methods of presentation delivery

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14.1 Four Methods of Delivery

Learning objectives.

• Differentiate among the four methods of speech delivery.
• Understand when to use each of the four methods of speech delivery.

Maryland GovPics – House of Ruth Luncheon – CC BY 2.0.

The easiest approach to speech delivery is not always the best. Substantial work goes into the careful preparation of an interesting and ethical message, so it is understandable that students may have the impulse to avoid “messing it up” by simply reading it word for word. But students who do this miss out on one of the major reasons for studying public speaking: to learn ways to “connect” with one’s audience and to increase one’s confidence in doing so. You already know how to read, and you already know how to talk. But public speaking is neither reading nor talking.

Speaking in public has more formality than talking. During a speech, you should present yourself professionally. This doesn’t mean you must wear a suit or “dress up” (unless your instructor asks you to), but it does mean making yourself presentable by being well groomed and wearing clean, appropriate clothes. It also means being prepared to use language correctly and appropriately for the audience and the topic, to make eye contact with your audience, and to look like you know your topic very well.

While speaking has more formality than talking, it has less formality than reading. Speaking allows for meaningful pauses, eye contact, small changes in word order, and vocal emphasis. Reading is a more or less exact replication of words on paper without the use of any nonverbal interpretation. Speaking, as you will realize if you think about excellent speakers you have seen and heard, provides a more animated message.

The next sections introduce four methods of delivery that can help you balance between too much and too little formality when giving a public speech.

Impromptu Speaking

Impromptu speaking is the presentation of a short message without advance preparation. Impromptu speeches often occur when someone is asked to “say a few words” or give a toast on a special occasion. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “Hi, my name is Steve, and I’m a volunteer with the Homes for the Brave program.” Another example of impromptu speaking occurs when you answer a question such as, “What did you think of the documentary?”

The advantage of this kind of speaking is that it’s spontaneous and responsive in an animated group context. The disadvantage is that the speaker is given little or no time to contemplate the central theme of his or her message. As a result, the message may be disorganized and difficult for listeners to follow.

Here is a step-by-step guide that may be useful if you are called upon to give an impromptu speech in public.

• Take a moment to collect your thoughts and plan the main point you want to make.
• Thank the person for inviting you to speak.
• Deliver your message, making your main point as briefly as you can while still covering it adequately and at a pace your listeners can follow.
• Thank the person again for the opportunity to speak.
• Stop talking.

As you can see, impromptu speeches are generally most successful when they are brief and focus on a single point.

Extemporaneous Speaking

Extemporaneous speaking is the presentation of a carefully planned and rehearsed speech, spoken in a conversational manner using brief notes. By using notes rather than a full manuscript, the extemporaneous speaker can establish and maintain eye contact with the audience and assess how well they are understanding the speech as it progresses. The opportunity to assess is also an opportunity to restate more clearly any idea or concept that the audience seems to have trouble grasping.

For instance, suppose you are speaking about workplace safety and you use the term “sleep deprivation.” If you notice your audience’s eyes glazing over, this might not be a result of their own sleep deprivation, but rather an indication of their uncertainty about what you mean. If this happens, you can add a short explanation; for example, “sleep deprivation is sleep loss serious enough to threaten one’s cognition, hand-to-eye coordination, judgment, and emotional health.” You might also (or instead) provide a concrete example to illustrate the idea. Then you can resume your message, having clarified an important concept.

Speaking extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and nonverbally. The disadvantage of extemporaneous speaking is that it requires a great deal of preparation for both the verbal and the nonverbal components of the speech. Adequate preparation cannot be achieved the day before you’re scheduled to speak.

Because extemporaneous speaking is the style used in the great majority of public speaking situations, most of the information in this chapter is targeted to this kind of speaking.

Speaking from a Manuscript

Manuscript speaking is the word-for-word iteration of a written message. In a manuscript speech, the speaker maintains his or her attention on the printed page except when using visual aids.

The advantage to reading from a manuscript is the exact repetition of original words. As we mentioned at the beginning of this chapter, in some circumstances this can be extremely important. For example, reading a statement about your organization’s legal responsibilities to customers may require that the original words be exact. In reading one word at a time, in order, the only errors would typically be mispronunciation of a word or stumbling over complex sentence structure.

However, there are costs involved in manuscript speaking. First, it’s typically an uninteresting way to present. Unless the speaker has rehearsed the reading as a complete performance animated with vocal expression and gestures (as poets do in a poetry slam and actors do in a reader’s theater), the presentation tends to be dull. Keeping one’s eyes glued to the script precludes eye contact with the audience. For this kind of “straight” manuscript speech to hold audience attention, the audience must be already interested in the message before the delivery begins.

It is worth noting that professional speakers, actors, news reporters, and politicians often read from an autocue device, such as a TelePrompTer, especially when appearing on television, where eye contact with the camera is crucial. With practice, a speaker can achieve a conversational tone and give the impression of speaking extemporaneously while using an autocue device. However, success in this medium depends on two factors: (1) the speaker is already an accomplished public speaker who has learned to use a conversational tone while delivering a prepared script, and (2) the speech is written in a style that sounds conversational.

Speaking from Memory

Memorized speaking is the rote recitation of a written message that the speaker has committed to memory. Actors, of course, recite from memory whenever they perform from a script in a stage play, television program, or movie scene. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker doesn’t want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses visual aids, this freedom is even more of an advantage. However, there are some real and potential costs. First, unless you also plan and memorize every vocal cue (the subtle but meaningful variations in speech delivery, which can include the use of pitch, tone, volume, and pace), gesture, and facial expression, your presentation will be flat and uninteresting, and even the most fascinating topic will suffer. You might end up speaking in a monotone or a sing-song repetitive delivery pattern. You might also present your speech in a rapid “machine-gun” style that fails to emphasize the most important points. Second, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. More frighteningly, if you go completely blank during the presentation, it will be extremely difficult to find your place and keep going.

Key Takeaways

• There are four main kinds of speech delivery: impromptu, extemporaneous, manuscript, and memorized.
• Impromptu speaking involves delivering a message on the spur of the moment, as when someone is asked to “say a few words.”
• Extemporaneous speaking consists of delivering a speech in a conversational fashion using notes. This is the style most speeches call for.
• Manuscript speaking consists of reading a fully scripted speech. It is useful when a message needs to be delivered in precise words.
• Memorized speaking consists of reciting a scripted speech from memory. Memorization allows the speaker to be free of notes.
• Find a short newspaper story. Read it out loud to a classroom partner. Then, using only one notecard, tell the classroom partner in your own words what the story said. Listen to your partner’s observations about the differences in your delivery.
• In a group of four or five students, ask each student to give a one-minute impromptu speech answering the question, “What is the most important personal quality for academic success?”
• Watch the evening news. Observe the differences between news anchors using a TelePrompTer and interviewees who are using no notes of any kind. What differences do you observe?

Stand up, Speak out Copyright © 2016 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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7.2 Methods of Presentation Delivery

Jordan Smith; Melissa Ashman; eCampusOntario; Brian Dunphy; Andrew Stracuzzi; and Linda Macdonald

The Importance of Delivery

Delivery is what you are probably most concerned about when it comes to giving presentations. This section is designed to help you give the best delivery possible and eliminate some of the nervousness you might be feeling. To do that, you should first dismiss the myth that presenting is just reading and talking at the same time. Presentations have more formality than talking. During a presentation, such as an oral report, you should project professionalism. This means meeting the expectations of your situation and audience. Start by being well groomed and wearing clean, appropriate clothes for the situation. Professionalism in speaking also means being prepared to use language correctly and appropriately for the audience and the topic, making eye contact with your audience, projecting confidence, and knowing your topic very well.

Methods of Presentation Delivery

There are four methods of delivery that can help you balance between too much and too little formality and memorization when giving a presentation.

Impromptu Speaking

Impromptu speaking is the presentation of a short message without advance preparation. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “Hi, my name is Jocelyn, and I’m an account manager.” Another example of impromptu presenting occurs when you answer a question such as, “What did you think of the report?” Your response has not been pre-planned, and you are constructing your arguments and points as you speak.

The advantage of this kind of speaking is that it is spontaneous and responsive in a group context. The disadvantage is that the speaker is given little or no time to think of the central theme of their message. As a result, the message may be disorganized and difficult for listeners to follow.

This step-by-step guide may be useful if you are called upon to give an impromptu presentation in public:

• Take a moment to collect your thoughts and plan the main point you want to make. You might write a few keywords on a notepad if you have one near.
• Thank the person for inviting you to speak. Avoid making comments about being unprepared, called upon at the last moment, on the spot, or feeling uneasy.
• Deliver your message, making your main point as briefly as you can while still covering it adequately and at a pace your listeners can follow.
• If you can use a structure, using numbers if possible: “Two main reasons . . .” or “Three parts of our plan. . .” or “Two side effects of this drug. . .” Timeline structures are also effective, such as “past, present, and future” or “East Coast, Midwest, and West Coast”.
• Thank the person again for the opportunity to speak.
• Stop talking (it is easy to “ramble on” when you do not have something prepared). If in front of an audience, do not keep talking as you move back to your seat.

Impromptu presentations are generally most successful when they are brief and focus on a single point.

For additional advice on impromptu speaking, watch the following 4-minute video from Toastmasters: Impromptu Speaking :

(Direct link to Toastmasters Impromptu Speaking )

Manuscript Presentations

Manuscript presentations  are the word-for-word iteration of a written message . The advantage of reading from a manuscript is the exact repetition of original words. In some circumstances, this exact wording can be extremely important. For example, reading a statement about your organization’s legal responsibilities to customers may require that the original words be exact. Acceptable uses of a manuscript include

• Highly formal occasions (e.g. a commencement speech)
• Particularly emotional speeches (e.g. a wedding speech, a eulogy)
• Situations in which word-for-word reading is required (e.g. a speech written by someone else; a corporate statement; a political speech)
• Within a larger speech, the reading of a passage from another work (e.g. a poem; a book excerpt).

Manuscript presentations, however, have a significant disadvantage: Your connection with the audience may be affected. Eye contact, so important for establishing credibility and relationship, may be limited by reading, your use of gestures will be limited if you are holding a manuscript, and a handheld manuscript itself might appear as a barrier between you and the audience. In addition, it is difficult to change language or content in response to unpredictable audience reactions. Reading a manuscript is not as easy as one might think. Keeping your place in a manuscript is difficult and most of us will sound monotone.

• Write the speech in a conversational style, and
• Practice your speech so that it flows naturally.

Preparation will make the presentation more engaging and enhance your credibility:

• Select and edit material so that it fits within your time limit;
• Select material that will be meaningful for your particular audience;
• Know the material well so that you can look up at your audience and back at the manuscript without losing your place; and
• Identify keywords for emphasis.

An essential part of preparation is preparing your manuscript. The following suggestions are adapted from the University of Hawai’i Maui Community College Speech Department:

• Use a full 8.5 x 11inch sheet of paper, not notecards.
• Use only one side of the page.
• Include page numbers.
• Use double or triple line spacing.
• Use a minimum of 16 pt. font size.
• Avoid overly long or complex sentences.
• Use bold or highlight the first word of each sentence, as illustrated by the University of Hawai’i.

• Add notations—“slow down,” “pause,” “look up,” underline keywords, etc. as reminders about delivery.
• Highlight words that should be emphasized.
• Add notes about pronunciation.
• Include notations about time, indicating where you should be at each minute marker.

To deliver the speech effectively, make sure you are comfortable with the manuscript delivery style. To engage your audience,

• Practice your presentation.
• Try to avoid reading in a monotone. Just as contrast is important for document design, contrast is important in speaking. Vary your volume, pace, tone, and gestures.
• Make sure that you can be clearly understood. Speak loud enough that the back of the room can hear you, pronounce each word clearly, and try not to read too fast.
• Maintain good eye contact with your audience. Look down to read and up to speak.
• Match gestures to the content of the speech, and avoid distracting hand or foot movements.
• If there is no podium, hold the manuscript at waist height.

