA (with a KMO value = 0.82). The PCA generated five factors for the remaining items that explained 59.30% of the variance. However, we found that the two items “Does the doctor usually listen to you with patience?” and “Does this doctor respect your opinion during the diagnosis and treatment process?” both loaded onto the information continuity dimension and the interpersonal continuity dimension. Because the factor loadings of these two dimensions were nearly the same (0.46 and 0.45, respectively, for the former item; 0.41 and 0.40, respectively, for the latter item), the two items were both removed from the model (table not shown). In summary, there were 26 items in the original COCCCA questionnaire, and 10 items were deleted in the process of item analysis and PCA. Therefore, the final COCCCA instrument consisted of 16 items, with 10 items for the care continuity construct (2 items for longitudinal continuity; 4 items for information sharing continuity between patient and physician; 4 items for interpersonal continuity) and 6 items for the care coordination construct (3 items for information exchange between patient and physician and 3 items for communication and cooperation among multiple physicians).

Validity and reliability evaluation

Among the study subjects (n = 1,730), only those who responded to all 16 items in the COCCCA questionnaire were included in the validity and reliability analysis (n = 1523; 88.03%). Table 2 shows the mean and standard deviation of each item score, the item-total correlation coefficient, and the factor loading according to the five dimensions in the final version of the COCCCA questionnaire after the item reduction process. For the care continuity construct, the mean scores of the items in the dimensions of longitudinal, information transfer and interpersonal continuity ranged from 3.66 to 4.54. For the care coordination construct, the mean scores of the items in the dimensions of information exchange and communication/cooperation among multiple physicians ranged from 1.20 to 2.68.

The COCCCA core items: Descriptive results, internal consistency and PCA results (N = 1523).

COCCCA, Combined Outpatient Care Continuity and Coordination Assessment; PCA, principal component analysis; SD, standard deviation.

PCA and CFA results

We performed exploratory factor analysis by PCA on the final version of the COCCCA questionnaire with 16 items, and the sample data were adequate for PCA (KMO value = 0.80). The PCA generated five factors that explained 63.27% of the variance. We found that all of the factor loadings were larger than 0.4. The continuity-oriented dimensions included “interpersonal continuity” (factor 1), “information-sharing continuity” (factor 3), and “longitudinal continuity” (factor 5) between patients and their physicians. In addition, the coordination-oriented dimensions included “information exchange among multiple physicians” (factor 4) and “communication or cooperation among multiple physicians” (factor 2). The structure of the five factors was generally consistent with the a priori assumption and the results of the pilot study, and all of the items loaded onto the factors originally proposed for them ( Table 2 ). Figure 1 shows the second-order CFA model, which confirms the factor structure from the final version of the COCCCA questionnaire. The CFA model in the analysis shows an excellent fit to the data. The goodness-of-fit statistics were χ 2 = 425.423 (df = 98), RMSEA = 0.047, GFI = 0.949, TLI = 0.937 and SRMR = 0.041. In addition, the modest correlation between the two constructs of care continuity and care coordination (r = 0.468) indicated that care continuity and coordination are unique and distinct constructs.

Confirmatory factor analysis of care continuity and care coordination.

Criterion validity

Table 3 shows the association between the COCCCA items and the corresponding criterion-related measures. We found that the subjects who had a usual provider had significantly higher scores on all items of the three continuity dimensions. Similarly, we observed that the subjects who had experienced a lack of coordination tended to have lower scores on all of the items of the two coordination dimensions. Thus, the predictive validity of the care continuity and coordination construct was confirmed.

Relationship between COCCCA items and the corresponding criterion-related measures.

COCCCA, Combined Outpatient Care Continuity and Coordination Assessment; PCA, principal component analysis.

Reliability analyses

The Cronbach’s alpha coefficients ranged from 0.83 to 0.92 for the three dimensions of the care continuity construct and were 0.85 and 0.89 for the two dimensions of the care coordination construct. We found that the five dimensions of the COCCCA had acceptable internal consistency ( Table 2 ).

Results of sensitivity analyses

In the first sensitivity analysis, we found that there were no differences in the factor structures between the orthogonal varimax and direct oblimin or promax oblique rotated solutions (Supplementary Table 2). Second, we randomly selected 500 subjects (of 1523 respondents) for model building, including item analysis and PCA, and the remaining 1023 subjects were used for the CFA model. The results of these sensitivity analyses were similar to those of the original analyses (Supplementary Table 4 and Supplementary Figure 1).

This study aimed to differentiate the concepts of care continuity and care coordination by developing and testing the reliability and validity of the COCCCA questionnaire among subjects aged 60 years or older. This measurement tool appears to be a concise, reliable and valid instrument that can be applied to measure the multidimensional concept of both care continuity and care coordination from a patient perspective. In addition, the results indicated that distinct dimensions of care continuity and care coordination can be identified.

Strengths and limitations

The limitations of this study should be mentioned. First, the response rate to our survey was relatively low (44.67%); however, it was similar to those in other surveys on patient experience of care continuity or care coordination, which ranged from 22.5% to 48% [ 36 , 39 , 40 , 41 , 45 ], except the response rates reported by Uijen and colleagues in 2011 and 2012 of 72% and 76%, respectively [ 37 , 38 ]. In addition, there were slight differences in age and sex between the target population aged 60 years and above and the study sample, so generalizations should be made with caution. Second, patient experience measures of care continuity and care coordination might have been affected by patient preferences or health literacy, which were not considered in this study. Third, care coordination activities between physicians usually could not be observed by the patients, as has been noted by previous researchers [ 39 ]. Finally, the COCCCA instrument focused on care coordination among different physicians (or specialists) in the outpatient setting (or ambulatory care setting) only. Therefore, the COCCCA instrument might not be applicable across different settings, such as in hospitals or long-term care.