Memorized Speaking

Memorized speakin g is the recitation of a written message that the speaker has committed to memory. Actors , of course, recite from memory whenever they perform from a script in a stage play, television program, or movie scene. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker does not want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses visual aids, this freedom is even more of an advantage. However, there are some real and potential costs.

First, unless you also plan and memorize every vocal cue (the subtle but meaningful variations in speech delivery, which can include the use of pitch, tone, volume, and pace), gesture, and facial expression, your presentation will be flat and uninteresting, and even the most fascinating topic will suffer and you will not effectively engage your audience. (Manuscript speaking often suffers the same fate.) Second, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. More frighteningly, if you go completely blank during the presentation, it will be extremely difficult to find your place and keep going. Memorizing a presentation takes a great deal of time and effort to achieve a natural flow and conversational tone.

Extemporaneous Presentations

The extemporaneous speaking style benefits from the flexibility and naturalness that comes with impromptu speaking as well as the benefits of well-developed content and organization that comes with manuscript or memorized speaking. This presentation delivery style maximizes all of the benefits of the various presentation styles while minimizing their challenges.

Extemporaneous presentations are carefully planned and rehearsed presentations, delivered in a conversational manner using brief notes or a slide deck . By using notes rather than a full manuscript, the extemporaneous presenter can establish and maintain eye contact with the audience and assess how well they are understanding the presentation as it progresses.

To avoid over-reliance on notes or slides, you should have a strong command of your subject matter.  Then select an organizational pattern that works well for your topic. Your notes or slide deck should reflect this organizational pattern. In preparation, create an outline of your speech.

Watch some of the following 10-minute videos of a champion speaker presenting an extemporaneous speech at the 2017 International Extemporaneous Speaking National Champion. :

(Direct link to 2017 International Extemporaneous Speaking National Champion video)

Presenting extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible since you know the speech well  enough that you do not need to read it. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and non-verbally. It also allows flexibility; you are working from the strong foundation of an outline, but if you need to delete, add, or rephrase something at the last minute or to adapt to your audience, you can do so.

Adequate preparation cannot be achieved the day before you are scheduled to present, so be aware that if you want to present a credibly delivered speech, you will need to practice many times. Extemporaneous presenting is the style used in the great majority of business presentation situations.

7.2 Methods of Presentation Delivery Copyright © 2022 by Jordan Smith; Melissa Ashman; eCampusOntario; Brian Dunphy; Andrew Stracuzzi; and Linda Macdonald is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Complete Guide for Effective Presentations, with Examples

July 9, 2018 - Dom Barnard

During a presentation you aim to look confident, enthusiastic and natural. You’ll need more than good words and content to achieve this – your delivery plays a significant part. In this article, we discuss various techniques that can be used to deliver an effective presentation.

Effective presentations

Think about if you were in the audience, what would:

• Get you to focus and listen
• Make you understand
• Activate your imagination
• Persuade you

Providing the audience with interesting information is not enough to achieve these aims – you need to ensure that the way you present is stimulating and engaging. If it’s not, you’ll lose the audience’s interest and they’ll stop listening.

Tips for an Effective Presentation

Professional public speakers spend hours creating and practicing presentations. These are the delivery techniques they consider:

Keep it simple

You shouldn’t overwhelm your audience with information – ensure that you’re clear, concise and that you get to the point so they can understand your message.

Have a maximum of  three main points  and state them at the beginning, before you explain them in more depth, and then state them at the end so the audience will at least remember these points.

If some of your content doesn’t contribute to your key message then cut it out. Also avoid using too many statistics and technical terminology.

Connect with your audience

One of the greatest difficulties when delivering a presentation is connecting with the audience. If you don’t  connect with them  it will seem as though you’re talking to an empty room.

Trying to make contact with the audience makes them feel like they’re part of the presentation which encourages them to listen and it shows that you want to speak to them.

Eye contact and smile

Avoiding eye contact is uncomfortable because it make you look insecure. When you  maintain eye contact  the audience feels like you’re speaking to them personally. If this is something you struggle with, try looking at people’s foreheads as it gives the impression of making eye contact.

Try to cover all sections of the audience and don’t move on to the next person too quickly as you will look nervous.

Smiling also helps with rapport and it reduces your nerves because you’ll feel less like you’re talking to group of faceless people. Make sure you don’t turn the lights down too much before your presentation so you can all clearly see each other.

Body language

Be aware of your body language and use it to connect:

• Keep your arms uncrossed so your  body language is more open .
• Match your facial expressions with what you’re saying.
• Avoid fidgeting and displaying nervous habits, such as, rocking on your feet.
• You may need to glance at the computer slide or a visual aid but make sure you predominantly face the audience.
• Emphasise points by using hand gestures but use them sparingly – too little and they’ll awkwardly sit at your side, too much and you’ll be distracting and look nervous.
• Vary your gestures so you don’t look robotic.
• Maintain a straight posture.
• Be aware of  cultural differences .

Move around

Avoid standing behind the lectern or computer because you need to reduce the distance and barriers between yourself and the audience.  Use movement  to increase the audience’s interest and make it easier to follow your presentation.

A common technique for incorporating movement into your presentation is to:

• Start your introduction by standing in the centre of the stage.
• For your first point you stand on the left side of the stage.
• You discuss your second point from the centre again.
• You stand on the right side of the stage for your third point.
• The conclusion occurs in the centre.

Watch 3 examples of good and bad movement while presenting

Example: Movement while presenting

Your movement at the front of the class and amongst the listeners can help with engagement. Think about which of these three speakers maintains the attention of their audience for longer, and what they are doing differently to each other.

Speak with the audience

You can conduct polls using your audience or ask questions to make them think and feel invested in your presentation. There are three different types of questions:

Direct questions require an answer: “What would you do in this situation?” These are mentally stimulating for the audience. You can pass a microphone around and let the audience come to your desired solution.

Rhetorical questions  do not require answers, they are often used to emphasises an idea or point: “Is the Pope catholic?

Loaded questions contain an unjustified assumption made to prompt the audience into providing a particular answer which you can then correct to support your point: You may ask “Why does your wonderful company have such a low incidence of mental health problems?” The audience will generally answer that they’re happy.

After receiving the answers you could then say “Actually it’s because people are still unwilling and too embarrassed to seek help for mental health issues at work etc.”

Be specific with your language

Make the audience feel as though you are speaking to each member individually by using “you” and “your.”

For example: asking “Do you want to lose weight without feeling hungry?” would be more effective than asking “Does anyone here want to lost weight without feeling hungry?” when delivering your presentation. You can also increase solidarity by using “we”, “us” etc – it makes the audience think “we’re in this together”.

Be flexible

Be prepared to adapt to the situation at the time, for example, if the audience seems bored you can omit details and go through the material faster, if they are confused then you will need to come up with more examples on the spot for clarification. This doesn’t mean that you weren’t prepared because you can’t predict everything.

Vocal variety

How you say something is just as is important as the content of your speech – arguably, more so.

For example, if an individual presented on a topic very enthusiastically the audience would probably enjoy this compared to someone who covered more points but mumbled into their notes.

• Adapt your voice  depending on what are you’re saying – if you want to highlight something then raise your voice or lower it for intensity. Communicate emotion by using your voice.
• Avoid speaking in monotone as you will look uninterested and the audience will lose interest.
• Take time to pronounce every word carefully.
• Raise your pitch when asking questions and lower it when you want to sound severe.
• Sound enthusiastic – the more you sound like you care about the topic, the more the audience will listen. Smiling and pace can help with this.
• Speak loudly and clearly – think about projecting your voice to the back of the room.
• Speak at a  pace that’s easy to follow . If you’re too fast or too slow it will be difficult for the audience to understand what you’re saying and it’s also frustrating. Subtly fasten the pace to show enthusiasm and slow down for emphasis, thoughtfulness or caution.

Prior to the presentation, ensure that you  prepare your vocal chords :

• You could read aloud a book that requires vocal variety, such as, a children’s book.
• Avoid dairy and eating or drinking anything too sugary beforehand as mucus can build-up leading to frequent throat clearing.
• Don’t drink anything too cold before you present as this can constrict your throat which affects vocal quality.
• Some people suggest a warm cup of tea beforehand to relax the throat.

Practice Presentation Skills

Improve your public speaking and presentation skills by practicing them in realistic environments, with automated feedback on performance. Learn More

Pause to breathe

When you’re anxious your breathing will become quick and shallow which will affect the control you have on your voice. This can consequently make you feel more nervous. You want to breathe steadily and deeply so before you start speaking take some deep breaths or implement controlled breathing.

Controlled breathing is a common technique that helps slow down your breathing to normal thus reducing your anxiety. If you think this may be useful practice with these steps:

• Sit down in an upright position as it easier for your lungs to fill with air
• Breathe in through your nose and into your abdomen for four seconds
• Hold this breathe for two seconds
• Breathe out through your nose for six seconds
• Wait a few seconds before inhaling and repeating the cycle

It takes practice to master this technique but once you get used to it you may want to implement it directly before your presentation.

Completely filling your lungs during a pause will ensure you reach a greater vocal range.

During the presentation delivery, if you notice that you’re speaking too quickly then pause and breathe. This won’t look strange – it will appear as though you’re giving thought to what you’re saying. You can also strategically plan some of your pauses, such as after questions and at the end of sections, because this will give you a chance to calm down and it will also give the audience an opportunity to think and reflect.

Pausing will also help you  avoid filler words , such as, “um” as well which can make you sound unsure.

• 10 Effective Ways to use Pauses in your Speech

Strong opening

The first five minutes are  vital to engage the audience  and get them listening to you. You could start with a story to highlight why your topic is significant.

For example, if the topic is on the benefits of pets on physical and psychological health, you could present a story or a study about an individual whose quality of life significantly improved after being given a dog. The audience is more likely to respond better to this and remember this story than a list of facts.

Example: Which presentation intro keeps you engaged?

Watch 5 different presentation introductions, from both virtual and in-person events. Notice how it can only take a few seconds to decide if you want to keep listening or switch off. For the good introductions, what about them keeps you engaged?

More experienced and confident public speakers use humour in their presentations. The audience will be incredibly engaged if you make them laugh but caution must be exercised when using humour because a joke can be misinterpreted and even offend the audience.

Only use jokes if you’re confident with this technique, it has been successful in the past and it’s suitable for the situation.

Stories and anecdotes

Use stories whenever you can and judge whether you can tell a story about yourself because the audience are even more interested in seeing the human side of you.

Consider telling a story about a mistake you made, for example, perhaps you froze up during an important presentation when you were 25, or maybe life wasn’t going well for you in the past – if relevant to your presentation’s aim. People will relate to this as we have all experienced mistakes and failures. The more the audience relates to you, the more likely they will remain engaged.

These stories can also be  told in a humorous way  if it makes you feel more comfortable and because you’re disclosing a personal story there is less chance of misinterpretation compared to telling a joke.

Anecdotes are especially valuable for your introduction and between different sections of the presentation because they engage the audience. Ensure that you plan the stories thoroughly beforehand and that they are not too long.

Focus on the audience’s needs

Even though your aim is to persuade the audience, they must also get something helpful from the presentation. Provide the audience with value by giving them useful information, tactics, tips etc. They’re more likely to warm to you and trust you if you’re sharing valuable information with them.

You could also highlight their pain point. For example, you might ask “Have you found it difficult to stick to a healthy diet?” The audience will now want to remain engaged because they want to know the solution and the opportunities that you’re offering.

Use visual aids

Visual aids are items of a visual manner, such as graphs, photographs, video clips etc used in addition to spoken information. Visual aids are chosen depending on their purpose, for example, you may want to:

• Summarise information.
• Reduce the amount of spoken words, for example, you may show a graph of your results rather than reading them out.
• Clarify and show examples.
• Create more of an impact. You must consider what type of impact you want to make beforehand – do you want the audience to be sad, happy, angry etc?
• Emphasise what you’re saying.
• Make a point memorable.
• Enhance your credibility.
• Engage the audience and maintain their interest.
• Make something easier for the audience to understand.

Some general tips for  using visual aids :

• Think about how can a visual aid can support your message. What do you want the audience to do?
• Ensure that your visual aid follows what you’re saying or this will confuse the audience.
• Avoid cluttering the image as it may look messy and unclear.
• Visual aids must be clear, concise and of a high quality.
• Keep the style consistent, such as, the same font, colours, positions etc
• Use graphs and charts to present data.
• The audience should not be trying to read and listen at the same time – use visual aids to highlight your points.
• One message per visual aid, for example, on a slide there should only be one key point.
• Use visual aids in moderation – they are additions meant to emphasise and support main points.
• Ensure that your presentation still works without your visual aids in case of technical problems.

10-20-30 slideshow rule

Slideshows are widely used for presentations because it’s easy to create attractive and professional presentations using them. Guy Kawasaki, an entrepreneur and author, suggests that slideshows should  follow a 10-20-30 rule :

• There should be a maximum of 10 slides – people rarely remember more than one concept afterwards so there’s no point overwhelming them with unnecessary information.
• The presentation should last no longer than 20 minutes as this will leave time for questions and discussion.
• The font size should be a minimum of 30pt because the audience reads faster than you talk so less information on the slides means that there is less chance of the audience being distracted.

If you want to give the audience more information you can provide them with partially completed handouts or give them the handouts after you’ve delivered the presentation.

Keep a drink nearby

Have something to drink when you’re on stage, preferably water at room temperature. This will help maintain your vocal quality and having a sip is a subtle way of introducing pauses.

Practice, practice, practice

If you are very familiar with the content of your presentation, your audience will perceive you as confident and you’ll be more persuasive.

• Don’t just read the presentation through – practice everything,  including your transitions  and using your visual aids.
• Stand up and speak it aloud, in an engaging manner, as though you were presenting to an audience.
• Ensure that you practice your body language and gesturing.
• Use VR to  practice in a realistic environment .
• Practice in front of others and get their feedback.
• Freely improvise so you’ll sound more natural on the day. Don’t learn your presentation verbatim because you will sound uninterested and if you lose focus then you may forget everything.
• Create cards to use as cues – one card should be used for one key idea. Write down brief notes or key words and ensure that the cards are physically connected so the order cannot be lost. Visual prompts can also be used as cues.

This video shows how you can practice presentations in virtual reality. See our  VR training courses .

Two courses where you can practice your presentations in interactive exercises:

• Essential Public Speaking
• How to Present over Video

Try these different presentation delivery methods to see which ones you prefer and which need to be improved. The most important factor is to feel comfortable during the presentation as the delivery is likely to be better.

Remember that the audience are generally on your side – they want you to do well so present with confidence.

Module 6: Organizing and Outlining Your Speech

Methods of speech delivery, learning objectives.

Identify the four types of speech delivery methods and when to use them.

There are four basic methods of speech delivery: manuscript, memorized, impromptu, and extemporaneous. We’ll look at each method and discuss the advantages and disadvantages of each.

A manuscript page from President George W. Bush’s address to the nation on the day of the 9/11 attacks in 2001.

A manuscript speech is when the speaker writes down every word they will speak during the speech. When they deliver the speech, they have each word planned and in front of them on the page, much like a newscaster who reads from a teleprompter.

The advantage of using a manuscript is that the speaker has access to every word they’ve prepared in advance. There is no guesswork or memorization needed. This method comforts some speakers’ nerves as they don’t have to worry about that moment where they might freeze and forget what they’ve planned to say. They also are able to make exact quotes from their source material.

When the exact wording of an idea is crucial, speakers often read from a manuscript, for instance in communicating public statements from a company.

However, the disadvantage with a manuscript is that the speakers have MANY words in front of them on the page. This prohibits one of the most important aspects of delivery, eye contact. When many words are on the page, the speakers will find themselves looking down at those words more frequently because they will need the help. If they do look up at the audience, they often cannot find their place when the eye returns to the page. Also, when nerves come into play, speakers with manuscripts often default to reading from the page and forget that they are not making eye contact or engaging their audience. Therefore, manuscript is a very difficult delivery method and not ideal.  Above all, the speakers should remember to rehearse with the script so that they practice looking up often.

Public Speaking in History

The fall of the Berlin Wall on November 9, 1989, owed in large part to a momentary error made by an East German government spokesperson. At a live press conference, Günter Schabowski tried to explain new rules relaxing East Germany’s severe travel restrictions. A reporter asked, “when do these new rules go into effect?” Visibly flustered, Schabowski said, “As far as I know, it takes effect immediately, without delay.” In fact, the new visa application procedure was supposed to begin the following day, and with a lot of bureaucracy and red tape. Instead, thousands of East Berliners arrived within minutes at the border crossings, demanding to pass through immediately. The rest is history.

The outcome of this particular public-relations blunder was welcomed by the vast majority of East and West German citizens, and hastened the collapse of communism in Eastern and Central Europe. It’s probably good, then, that Schabowski ran this particular press conference extemporaneously, rather than reading from a manuscript.

You can view the transcript for “The mistake that toppled the Berlin Wall” here (opens in new window) .

A memorized speech is also fully prepared in advance and one in which the speaker does not use any notes. In the case of an occasion speech like a quick toast, a brief dedication, or a short eulogy, word-for-word memorization might make sense. Usually, though, it doesn’t involve committing each and every word to memory, Memorizing a speech isn’t like memorizing a poem where you need to remember every word exactly as written. Don’t memorize a manuscript! Work with your outline instead. Practice with the outline until you can recall the content and order of your main points without effort. Then it’s just a matter of practicing until you’re able to elaborate on your key points in a natural and seamless manner. Ideally, a memorized speech will sound like an off-the-cuff statement by someone who is a really eloquent speaker and an exceptionally organized thinker!

The advantage of a memorized speech is that the speaker can fully face their audience and make lots of eye contact. The problem with a memorized speech is that speakers may get nervous and forget the parts they’ve memorized. Without any notes to lean on, the speaker may hesitate and leave lots of dead air in the room while trying to recall what was planned. Sometimes, the speaker can’t remember or find his or her place in the speech and are forced to go get the notes or go back to the PowerPoint in some capacity to try to trigger his or her memory. This can be an embarrassing and uncomfortable moment for the speaker and the audience, and is a moment which could be easily avoided by using a different speaking method.

How to: memorize a speech

There are lots of tips out there about how to memorize speeches. Here’s one that loosely follows an ancient memorization strategy called the method of loci or “memory palace,” which uses visualizations of familiar spatial environments in order to enhance the recall of information.

You can view the transcript for “How to Memorize a Speech” here (opens in new window) .

An impromptu speech is one for which there is little to no preparation. There is often not a warning even that the person may be asked to speak. For example, your speech teacher may ask you to deliver a speech on your worst pet peeve. You may or may not be given a few minutes to organize your thoughts. What should you do? DO NOT PANIC. Even under pressure, you can create a basic speech that follows the formula of an introduction, body, and conclusion. If you have a few minutes, jot down some notes that fit into each part of the speech. (In fact, the phrase “speaking off the cuff,” which means speaking without preparation, probably refers to the idea that one would jot a few notes on one’s shirt cuff before speaking impromptu.) [1] ) An introduction should include an attention getter, introduction of the topic, speaker credibility, and forecasting of main points. The body should have two or three main points. The conclusion should have a summary, call to action, and final thought. If you can organize your thoughts into those three parts, you will sound like a polished speaker. Even if you only hit two of them, it will still help you to think about the speech in those parts. For example, if a speech is being given on a pet peeve of chewed gum being left under desks in classrooms, it might be organized like this.

• Introduction : Speaker chews gum loudly and then puts it under a desk (attention getter, demonstration). Speaker introduces themselves and the topic and why they’re qualified to speak on it (topic introduction and credibility). “I’m Katie Smith and I’ve been a student at this school for three years and witnessed this gum problem the entire time.”
• Body : Speaker states three main points of why we shouldn’t leave gum on desks: it’s rude, it makes custodians have to work harder, it affects the next student who gets nastiness on their seat (forecast of order). Speaker then discusses those three points
• Conclusion : Speaker summarizes those three points (summary, part 1 of conclusion), calls on the audience to pledge to never do this again (call to action), and gives a quote from Michael Jordan about respecting property (final thought).

While an impromptu speech can be challenging, the advantage is that it can also be thrilling as the speaker thinks off the cuff and says what they’re most passionate about in the moment. A speaker should not be afraid to use notes during an impromptu speech if they were given any time to organize their thoughts.

The disadvantage is that there is no time for preparation, so finding research to support claims such as quotes or facts cannot be included. The lack of preparation makes some speakers more nervous and they may struggle to engage the audience due to their nerves.

Extemporaneous

The last method of delivery we’ll look at is extemporaneous. When speaking extemporaneously, speakers prepare some notes in advance that help trigger their memory of what they planned to say. These notes are often placed on notecards. A 4”x6” notecard or 5”x7” size card works well. This size of notecards can be purchased at any office supply store. Speakers should determine what needs to go on each card by reading through their speech notes and giving themselves phrases to say out loud. These notes are not full sentences, but help the speakers, who turn them into a full sentence when spoken aloud. Note that if a quote is being used, listing that quote verbatim is fine.

The advantage of extemporaneous speaking is that the speakers are able to speak in a more conversational tone by letting the cards guide them, but not dictate every word they say. This method allows for the speakers to make more eye contact with the audience. The shorter note forms also prevent speakers from getting lost in their words. Numbering these cards also helps if one gets out of order. Also, these notes are not ones the teacher sees or collects. While you may be required to turn in your speech outline, your extemporaneous notecards are not seen by anyone but you. Therefore, you can also write yourself notes to speak up, slow down, emphasize a point, go to the next slide, etc.

The disadvantage to extemporaneous is the speakers may forget what else was planned to say or find a card to be out of order. This problem can be avoided through rehearsal and double-checking the note order before speaking.

Many speakers consider the extemporaneous method to be the ideal speaking method because it allows them to be prepared, keeps the audience engaged, and makes the speakers more natural in their delivery. In your public speaking class, most of your speeches will probably be delivered extemporaneously.

• As per the Oxford English Dictionary' s entry for "Off the Cuff." See an extensive discussion at Mark Liberman's Language Log here: https://languagelog.ldc.upenn.edu/nll/?p=4130 ↵
• Method of loci definition. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Method_of_loci . License : CC BY-SA: Attribution-ShareAlike
• The mistake that toppled the Berlin Wall. Provided by : Vox. Located at : https://youtu.be/Mn4VDwaV-oo . License : Other . License Terms : Standard YouTube License
• How to Memorize a Speech. Authored by : Memorize Academy. Located at : https://youtu.be/rvBw__VNrsc . License : Other . License Terms : Standard YouTube License
• Address to the Nation. Provided by : U.S. National Archives. Located at : https://prologue.blogs.archives.gov/2011/09/06/911-an-address-to-the-nation/ . License : Public Domain: No Known Copyright
• Methods of Speech Delivery. Authored by : Misti Wills with Lumen Learning. License : CC BY: Attribution

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12.2: Methods of Delivery

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• Victor Capecce@Millersville University
• Millersville University via Public Speaking Project

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There are four basic methods(sometimes called styles) of presenting a speech: manuscript, memorized, extemporaneous, and impromptu. Each has a variety of uses in various forums of communication.

manuscript style

The word manuscript is the clue to the style. The speech is written and the speaker reads it word for word to the audience. Originally, it was done from the hand-written paper manuscript. Today the manuscript style is common, but the paper is gone. Who reads the speech to the audience? Answer: Newscasters and television personalities. In the old days, the manuscript was hand-lettered on cue cards, which were held next to the camera lens. Then paper scrolls, like printed piano rolls were used, especially in Soap Operas. Today, a special teleprompter (working like a periscope) is attached to the camera so the newscaster is looking at the lens while reading.