A strength of this study is that we used a nationwide representative random sample of older adults sampled via stratified multistage systematic sampling with PPS to develop the instrument. A number of instruments have been developed based mainly on specific groups of subjects recruited for the research, such as respondents invited by a limited number of general practitioners [ 36 , 37 , 38 , 39 , 40 ], subjects recruited in hospital outpatient departments [ 38 ] and subjects recruited in community health centers in certain geographic areas [ 45 ]. In other studies, patients have been recruited by random sampling in certain practice settings [ 36 , 40 , 45 ]. Therefore, the results from this study may be more representative than those from previous studies that were based on subjects who were recruited by health care providers or were recruited in limited geographic areas. In addition, existing instruments measuring care continuity or care coordination tended to include the other as part of the concept, thus treated as the subscales, and each instrument has individual features. The COCCCA instrument developed in this study measures both care continuity and care coordination as separate concepts and incorporates the corresponding dimensions under each concept.

Comparison with previous studies

In general, the findings of this study support the argument of previous researchers that both care continuity and care coordination are multidimensional concepts [ 16 , 18 , 19 ]. The COCCCA instrument consists of five dimensions from the patient’s perspective: three dimensions (longitudinal continuity, information sharing continuity and interpersonal relationship continuity between patients and physicians) under the care continuity construct and two dimensions (information exchange and communication/coordination among multiple physicians) under the care coordination construct.

Regarding the longitudinal dimension of care continuity, Saultz considered longitudinal continuity to be a dimension of care continuity [ 19 ]. However, Haggerty considered the longitudinal aspect to be not a dimension of care continuity but an intrinsic part of continuity [ 18 ]. In this study, we found that longitudinal continuity is one of the dimensions under the care continuity construct, which is consistent with other reports [ 41 , 57 ]. In addition, the majority of the existing instruments have included the aspects of interpersonal or relational continuity [ 28 , 36 , 37 , 38 , 39 , 40 ]. Previous researchers have argued that interpersonal continuity is the most important aspect of care continuity [ 19 , 20 ]. In this study, we found that the interpersonal dimension is highly correlated with the continuity construct compared with the longitudinal and information transfer dimensions.

Regarding the dimension of information transfer or exchange, in this study, we demonstrated that there are two types of information transfer [ 58 ], including information sharing between patients and their physicians under the care continuity construct and information exchange among multiple physicians under the care coordination construct. Information sharing between patients and their physicians has been identified in previous studies as relational continuity [ 40 ] or information continuity [ 39 , 40 , 59 ]. Notably, we considered the importance of patient engagement in care continuity [ 39 ] by incorporating the item “Does the doctor teach you how to take care of your medical conditions or treatment problems after you go home?” in the information dimension, which indicates that knowledge transferred from the physician might empower the patient’s self-care ability at home.

Information exchange among multiple physicians was identified as one dimension of care coordination in this study. Previous researchers have considered information transfer among physicians to be important in achieving care coordination [ 18 , 36 ] and several studies have included the dimension of information exchange between physicians [ 39 , 40 ]. In a health system without primary care physicians, such as that in Taiwan, we suggest that no physician is responsible for information transfer among physicians. Therefore, we developed a new item, “Do you actively tell the doctor about other physician visits you have elsewhere?,” which implies the importance of patient engagement in care coordination among multiple physicians. The inclusion of this item was supported by a previous study that revealed that patient engagement is associated with a lower likelihood of care coordination problems [ 60 ].

Finally, the dimension of communication/cooperation among physicians in this study is similar to the dimensions of managerial continuity [ 36 , 39 , 40 ], team and cross-boundary continuity [ 36 , 37 , 38 ] and care coordination [ 28 , 35 ]. The items in this dimension measure adequate communication or cooperation between physicians on behalf of the patient. Interestingly, compared to the dimensions of care continuity, the dimension of communication/cooperation among physicians has a negatively skewed distribution (with a mean value lower than 2). This may be because patients cannot easily observe physicians’ efforts to communicate or cooperate with other physicians. We believe that it would be valuable to measure the degree of care coordination on the basis of positive and negative items as well as from the perspectives of both patients and their physicians in future studies [ 45 ].

This study developed the COCCCA instrument for measuring care continuity and care coordination by using a nationwide representative sample of community-dwelling older adults. The COCCCA instrument differentiates the concepts of care continuity and care coordination, and it was demonstrated to be valid and reliable. The instrument reliably assesses care continuity and coordination simultaneously in outpatient care settings from a patient perspective. Future studies are recommended to examine the agreement of patient-reported and claim-based care continuity and care coordination measures by involving general population and employing advanced scoring instruments, and to investigate the effects of both types of measures on patient health outcomes.

Additional File

The additional file for this article can be found as follows:

Supplemental file.

Supplementary Tables 1 to 4 and Supplementary Figure 1.

Acknowledgements

The study was supported by grants from the Ministry of Science and Technology (MOST 103-2410-H-002-202-MY3; MOST 108-2410-H-030 -083 -SS3) and the National Health Research Institutes (NHRI-EX111-11001PI) in Taiwan. The funding source had no role in the study.

Funding Statement

Adelaide Belo, Senior Consultant of Internal Medicine, Coordinator of Integrated Care Program – Unidade Local de Saúde do Litoral Alentejano – Portugal and President of the Portuguese Association on Integrated Care.

Ye Fan Wang Glavin, PhD Clinical Faculty, School of Medicine, Case Western Reserve University, USA and Honorable Professor and Principal Advisor, Chinese Academy of Medical Sciences, Peking Union Medical College, China.

Competing Interests

The authors have no competing interests to declare.