Why is the manuscript important and in use? Precision. In the news- reporting industry, every fraction of a second counts because broadcast time is costly. Also, the facts and names must be exact and accurate so there is no room for error. Errors in reporting decrease the credibility of the news organization and the newscaster.

The most regular use of the teleprompter for manuscript delivery is by the U.S. President. In fact, the teleprompter, used by every President since Reagan, is called a “Presidential Teleprompter.” It is made of two pieces of glass, each flanking the podium. They reflect the text from a monitor on the floor like a periscope. The glass on both sides has the same text, and the speaker looks alternately from one glass to the other as though looking at the audience through the glass. The audience cannot see the projected text. The speeches a President gives will often reflect national policy, define international relationships, and the press will scrutinize every syllable. It has to be more than brilliantly accurate; it has to be impeccably phased. Professional writers and policy experts compose the speech; and the President delivers it as though he not only wrote it, but made it up on the spot. That is the skill of a good politician, actor, or speaker. Those who are not skilled using a teleprompter or manuscript will sound stilted and boring.

memorized style

The memorized style of speaking is when the manuscript is committed to memory and recited to the audience verbatim (word for word). In the days when elocution was taught, this was a typical approach. A speech was a recitation. The Optimists Club (a national organization) used to have a “Oratory” contest for high school students. Contestants wrote essays on a given theme, to create a speech at a specific time length (e.g.: three minutes). The essay was memorized and the delivery was judged by 1) the quality of the writing, 2) the accuracy with which it was recited; and 3) the precise length of time. Such contests seem archaic by today’s more casual and somewhat less formal standards.

Where is a memorized delivery style still common? Due to copyright laws and licensing contract agreements (other than scripts that are in the public domain), actors on stage are obligated to memorize the script of the play and perform it verbatim exactly as written. It is typical for speakers on high school and university speech and debate teams to memorize their competitive speeches. Corporate conventions often use large LCD monitors on the front of the stage as teleprompters. This allows the speaker to move more freely across the stage while sticking to his or her script. Some monologists (such as the stand-up comics mentioned at the start of the chapter) also use a memorized delivery style. In all cases, they create the impression that the speech is using the memorized delivery style if your speech is relatively short, or you know you will have to deliver your speech repeatedly such as a tour operator would.

Try This! Manuscript Delivery

Watch the local or national 6 p.m., 11 p.m. and 6 a.m. newscasts on the same T.V. station. Make notes on which news items repeat and how closely, or exactly, the phrasing is, even if different personalities are presenting the same item.

impromptu style

Theoretically, an “impromptu” speech is “made up on the spot.” It is unprepared and unrehearsed. Often ceremonial toasts, grace before meals, an acknowledgement, an introduction, offering thanks and so on, fall into this category. While there are some occasions when a speech in those categories is actually prepared (prepare your acceptance for the Academy Award BEFORE you are called!), there are many occasions when there is little or no opportunity to prepare.

Impromptu speeches are generally short and are often given with little or no notice. Notes are rare and the speaker generally looks directly at the audience. It would be presumptuous and arrogant to declare rules for Impromptu Speaking. It is fair to explain that “impromptu” describes a range from absolutely no preparation, to a modest amount of preparation (mostly thought) and rarely incorporates research or the formalities of outlines and citations that more formal speeches would include.

Be still when you have nothing to say; when genuine passion moves you, say what you've got to say, and say it hot. ~ D. H. Lawrence

An indelibly memorable example occurred to me when my siblings threw a surprise 10\(^{th}\) anniversary party for my Mom (Margaret) and our stepdad (Lidio). It was the third marriage for both of them, and they were in their 60’s. As soon as the yells of “surprise” subsided, Lidio picked up his wine glass and proposed a toast:

“I can’t believe this surprise! I don’t know what to say... um, Dino [his brother] when was that Yankee game Dad took us to when we were kids? It was 4\(^{th}\) of July, wasn’t it? 1939? And it was like it was yesterday; and today reminds me of that day, when Lou Gehrig came out to the mound. He was slow, but we were all cheering the ‘Pride of the Yankees.’ He wasn’t playing anymore, he was too sick, but he looked around the crowd, and said ‘I’m the luckiest man alive.’ That’s how I feel with you all here today; to celebrate our 10\(^{th}\) anniversary. I’m here with you and with Margaret; and I’m the luckiest man alive.”

The speech was short, emotionally charged, wonderfully articulate, and absolutely unprepared. The speech had one central emotionally charged message; simple, in words and phrasing, but complex by bringing an image of great sentimentality to the occasion. He was able to react to the moment, and speak “from the heart.”

In contrast, legendary magician Harry Houdini was often asked to perform for the amusement of his fellow passengers when sailing to Europe. I always associate “impromptu” with the stories of Houdini’s shipboard conjuring. Nothing was further from “impromptu.” The skill of the great magician was in making his illusions seem spontaneous with what appeared to be ordinary items that “happened” to be on hand. Houdini spent endless hours planning and rehearsing. The true illusion was that they “appeared” to be impromptu.

Take advantage of every opportunity to practice your communication skills so that when important occasions arise, you will have the gift, the style, the sharpness, the clarity, and the emotions to affect other people.~ Jim Rohn

extemporaneous style

Sandwiched between the memorized and impromptu delivery styles you find the extemporaneous speech style. For this style, the speech is not completely written out. It is usually delivered with keynotes for reference. Most public speaking courses and books describe extemporaneous speeches as carefully prepared and rehearsed, but delivered using notes of key words and phrases to support the speaker. Phrasing is pre- rehearsed, words are pre-chosen, and the organization is fluid and well constructed. There should be no fumbling for words, no rambling, and length of time should be carefully monitored. The style does offer the speaker flexibility to include references to the immediate surroundings, previous speeches, news of the day, and so on.

The trouble with talking too fast is you may say something you haven't thought of yet." ~ Ann Landers

How you develops the notes and what they look like are up to the individual, but a natural extemporaneous delivery is difficult if you are relying on a manuscript. Under no circumstances should the speaker be spending more than 20% of the speaking time looking at the notes. It would be ideal to practice so you only glance at your notes approximately 5% of the time of the speech.

Those who have limited experience in formal speaking find it helpful to write out the speech as though it were an essay, then read it, edit it, then create speaking notes from the text. This helps with editing and with thinking through the phrases. This process of public speaking was taught decades ago to my contemporaries and me and has fallen out of fashion. But it is a useful way of thoroughly thinking through the speech. If this procedure is used, it is advisable to rehearse the speech with the notes without the essay prior to delivering the speech. But be warned: having the fully written essay at the podium might detract from the delivery.

The extemporaneous style is the method most often recommended (and often required) in today’s public speaking courses, and is generally the best method in other settings as well. While it is not the only method of delivering a speech, it is the most useful for presentations in other courses, in the corporate world and in pursuing future careers.

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10.2 Methods of Presentation Delivery

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The Importance of Delivery

Delivery is what you are probably most concerned about when it comes to giving presentations. This chapter is designed to help you give the best delivery possible and eliminate some of the nervousness you might be feeling. To do that, you should first dismiss the myth that public speaking is just reading and talking at the same time. Speaking in public has more formality than talking. During a speech, you should present yourself professionally. This doesn’t necessarily mean you must wear a suit or “dress up”, but it does mean making yourself presentable by being well groomed and wearing clean, appropriate clothes. It also means being prepared to use language correctly and appropriately for the audience and the topic, to make eye contact with your audience, and to look like you know your topic very well.

While speaking has more formality than talking, it has less formality than reading. Speaking allows for flexibility, meaningful pauses, eye contact, small changes in word order, and vocal emphasis. Reading is a more or less exact replication of words on paper without the use of any nonverbal interpretation. Speaking, as you will realize if you think about excellent speakers you have seen and heard, provides a more animated message.

Methods of Presentation Delivery

There are four methods of delivery that can help you balance between too much and too little formality when giving a presentation.

Impromptu Speaking

Impromptu speaking is the presentation of a short message without advance preparation. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “Hi, my name is Steve, and I’m an account manager.” Another example of impromptu presenting occurs when you answer a question such as, “What did you think of the report?” Your response has not been preplanned, and you are constructing your arguments and points as you speak. Even worse, you might find yourself going into a meeting and your boss says, “I want you to talk about the last stage of the project. . . “ and you had no warning.

The advantage of this kind of speaking is that it’s spontaneous and responsive in an animated group context. The disadvantage is that the speaker is given little or no time to contemplate the central theme of his or her message. As a result, the message may be disorganized and difficult for listeners to follow.

Here is a step-by-step guide that may be useful if you are called upon to give an impromptu presentation in public:

• Take a moment to collect your thoughts and plan the main point you want to make.
• Thank the person for inviting you to speak. Avoid making comments about being unprepared, called upon at the last moment, on the spot, or feeling uneasy.
• Deliver your message, making your main point as briefly as you can while still covering it adequately and at a pace your listeners can follow.
• If you can use a structure, using numbers if possible: “Two main reasons . . .” or “Three parts of our plan. . .” or “Two side effects of this drug. . .” Timeline structures are also effective, such as “past, present, and future or East Coast, Midwest, and West Coast”.
• Thank the person again for the opportunity to speak.
• Stop talking (it is easy to “ramble on” when you don’t have something prepared). If in front of an audience, don’t keep talking as you move back to your seat.

Impromptu presentations:  the presentation of a short message without advance preparation . Impromptu presentations are generally most successful when they are brief and focus on a single point.

For additional advice on impromptu speaking, watch the following 4 minute video from Toastmasters: Impromptu Speaking

Manuscript Presentations

Manuscript presentations  are the word-for-word iteration of a written message . In a manuscript presentation, the speaker maintains their attention on the printed page except when using visual aids. The advantage of reading from a manuscript is the exact repetition of original words. In some circumstances this can be extremely important. For example, reading a statement about your organization’s legal responsibilities to customers may require that the original words be exact.

A manuscript presentation may be appropriate at a more formal affair (like a report to shareholders), when your presentation must be said exactly as written in order to convey the proper emotion or decorum the situation deserves.

However, there are costs involved in manuscript presentations. First, it’s typically an uninteresting way to present. Unless the presenter has rehearsed the reading as a complete performance animated with vocal expression and gestures, the presentation tends to be dull. Keeping one’s eyes glued to the script prevents eye contact with the audience. For this kind of “straight” manuscript presentation to hold audience attention, the audience must be already interested in the message and presenter before the delivery begins.

It is worth noting that professional speakers, actors, news reporters, and politicians often read from an autocue device, commonly called a teleprompter, especially when appearing on television, where eye contact with the camera is crucial. With practice, a presenter can achieve a conversational tone and give the impression of speaking extemporaneously and maintaining eye contact while using an autocue device. However, success in this medium depends on two factors: (1) the presenter is already an accomplished public speaker who has learned to use a conversational tone while delivering a prepared script, and (2) the presentation is written in a style that sounds conversational and in spoken rather than written, edited English.

Extemporaneous Presentations

Extemporaneous presentations  are carefully planned and rehearsed presentations, delivered in a conversational manner using brief notes . By using notes rather than a full manuscript, the extemporaneous presenter can establish and maintain eye contact with the audience and assess how well they are understanding the presentation as it progresses. Without all the words on the page to read, you have little choice but to look up and make eye contact with your audience.

Watch the following 10 minute video of a champion speaker presenting his extemporaneous speech: 2017 International Extemporaneous Speaking National Champion — Connor Rothschild Speech

Presenting extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible since you know the speech well  enough that you don’t need to read it. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and nonverbally. It also allows flexibility; you are working from the strong foundation of an outline, but if you need to delete, add, or rephrase something at the last minute or to adapt to your audience, you can do so.

The disadvantage of extemporaneous presentations is that it in some cases it does not allow for the verbal and the nonverbal preparation that are almost always required for a good speech.

Adequate preparation cannot be achieved the day before you’re scheduled to present, so be aware that if you want to present a credibly delivered speech, you will need to practice many times. Because extemporaneous presenting is the style used in the great majority of business presentation situations, most of the information in the subsequent sections of this chapter is targeted toward this kind of speaking.

Memorized Speaking

Memorized speakin g is the recitation of a written message that the speaker has committed to memory. Actors , of course, recite from memory whenever they perform from a script in a stage play, television program, or movie scene. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker doesn’t want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses visual aids, this freedom is even more of an advantage. However, there are some real and potential costs.

First, unless you also plan and memorize every vocal cue (the subtle but meaningful variations in speech delivery, which can include the use of pitch, tone, volume, and pace), gesture, and facial expression, your presentation will be flat and uninteresting, and even the most fascinating topic will suffer. Second, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. More frighteningly, if you go completely blank during the presentation, it will be extremely difficult to find your place and keep going. Obviously, memorizing a typical seven-minute presentation takes a great deal of time and effort, and if you aren’t used to memorizing, it is very difficult to pull off. Realistically, you probably will not have the time necessary to give a completely memorized speech. However, if you practice adequately, your approach will still feel like you are being extemporaneous.

10.2 Methods of Presentation Delivery Copyright © 2024 by eCampusOntario is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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3.2 Methods of Presentation Delivery

Jordan Smith; Melissa Ashman; eCampusOntario; Brian Dunphy; Andrew Stracuzzi; and Linda Macdonald

Learning Objectives

By the end of this chapter, you should be able to

• Identify and describe the four methods of delivery
• Organize an impromptu speech
• Design a manuscript for presentation
• Explain the need for practice in delivering extemporaneously
• Explain the advantages and disadvantages of memorization

The Importance of Delivery

Delivery is what you are probably most concerned about when it comes to giving presentations. This chapter is designed to help you give the best delivery possible and eliminate some of the nervousness you might be feeling. To do that, you should first dismiss the myth that public speaking is just reading and talking at the same time. Speaking in public has more formality than talking. During a speech, you should present yourself professionally. Your clothes should be appropriate for the situation, your language should be correct and appropriate for the audience, and you should appear knowledgeable about your topic. The level of formality is determined by the context, audience expectations, and purpose of the message.

Methods of Presentation Delivery

There are four methods of delivery that can help you balance between too much and too little formality when giving a presentation.

Impromptu Speaking

Impromptu speaking is the presentation of a short message without advance preparation. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “Hi, my name is Maru, and I’m an account manager.” Another example of impromptu presenting occurs when you answer a question such as, “What did you think of the report?” Your response has not been pre-planned, and you are constructing your arguments and points as you speak.

The advantage of this kind of speaking is that it’s spontaneous and responsive in an animated group context. The disadvantage is that the speaker is given little or no time to contemplate the central theme of their message. As a result, the message may be disorganized and difficult for listeners to follow.

This step-by-step guide that may be useful if you are called upon to give an impromptu presentation in a public setting:

• Take a moment to collect your thoughts and plan the main point you want to make.
• Thank the person for inviting you to speak. Avoid making comments about being unprepared, called upon at the last moment, on the spot, or feeling uneasy.
• Deliver your message, making your main point as concisely as you can while still covering it adequately and at a pace your listeners can follow.
• If possible, create a structure for your points. For example, use numbers: “Two main reasons . . .” or “Three parts of our plan. . .” or “Two side effects of this drug. . .” Timeline structures are also effective, such as “past, present, and future”.
• Thank the person again for the opportunity to speak.
• Stop talking (it is easy to “ramble on” when you don’t have something prepared). If in front of an audience, don’t keep talking as you move back to your seat.

Impromptu presentations are generally most successful when they are brief and focus on a single point.

For additional advice on impromptu speaking, watch the following 4 minute video from Toastmasters: Impromptu Speaking :

(Direct link to Toastmasters Impromptu Speaking )

Manuscript Presentations

Manuscript presentations  are the word-for-word iteration of a written message . The advantage of reading from a manuscript is the exact repetition of original words. In some circumstances, this exact wording can be extremely important. For example, reading a statement about your organization’s legal responsibilities to customers may require that the original words be exact. Acceptable uses of a manuscript include

• Highly formal occasions (e.g. a commencement speech)
• Particularly emotional speeches (e.g. a wedding speech, a eulogy)
• Situations in which word-for-word reading is required (e.g. a speech written by someone else; a corporate statement; a political speech)
• Within a larger speech, the reading of a passage from another work (e.g. a poem; a book excerpt).

Manuscript presentations, however, have a significant disadvantage: Your connection with the audience may be affected. Eye contact, so important for establishing credibility and relationship in Western cultures, may be limited by reading; your use of gestures will be limited if you are holding a manuscript, and a handheld manuscript itself might appear as a barrier between you and the audience. The speaker can appear to be more connected to the manuscript than to the audience. In addition, it is difficult to change your language or content in response to unpredictable audience reactions.

• Write the speech in a conversational style, and
• Practice your speech so that it flows naturally.

Preparation will make the presentation more engaging and enhance your credibility:

• Select and edit material so that it fits within your time limit,
• Select material that will be meaningful for your particular audience,
• Know the material well so that you can look up at your audience and back at the manuscript without losing your place, and
• Identify key words for emphasis.

An essential part of preparation is preparing your manuscript. The following suggestions are adapted from the University of Hawai’i Maui Community College Speech Department:

Make the manuscript readable

• Use a full 8.5 x 11inch sheet of paper, not note cards.
• Print on only one side of each page.
• Include page numbers.
• Use double or triple line spacing.
• Use a minimum of 16 pt. font size.
• Avoid overly long or complex sentences.
• Use bold or highlight the first word of each sentence, as illustrated by the University of Hawai’i.

Mark up your manuscript

• Add notations—“slow down,” “pause,” “look up,” underline key words, etc. as reminders about delivery.
• Highlight words that should be emphasized.
• Add notes about pronunciation.
• Include notations about time, indicating where you should be at each minute marker.

Engage Your Audience

• Practice your presentation.
• Try to avoid reading in a monotone. Just as contrast is important for document design, contrast is important in speaking. Vary your volume, pace, tone, and gestures.
• Make sure that you can be clearly understood. Speak loud enough that the back of the room can hear you, pronounce each word clearly, and try not to read too fast.
• Maintain good eye contact with your audience. Look down to read and up to speak.
• Match gestures to the content of the speech, and avoid distracting hand or foot movements.
• If there is no podium, hold the manuscript at waist height.

Extemporaneous Presentations

Extemporaneous presentations are carefully planned and rehearsed presentations, delivered in a conversational manner using brief notes or a slide deck . By using notes rather than a full manuscript, the extemporaneous presenter can establish and maintain eye contact with the audience and assess how well they are understanding the presentation as it progresses.

To avoid over-reliance on notes or slides, you should have strong command of your subject matter.  Then select an organizational pattern that works well for your topic. Your notes or slide deck should reflect this organizational pattern. In preparation, create an outline of your speech.

Watch some of the following 10-minute video of a champion speaker presenting an extemporaneous speech at the 2017 International Extemporaneous Speaking National Champion. :

(Direct link to 2017 International Extemporaneous Speaking National Champion video)

Presenting extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible since you know the speech well  enough that you don’t need to read it. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and non-verbally. It also allows flexibility; you are working from the strong foundation of an outline, but if you need to delete, add, or rephrase something at the last minute or to adapt to your audience, you can do so.

Adequate preparation cannot be achieved the day before you’re scheduled to present, so be aware that if you want to present a credibly delivered speech, you will need to practice many times. Extemporaneous presenting is the style used in the great majority of business presentation situations.

Memorized Speaking

Memorized speakin g is the recitation of a written message that the speaker has committed to memory. Actors , of course, recite from memory whenever they perform from a script in a stage play, television program, or movie scene. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker doesn’t want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses visual aids, this freedom is even more of an advantage. However, there are some real and potential costs.

First, unless you also plan and memorize every vocal cue (the subtle but meaningful variations in speech delivery, which can include the use of pitch, tone, volume, and pace), gesture, and facial expression, your presentation will be flat and uninteresting, and even the most fascinating topic will suffer. Second, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. More frighteningly, if you go completely blank during the presentation, it will be extremely difficult to find your place and keep going. Memorizing a presentation takes a great deal of time and effort to achieve a natural flow and conversational tone.

Check Your Knowledge (11 Questions)

University of Hawai’i Maui Community College. (2002). Commemorative speech objectives and tips. https://www.hawaii.edu/mauispeech/html/commemorative_speech1.html

3.2 Methods of Presentation Delivery Copyright © 2021 by Jordan Smith; Melissa Ashman; eCampusOntario; Brian Dunphy; Andrew Stracuzzi; and Linda Macdonald is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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How to Deliver Effective Presentations

Last Updated: April 27, 2024 Fact Checked

This article was co-authored by Maureen Taylor . Maureen Taylor is the CEO and Founder of SNP Communications, a leadership communications company based in the San Francisco Bay Area. She has been helping leaders, founders, and innovators in all sectors hone their messaging and delivery for almost 30 years, and has worked with leaders and teams at Google, Facebook, Airbnb, SAP, Salesforce, and Spotify. There are 7 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 581,372 times.

Delivering presentations is an everyday art form that anyone can master. To capture your audience's attention, present your information with ease and confidence. Act as if you are in a conversation with your audience, and they will pay attention to you. To get this level of fluency, write an engaging narrative, use more visuals than text in your slides, and practice, practice, practice.

Rehearsing Your Presentation

• Deliver your summary to them in friendly, direct language, as if you were telling the story to a friend in a bar.
• In fact, you can tell the story to a friend in a bar. However, telling a colleague over coffee can work just as well.
• Get them to tell you what their takeaway was. If they can summarize your message accurately, that's a good sign.

• Ask them to be your coach.
• Give them your presentation once or twice and let them ask you questions and give feedback.
• Ask them to point out moments that are dull or confusing.

• Write down what you're afraid of. What exactly worries you when you give a speech? Looking foolish? Being asked a hard question? Write down your exact fears, and then consider them each individually.
• Think about what you will do in each situation. For instance, if your fear is, "I'll forget what I'm saying," you can prepare a plan like, "If I forget what I'm saying, I'll pause, scan my notes, and find the next important point I need to make."
• Catch your negative thoughts, and calm them. If you think, "I'm going to get nervous and sweaty," replace it with, "I have important information to deliver and everyone is going to pay attention to that."

• Give yourself extra time if you plan to take questions, or if you anticipate lots of digressions.

• This doesn't mean sticking to a strict script every time. Instead, when you rehearse, improvise freely. Deliver your main points, but include quips and anecdotes that occur to you as you go. You'll remember the best ones when you actually deliver the presentation.

Delivering Your Presentation with Confidence

• Remind yourself that your audience likely can't see your nerves.
• Take a deep breath and exhale before you go on stage.

• If there are too many people to really see faces, just look boldly into the crowd.

• Move your hands as you speak. Don't wave them, as this will make you look nervous. Instead, try calmly gesturing with your palm out when you make a point. If you describe a shape, draw it in the air with your hands.

Crafting a Compelling Presentation

• Have a clear through line that runs through all parts of your presentation, leading to your main point.
• Include stories that put your listeners into a situation. Get their energy with tactile details (sound, sight, smell, taste, touch) and descriptions of an emotional state.
• Include moments of reflection in which you share how you felt or feel.

• As always with humor in a work setting, remember that humor varies widely between cultures. Avoid making any jokes that make fun of anybody's sex, gender, race, class, or ability. Remember to "punch up"—if your jokes take someone on, take on someone with more power than you, rather than less.
• If you get nervous, try starting your presentation with a simple joke or a funny story. It will put you and your audience at ease.

• Ask the crowd to consider something or imagine something, and hold a moment of quiet while they do.
• Interactive moments make great pivots from one section of your talk to another.

• Will these be experts, or newcomers to your ideas? If they're experts, you'll need to present them with specific, technical, and new ideas. If they're newcomers, plan to introduce them more generally to your topic, and avoid technical terms.
• Will audience members be on your side from the start, or will they need persuading?
• Will you have a large, faceless crowd, or a small group? If you're working with a small group, you can include them in parts of your presentation through questions, personal digressions, and conversations.

How Should You End a Presentation?

Expert Q&A

You Might Also Like

• ↑ http://firstround.com/review/This-Advice-From-IDEOs-Nicole-Kahn-Will-Transform-the-Way-You-Give-Presentations/
• ↑ https://www.student.unsw.edu.au/rehearse-your-presentation
• ↑ https://www.comm.pitt.edu/speech-anxiety
• ↑ https://www.unr.edu/writing-speaking-center/student-resources/writing-speaking-resources/speech-anxiety
• ↑ https://www.student.unsw.edu.au/speaking-audience
• ↑ https://www.toastmasters.org/resources/public-speaking-tips/gestures-and-body-language

About This Article

If you're worried about delivering an effective presentation, go over your notes again and make sure your presentation is telling a story with a distinct beginning, middle, and end. This type of structure will make it easier for people to follow along, and when you finish your presentation, they'll be more likely to remember what it was about! If you're still unsure, try practicing in front of other people before the big day. By rehearsing your presentation in advance, you'll not only feel more comfortable when you present it in front of an audience, but you can also get helpful feedback from your peers to make your presentation even better. Alternatively, if you're feeling a little nervous, identify what exactly you're afraid of happening during your presentation, and then come up with a plan for each scenario so you're less stressed about it. For example, if you're worried about forgetting what to say next, you could make a list of all the important points you need to make and have it with you during your presentation. For tips from our Communications co-author, like how to appear confident during a presentation, keep reading! Did this summary help you? Yes No

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15 Essential Presentation Techniques for Winning Over Any Audience

• The Speaker Lab
• April 13, 2024

Table of Contents

Ever found yourself standing before an audience, your heart racing? That’s the moment when knowing effective presentation techniques can prove to be your unwavering ally. But what are presentation techniques? And what makes them so powerful? In this article, we’re going to answer those questions.

Before we can talk about presentation techniques, though, we first have to talk about good communication. The power of effective communication isn’t just in what you say. It’s how you say it; it’s in those deep breaths that steady nerves, and in maintaining eye contact. It’s about turning a room full of strangers into an engaged audience hanging onto your every word. When it comes to public speaking, real success comes from mastering non-verbal cues to punctuate our words and using visual aids not as crutches but as tools for engagement.

As you hone your communication skills, you will begin to form effective presentation techniques. Expect rough patches as you get the hang of things, but view them as mere footholds propelling you towards your ultimate triumph. Keep pushing forward.

Mastering Presentation Techniques for Impactful Delivery

Presentation techniques are more than just standing in front of a crowd and talking. They’re about making connections, telling stories that resonate, and leaving your audience with something to remember you by.

Elements of an Effective Presentation

For your presentation to resonate, ensure the visuals are straightforward and supportive, rather than distracting. Your message should be concise yet powerful enough to stick. And let’s not forget engagement; keeping your audience on their toes is key.

• Visuals: Keep them simple but impactful.
• Message: Make every word count.
• Engagement: Interact with your audience, ask questions, make them think.

We’ve all seen those slides crammed with text or charts. When you make your slides, don’t cram information, because nobody wants to squint at tiny fonts or decipher complex graphs while trying to listen to you speak. This resource suggests focusing on clarity and simplicity when designing slides—advice worth taking.

Strategies for Delivering a Successful Presentation

To deliver a knockout presentation, start strong. Grab attention from the get-go with an intriguing fact or story related directly back into the topic at hand. Maintain eye contact across the room so everyone feels included in the conversation. Finally, end on a memorable note, either with a call to action or insight gained during the time together. Leave them wanting more information and eager to learn about the subject matter discussed today.

• The opener: Hook your audience with a relevant fact or anecdote.
• Maintain connection: Eyes up, engage everyone around.
• Closing remarks : Last chance for impact–what’s your mic drop?

As author Lilly Walters once said, “The success of your presentation will be judged not by the knowledge you send but by what the listener receives.” This quote reminds us that the true goal of any speech is the understanding achieved between the speaker and the listeners.

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Engaging Your Audience with Nonverbal Communication

As the name implies, nonverbal communication denotes all of the ways you communicate without using words. This includes eye contact, body language, and facial expressions. Although nonverbal communication might not be the first presentation technique that comes to mind, it’s nevertheless a very powerful tool to have in your arsenal. Let’s take a look.

The Power of Eye Contact, Body Language, and Facial Expressions

Making eye contact isn’t just about looking someone in the eye; it’s about forging a connection. Aim for brief moments of eye contact across different sections of your audience throughout your presentation. Establishing fleeting eye connections across diverse audience segments fosters a sense of trust and keeps them hooked, all while ensuring no one feels on edge.

Body language is similarly important. Stand tall with good posture; it exudes confidence even when you feel nervous. As you grow more confident, mix up standing still with moving around subtly. This dynamic shift holds attention better than being rooted to one spot or nervous pacing. Use your hands to gesture naturally as you speak—it adds emphasis and keeps things lively.

If there’s one thing people can spot from miles away, it’s insincerity. So let those facial expressions match your words. Smile when you share something amusing, and furrow your brow when diving into serious stuff. After all, it’s not just what you say but how visually engaged and passionate you appear while saying it that counts.

Tying these elements together helps you deliver impactful, memorable talks. When done right, folks will leave feeling more connected, understood, and fired up by your presentation, all thanks to your techniques.

Designing Compelling Presentation Materials

Knowing how to design engaging presentation materials is one technique you can’t do without. Far from mere embellishments, these implements are crafted to hammer your message home. Hence, it’s vital to select these aids with great care and discernment.

Tips for Creating Effective Slides

When it comes to crafting slides, think of each as a billboard advertisement for your idea. You want it clear, impactful, and memorable.

• Keep it simple : One idea per slide keeps confusion at bay and attention locked in.
• Use bullet points : Break down your points so your audience can track.
• Pick a font size : Generally speaking, bigger is better.
• Use color : Harness colors that pop without blinding anyone; contrast is key.
• Use images with purpose : A good picture or chart can help illustrate your point, but keep it relevant and don’t overdo it.

With a few helpful visuals, your presentation can go from good to great. For more on creating slides, check out this link here .

Handling Questions and Interactions Professionally

For some speakers, it’s not the presentation itself that makes them nervous—it’s the Q&A session that follows. This is the moment where you get to shine or stumble based on how well you handle those curveballs from your audience. If you want to round off your presentation well, you’re going to want to learn a few techniques for fielding these questions. Let’s look at a few ways of doing this.

Preparing for Audience Questions and How to Address Them Effectively

Below are six techniques that will help you address audience questions effectively.

• Listen Up : The first rule of thumb is to listen like it’s a superpower. When someone throws a question at you, don’t just hear them out—really listen. Demonstrating this level of attentiveness not only conveys your respect but also affords you a brief moment to collect your ideas.
• Stay Calm : You’ve got this. Even if a question catches you off guard, take a deep breath before diving into your answer. No one expects perfection, but showing confidence matters.
• Practice Beforehand : Before presentation day arrives, think about potential questions folks might ask and prep some responses in advance. Practice makes perfect, after all.
• Vary Your Techniques : Not every question needs an essay as an answer; sometimes short and sweet does the trick. Mix up how detailed or brief your answers are depending on what’s asked.
• Show You Care : If you ever get a question that leaves you stumped, say so honestly—but add that magical line: “Let me find out more and I’ll get back to you.” Then actually do it.
• Appreciate Audience Curiosity : Remember that the reason you audience is asking questions is because they’re interested. So no matter what questions you get, keep engaging with enthusiasm.

Go forth with confidence, knowing not only can these moments boost credibility—they make connections too. So next time when facing down those queries remember to listen hard, stay calm & always engage warmly. With these techniques under your belt, answering audience questions after your presentation will feel much less daunting.

Techniques for a Memorable and Effective Presentation

No matter what topic you cover in your presentation, you can easily add in a story, and more likely than not you can add a little humor too. Together, these two presentation techniques are perfect for making your speech memorable.

Incorporating Storytelling into Your Presentation

One great technique for making your presentation stick is telling stories. Stories have the power to touch people profoundly, especially when they depict relatable experiences. So, when you’re up there presenting, kick things off with a story that ties into your main message. It could be personal, something from history, or even an anecdote that gets your point across. Stories are not just fluff; they’re the glue of your presentation. They make complex ideas digestible and memorable.

Using Humor to Connect with the Audience

Another great way of engaging your audience is by using humor. But here’s the deal—use humor wisely. Keep it tasteful and tied closely to the content at hand so it enhances rather than detracts from your message.

• Pick universal themes everyone can relate to.
• Avoid anything potentially offensive.
• Tie jokes back to your key points to make them relevant.

If humor isn’t your thing, or you’re worried about your comedic timing, it’s perfectly okay to skip the jokes. Especially if you’re new to public speaking, humor can be hard to nail immediately. But as you grow and hone your presentation techniques, consider stretching yourself a bit. By starting small, you can practice using humor to connect with your audience. That is your goal, after all—to leave a positive, memorable impression on your audience.

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Overcoming Public Speaking Anxiety

For some speakers, stepping in front of a crowd to speak causes immediate anxiety. But fear not! Conquering public speaking anxiety is entirely within your grasp.

Techniques to Manage Stage Fright and Boost Confidence

First off, feeling nervous before taking the stage is completely normal. Even Mark Twain admitted, “There are two types of speakers. Those who get nervous and those who are liars.” So take that flutter in your stomach as a sign you care deeply about delivering value to your audience. In addition, consider the following tips as you prepare to hit the stage.

• Breathe Deep: Before stepping up, take some deep breaths. In through the nose, out through the mouth. Feel every muscle relax with each exhale.
• Mind Over Matter: Visualization is key. Picture yourself nailing that presentation, because if you can see it, you can achieve it.
• Keep It Simple: Stick to what you know best; this isn’t the time for surprises or untested waters.
• Pace Yourself: Speak slowly but surely—there’s no rush here.

Believe it or not, acting relaxed often leads to actually being relaxed. Remember when we said mind over matter? Well, it applies here big time. The power pose backstage might just be what turns those nerves into excitement.

So next time you feel stage fright coming on, fight back with these techniques. With these tricks up your sleeve, you’re more than ready. So go ahead, breathe deep, and step onto that stage. You’ve got this.

Using Different Presentation Methods to Engage Your Audience

While learning styles is “ little more than urban myth ,” presenting your material in a variety of ways is a great technique for engaging your audience. By switching it up, you increase your chances of explaining something in a way that clicks with individual audience members. This is especially helpful for more complex topics that might be hard to grasp.

There are three main ways of presenting your material to your audience: through visuals, audio, and hands-on activities.

• Visuals: Use slides packed with images, graphs, and bullet points.
• Audio: Tell stories, play audio clips or engage in discussions.
• Hands-on Activities: Include activities or demonstrations that allow audience members to participate physically.

Making sure everyone gets something from your presentation means considering these techniques when planning content. Not only can incorporating various methods increase audience engagement, but it can also elevate your presentation from decent to memorable.

Essential Tips for First-Time Presenters

Stepping onto the stage or logging into that webinar platform as a first-time presenter can feel nerve-wracking. But fear not! With these tips on how to dress appropriately, arrive early, and make your presentation shine, you’ll be ready to confidently nail that presentation.

Dress Appropriately

Your outfit is your armor. Choose something professional yet comfortable. Whether it’s in-person or online, dressing one notch above what you expect your audience to wear usually hits the sweet spot. Aim for solid colors that won’t distract your audience.

Arriving Early

If possible, arrive at the venue before your audience does. This gives you time to settle in, test any tech gear like microphones or projectors, and take those deep breaths. This extra time also lets you chat with early birds. By connecting with people before taking center stage, you can ease nerves significantly.

Making Presentation Time Count

You only have the audience’s attention for so long. Keep an eye on the clock as you present, but avoid rushing through content. It especially helps to pause after key points, letting information sink in. Your end goal? Leave you’re audience wanting more. You’ll know if you succeeded based on the number of questions you get during the Q&A.

So there you have it—the techniques you need to deliver an engaging presentation. By honing nonverbal communication, like eye contact and posture, you can captivate your audience with your energy. And visual aids? They’re not just ornamental; they help bolster your point and drive it home.

We also learned that tackling audience questions is not an art reserved for the eloquent few but a skill sharpened by preparation and presence. While it takes a little work to nail good storytelling and well-timed humor, the ultimate outcome is worth it.

So while standing before an audience may set your heart racing, know that arming yourself with knowledge and technique can transform not just your presentation, but you yourself. So don’t be afraid to try your hand at these skills; in doing so, you build your own confidence and become a better speaker in the process.

• Last Updated: April 11, 2024

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PRDV217: Introduction to Sales

Delivering Your Presentation

Read this chapter on how to deliver your presentation. It presents strategies for presenting more persuasively so you have an impact on your audience.

Methods of Delivery

There are four primary methods  or styles of presenting a speech: manuscript, memorized, extemporaneous, and impromptu. Each has a variety of uses in various forums of communication.

1. Manuscript Style

The word manuscript is the clue to the style. The speech is written, and the speaker reads it word for word to the audience. Originally, it was done from the hand-written paper manuscript. Today the manuscript style is common, but the paper is gone. Who reads the speech to the audience? Answer: Newscasters and television personalities. In the old days, the manuscript was hand-lettered on cue cards, which were held next to the camera lens. The paper scrolls, like printed piano rolls, were used, especially in Soap Operas. Today, a special teleprompter (working like a periscope) is attached to the camera so the newscaster looks at the lens while reading.

Why is the manuscript important and in use? Precision. In the news-reporting industry, every fraction of q second counts because broadcast time is costly. Also, the facts and names must be exact and accurate, so there is no room for error. Errors in reporting decrease the credibility of the news organization and the newscaster.

The most regular use of the teleprompter for manuscript delivery is by the U.S. President. The teleprompter, used by every President since Reagan, is called a "Presidential Teleprompter." It is made of two pieces of glass, each flanking the podium. They reflect the text from a monitor on the floor like a periscope. The glass on both sides has the same text, and the speaker looks alternately from one glass to another as though looking at the audience through the glass. The audience cannot see the projected text.

The speeches a President gives will often reflect national policy, define international relationships, and the press will scrutinize every syllable. It has to be more than brilliantly accurate; it has to be impeccably phased. Professional writers and policy experts compose the speech, and the President delivers it as though he not only wrote it but made it up on the spot. That is the skill of a good politician, actor, or speaker. Those not skilled in using a teleprompter or manuscript will sound stilted and boring.

Try This! Manuscript Delivery

Watch the local or national 6 p.m., 11 p.m., and 6 a.m. newscasts on the same T.V. station. Make notes on which news items repeat and how closely, or precisely, the phrasing is, even if different personalities are presenting the same item.

2. Memorized Style

The memorized speaking style  is when the manuscript is committed to memory and recited to the audience verbatim (word for word). In the days when elocution was taught, this was a typical approach. A speech was a recitation. The Optimists Club (a national organization) used to have an "Oratory" contest for high school students. Contestants wrote essays on a given theme to create a speech at a specific length (e.g., three minutes).

The essay was memorized, and the delivery was judged by 1. the quality of the writing, 2. the accuracy with which it was recited, and 3. the precise length of time. These contests seem archaic by today's more casual and somewhat less formal standards.

Where is a memorized delivery style still common? Due to copyright laws and licensing contract agreements (other than scripts in the public domain), actors on stage must memorize the script of the play and perform it verbatim exactly as written. It is typical for speakers on high school and university speech and debate teams to memorize their competitive speeches.

Corporate conventions often use large LCD monitors on the front of the stage as teleprompters. This allows the speaker to move more freely across the stage while sticking to his or her script. Some monologists (such as the stand-up comics mentioned at the start of the chapter) also use a memorized delivery style. In all cases, they create the impression that the speech is spontaneous. You might consider using the memorized delivery style if your speech is relatively short or you know you will have to deliver your speech repeatedly, such as a tour operator would.

3. Impromptu Style

Theoretically, an "impromptu" speech is "made up on the spot." It is unprepared and unrehearsed. Often ceremonial toasts, grace before meals, an acknowledgment, an introduction, offering thanks, and so on fall into this category. While there are some occasions when a speech in those categories is prepared (prepare your acceptance for the Academy Award BEFORE you are called!), there are many occasions when there is little or no opportunity to prepare.

Impromptu speeches are generally short and are often given with little or no notice. Notes are rare, and the speaker generally looks directly at the audience. It would be presumptuous and arrogant to declare rules for Impromptu Speaking. It is fair to explain that "impromptu" describes a range from absolutely no preparation to a modest amount of preparation (mostly thought). It rarely incorporates research or the formalities of outlines and citations that more formal speeches would include.

Be still when you have nothing to say; when genuine passion moves you, say what you have got to say, and say it hot.  — D. H. Lawrence

An indelibly memorable example occurred when my siblings threw a surprise 10th-anniversary party for my Mom (Margaret) and our stepdad (Lidio). It was the third marriage for both of them, and they were in their 60s. As soon as the yells of "surprise" subsided, Lidio picked up his wine glass and proposed a toast:

"I can't believe this surprise! I don't know what to say… um, Dino [his brother], when was that Yankee game Dad took us to when we were kids? It was 4th of July, wasn't it? 1939? It was like yesterday; today reminds me of when Lou Gehrig came out to the mound. He was slow, but we were all cheering the ‘Pride of the Yankees.' He wasn't playing anymore, he was too sick, but he looked around the crowd and said, ‘I'm the luckiest man alive.' That's how I feel with you all here today; to celebrate our 10th anniversary. I'm here with you and Margaret, the luckiest man alive."

The speech was short, emotionally charged, wonderfully articulate, and unprepared. The speech had one central emotionally charged message, simple in words and phrasing but complex, bringing an image of great sentimentality to the occasion. He could react to the moment and speak "from the heart."

In contrast, legendary magician Harry Houdini was often asked to perform for the amusement of his fellow passengers when sailing to Europe. I always associate impromptu with the stories of Houdini's shipboard conjuring. Nothing was further from impromptu. The skill of the great magician was in making his illusions seem spontaneous with what appeared to be ordinary items that "happened" to be on hand. Houdini spent endless hours planning and rehearsing. The true illusion was that they "appeared" to be impromptu.

Take advantage of every opportunity to practice your communication skills so that when important occasions arise, you will have the gift, the style, the sharpness, the clarity, and the emotions to affect other people.  — Jim Rohn

4. Extemporaneous Style

Sandwiched between the memorized and impromptu delivery styles, you find the extemporaneous speech style. In this style, the speech is not entirely written out. It is usually delivered with keynotes for reference. Most public speaking courses and books describe extemporaneous speeches as carefully prepared and rehearsed but delivered using notes of keywords and phrases to support the speaker.

Phrasing is pre-rehearsed, words are pre-chosen, and the organization is fluid and well-constructed. There should be no fumbling for words, no rambling, and the length of time should be carefully monitored. The style does offer the speaker flexibility to include references to the immediate surroundings, previous speeches, news of the day, and so on.

The trouble with talking too fast is you may say something you have not thought of yet.  — Ann Landers

How you develop the notes and what they look like are up to the individual, but a natural extemporaneous delivery is difficult if you rely on a manuscript. Under no circumstances should the speaker be spending more than 20 percent of the speaking time looking at the notes. It would be ideal to practice so you only glance at your notes approximately 5 percent of the speech time.

Those who have limited experience in formal speaking find it helpful to write out the speech as though it were an essay, then read it, edit it, then create speaking notes from the text. This helps with editing and thinking through the phrases. This public speaking process was taught decades ago to my contemporaries and me and has fallen out of fashion. But it is a valuable way of thoroughly thinking through the speech. If this procedure is used, it is advisable to rehearse the speech with notes without the essay before delivering the speech. But be warned: having the fully written essay at the podium might detract from the delivery.

The extemporaneous style is the method most often recommended (and often required) in today's public speaking courses and is generally the best method in other settings as well. While it is not the only method of delivering a speech, it is the most useful for presentations in other courses, in the corporate world and in pursuing future careers.

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What It Takes to Give a Great Presentation

• Carmine Gallo

Five tips to set yourself apart.

Never underestimate the power of great communication. It can help you land the job of your dreams, attract investors to back your idea, or elevate your stature within your organization. But while there are plenty of good speakers in the world, you can set yourself apart out by being the person who can deliver something great over and over. Here are a few tips for business professionals who want to move from being good speakers to great ones: be concise (the fewer words, the better); never use bullet points (photos and images paired together are more memorable); don’t underestimate the power of your voice (raise and lower it for emphasis); give your audience something extra (unexpected moments will grab their attention); rehearse (the best speakers are the best because they practice — a lot).

I was sitting across the table from a Silicon Valley CEO who had pioneered a technology that touches many of our lives — the flash memory that stores data on smartphones, digital cameras, and computers. He was a frequent guest on CNBC and had been delivering business presentations for at least 20 years before we met. And yet, the CEO wanted to sharpen his public speaking skills.

• Carmine Gallo is a Harvard University instructor, keynote speaker, and author of 10 books translated into 40 languages. Gallo is the author of The Bezos Blueprint: Communication Secrets of the World’s Greatest Salesman  (St. Martin’s Press).

Partner Center

26 Methods of Delivery

Learning Objectives

• Differentiate between four common delivery methods.
• Identify the most effective delivery method: extemporaneous speaking.

There are four basic methods or styles of presenting a speech: manuscript, memorized, extemporaneous, and impromptu. Each style will work well for differing speaking contexts. In this chapter, we will explore when each style should (and shouldn’t) be used.

Manuscript Style

In this delivery style, the speech is written and the speaker reads it word for word to the audience. This style is common with newscasters and television personalities. A teleprompter (working like a periscope) is attached to the camera so the newscaster is looking at the lens while reading. Another example of manuscript delivery is by the U.S. President. The speeches a President gives will often reflect national policy, define international relationships, and the press will scrutinize every syllable. It has to be more than brilliantly accurate; it has to be impeccably phased. Professional writers and policy experts compose the speech, and the President delivers it as though he not only wrote it but made it up on the spot. That is the skill of a good politician, actor, or speaker.

Why is this speaking style used? Precision. In the news reporting industry, every fraction of second counts because broadcast time is costly. Also, the facts and names must be exact and accurate so there is no room for error. Errors in reporting decrease the credibility of the news organization and the newscaster.

Those who are not skilled in using a teleprompter or manuscript will sound stilted and boring. Public speaking is about presenting, not reading, to an audience. Because of this, manuscript style should only be used in specific situations (such as those mentioned above) and never in a classroom speech.

Memorized style

This style is used when the manuscript is committed to memory and recited to the audience verbatim (word for word). Think about your fifth grade poetry contest where students received poems to the class.

There are several contexts where this style is appropriate. Often times actors on stage are obligated to memorize the script of the play and perform it exactly as written. Speakers on high school and university speech and debate teams may memorize their competitive speeches. Some monologists (such as the stand-up comics) also use a memorized delivery style. In all cases, they create the impression that the speech is spontaneous.

When we use memorization to present our speech, we are often times so focused on remembering what comes next that we lose focus on our audience. Our focus is internal and this causes us to sound robotic and monotone. We are disengaged from our audience and this causes them to be disengaged from our message. A better technique is to memorize your key points, not your word-for-word speech. We will talk about this strategy more when we discuss extemporaneous speaking.

Impromptu Style

Impromptu speaking is typically a short presentation without advance preparation. Impromptu speeches often occur when someone is asked to “say a few words” or give a toast on a special occasion. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking. Another example of impromptu speaking occurs when you answer a question in class.

The advantage of this kind of speaking is that it’s spontaneous and we tend to deliver our message more naturally and conversational. The disadvantage is that the speaker is given little or no time to contemplate the central theme or how to organize their message. As a result, the message may be disorganized and difficult for listeners to follow.

Impromptu speaking is an important skill to have. It can help us to get the job, stand out at work, be a good leader, and persuade others. However, it is a skill that takes time and effort to develop. Whenever you are given time to prepare for a presentation, this should not be your go-to style.

Extemporaneous Style

This speaking style is carefully planned and rehearsed, spoken in a conversational manner using brief notes. Speaking extemporaneously has many advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and nonverbally.

Extemporaneous speaking requires a great deal of preparation for both the verbal and the nonverbal components of the speech. Adequate preparation cannot be achieved the day before you’re scheduled to speak. The key to this speaking style is that it is carefully planned yet appears to be natural and conversational. Speaking extemporaneously requires speakers to work through the speechmaking process, create a preparation outline, use that outline to create speaking notes, and practice, practice, and practice some more.

Because extemporaneous speaking is the style used in the great majority of public speaking situations, this is the style we will learn and employ in this course.

Why Extemporaneous Style?

While there are several methods you can choose from to deliver a speech, the easiest approach to speech delivery is not always the best. Substantial work goes into the careful preparation of an effective speech, so it is understandable that students may have the impulse to avoid “messing it up” by simply reading it word for word. But students who do this miss out on one of the major reasons for studying public speaking: to learn ways to “connect” with one’s audience and to increase one’s confidence in doing so. You already know how to read, and you already know how to talk. But public speaking is neither reading nor talking. Speaking allows for meaningful pauses, eye contact, small changes in word order, and vocal emphasis. Reading is a more or less exact replication of words on paper without the use of any nonverbal interpretation. Extemporaneous speaking, as you will realize if you think about excellent speakers you have seen and heard, provides a more animated message that will connect with your audience and leave a lasting impression.

Key Takeaways

• There are four common methods of delivering speeches.
• Extemporaneous speaking is the most effective delivery method to engage your audience.

Licenses and Attributions

Chapter 12 Methods of Delivery.  Authored by : Victor Capecce, M.F.A..  Provided by : Millersville University, Millersville, PA.  Located at :  http://publicspeakingproject.org/psvirtualtext.html .  Project : The Public Speaking Project.  License :  CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives

marketing mix.  Authored by : Matthew Hurst.  Located at :  https://www.flickr.com/photos/skewgee/3911933434/ .  License :  CC BY-SA: Attribution-ShareAlike

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Chapter 32: Methods of Speech Delivery

Learning Objectives

By the end of this chapter, you should be able to:

• Distinguish between four methods of speech delivery: the impromptu speech, the manuscript speech, the memorized speech, and the extemporaneous speech
• List the advantages and disadvantages of the four types of speeches
• Explain why an extemporaneous is the preferred delivery style when using rhetorical theory

Key Terms and Concepts

• extemporaneous

We have established that presentations involve much more than the transfer of information. Sure, you could treat a presentation as an opportunity to simply read a report you’ve written out loud to a group, but you would fail to both engage your audience and make a connection with them. In other words, you would leave them wondering exactly why they had to listen to your presentation instead of reading  it at their leisure.

The Four Methods of Speech Delivery

One of the ways to ensure that you engage your audience effectively is by carefully considering how best to deliver your speech. Each of you has sat in a class, presentation, or meeting where you didn’t feel interested in the information the presenter was sharing. Part of the reason for your disengagement likely originated in the presenter’s method of speech delivery .

For our purposes, there are four different methods—or types—of speech delivery used in technical communication:

• Extemporaneous

Exercise #1: The Four Methods of Speech Delivery

What comes to mind when you think about the four methods of speech delivery? How do you think they are different from one another? Have you given a speech using any of these methods before?

Watch the video below for a brief overview of each one. After you are finished, answer the questions below:

• Which method are you most comfortable with? Why?
• Which method are you the least comfortable with? Why?
• Which method do you think is the best for connecting with your audience?  Why?

The public speaking section of this course will require you to deliver a speech using an extemporaneous style, but let’s take a look at how all four differ in approach:

Impromptu Speeches

Impromptu speaking is the presentation of a short message without advanced preparation. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “ Hi, my name is Shawnda, and I’m a student at the University of Saskatchewan .”

Another example of impromptu speaking occurs when you answer a question such as, “What did you think of the movie?” Your response has not been pre-planned, and you are constructing your arguments and points as you speak. Even worse, you might find yourself going into a meeting when your boss announces to you, “I want you to talk about the last stage of the project” with no warning.

The advantage of this kind of speaking is that it’s spontaneous and responsive in an animated group context. The  disadvantage is that the speaker is giv en little or no time to contemplate the central theme of their message. As a result, the message may be disorganized and difficult for listeners to follow.

Here is a step-by-step guide that may be useful if you are called upon to give an impromptu speech in public:

• Take a moment to collect your thoughts and plan the main point that you want to make (like a mini thesis statement).
• Thank the person for inviting you to speak. Do not make comments about being unprepared, called upon at the last moment, on the spot, or uneasy. In other words, try to avoid being self-deprecating!
• Deliver your message, making your main point as briefly as you can while still covering it adequately and at a pace your listeners can follow.
• If you can use a structure, use numbers if possible: “Two main reasons. . .” or “Three parts of our plan. . .” or “Two side effects of this drug. . .” Past, present, and future or East Coast, Midwest, and West Coast are pre-fab structures.
• Thank the person again for the opportunity to speak.
• Stop talking. It is easy to “ramble on” when you don’t have something prepared. If in front of an audience, don’t keep talking as you move back to your seat.

Impromptu speeches are generally most successful when they are brief and focus on a single point.

We recommend practicing your impromptu speaking regularly. Do you want to work on reducing your vocalized pauses in a formal setting? Great! You can begin that process by being conscious of your vocalized fillers during informal conversations and settings.

Exercise #2: Impromptu Speech Example

Below are two examples of an impromptu speech. In the first video, a teacher is demonstrating an impromptu speech to his students on the topic of strawberries. He quickly jots down some notes before presenting.

What works in his speech? What could be improved?

Link to Original Video: tinyurl.com/impromptuteacher

In the above example, the teacher did an okay job, considering how little time he had to prepare.

In this next example, you will see just how badly an impromptu speech can go. It is a video of a best man speech at a wedding. Keep in mind that the speaker is the groom’s brother.

Is there anything that he does well? What are some problems with his speech?

Link to Original Video: tinyurl.com/badimpromptubestman

Manuscript Speeches

Manuscript  speaking is the word-for-word iteration of a written message. In a manuscript speech, the speaker maintains their attention on the printed page except when using presentation aids.

The advantage to reading from a manuscript is the exact repetition of original words. This can be extremely important in some circumstances. For example, reading a statement about your organization’s legal responsibilities to customers may require that the original words be exact. In reading one word at a time, in order, the only errors would typically be the mispronunciation of a word or stumbling over complex sentence structure. A manuscript speech may also be appropriate at a more formal affair (like a funeral), when your speech must be said exactly as written in order to convey the proper emotion the situation deserves.

However, there are costs involved in manuscript speaking. First, it’s typically an uninteresting way to present. Unless the speaker has rehearsed the reading as a complete performance animated with vocal expression and gestures (well-known authors often do this for book readings), the presentation tends to be dull. Keeping one’s eyes glued to the script prevents eye contact with the audience.

For this kind of “straight” manuscript speech to hold audience attention, the audience must be already interested in the message and speaker before the delivery begins. Finally, because the full notes are required, speakers often require a lectern to place their notes, restricting movement and the ability to engage with the audience. Without something to place the notes on, speakers have to manage full-page speaking notes, and that can be distracting.

It is worth noting that professional speakers, actors, news reporters, and politicians often read from an autocue device such as a teleprompter. This device is especially common when these people appear on television where eye contact with the camera is crucial. With practice, a speaker can achieve a conversational tone and give the impression of speaking extemporaneously and maintaining eye contact while using an autocue device.

However, success in this medium depends on two factors:

• the speaker is already an accomplished public speaker who has learned to use a conversational tone while delivering a prepared script, and
• the speech is written in a style that sounds conversational.

Exercise #3: Manuscript Speech Example

Below is a video that shows an example of a manuscript speech. In the video, US Presidential Historian, Doris Kearns Goodwin, gives a speech about different US presidents.

What works in her speech? What could be improved?

Link to Original Video: tinyurl.com/goodwindepauw

Here’s a video that shows the dangers of relying on a manuscript for your speech:

Michael Bay heavily relied on his manuscript , so when he suddenly lost access to it, he was left feeling embarrassed and had to hastily leave the stage. As a result, he experienced face loss .

Link to original video: https://tinyurl.com/MBayManuscript

Memorized Speeches

Memorized  speaking is reciting a written message that the speaker has committed to memory. Actors, of course, recite from memory whenever they perform from a script in a stage play, television program, or movie. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker doesn’t want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses presentation aids, this freedom is even more of an advantage.

Memorization, however, can be tricky. First, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. If you go completely blank during the presentation, it will be extremely difficult to find your place and keep going. Obviously, memorizing a typical seven-minute classroom speech takes a great deal of time and effort, and if you aren’t used to memorizing, it is very difficult to pull off.

Exercise #4: Memorized Speech Example

Below is a video that shows an example of a memorized speech. In the video, former Louisiana governor, Bobby Jindal, responds to Barack Obama’s State of the Union address back in 2009.

Extemporaneous Speeches

Extemporaneous speaking is the presentation of a carefully planned and rehearsed speech, spoken in a conversational manner using brief notes.

Speaking extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible since you know the speech well enough that you don’t need to read it. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and nonverbally.

By using notes rather than a full manuscript (or everything that you’re going to say), the extemporaneous speaker can establish and maintain eye contact with the audience and assess how well they are understanding the speech as it progresses. It also allows flexibility; you are working from the strong foundation of an outline, but if you need to delete, add, or rephrase something at the last minute or to adapt to your audience, you can do so. The outline also helps you be aware of main ideas vs. subordinate ones.

Compared to the other three types of speech delivery, an extemporaneous style is the best for engaging your audience and making yourself sound like a natural speaker.

The video below provides some tips on how to deliver a speech using this method:

Link to Original Video:  tinyurl.com/deliverextempres

The slide below provides a brief overview of tips for preparing your extemporaneous presentation:

Exercise# 5: Extemporaneous Speech Example

Below is a video that shows an example of an extemporaneous speech. In the video, a former University of Saskatchewan student tries to persuade her peers to spend more solo time outside.

Link to Original Video: tinyurl.com/rcm401speech

Key Takeaways

• When designing any speech, it’s important to consider how you will deliver that speech. In technical communication, there are four different types of speech delivery, each with their advantages and disadvantages. They are: impromptu , manuscript , memorized , and extemporaneous .
• An impromptu  speech can take many forms such as a toast at a wedding, being asked to give a project update at a meeting, or even simply meeting someone for the first time. While this type of speech can be spontaneous and responsive, the speaker generally has little to no warning that they will need to speak.
• A  manuscript speech is completely written out and read word for word.  It is often a good style when you want to nail the specific wording and do not want to make an error. However, this type of speech is not very persuasive because it does not take advantage of the immediacy of public speaking. It also completely removes audience relation from the process.
• A  memorized  speech is when a speaker commits an entire speech to memory. This style also harms relation with the audience because the speaker is more focused on remembering the text of the speech rather than communicating with the audience. Additionally, if you lose your place and need to ad lib, it may be obvious to your audience.
• An extemporaneous speech is done in a natural, conversational speaking style. While it is carefully planned, it is never completely written out like a manuscript.  It is also not read or memorized . Instead, an outline is used to help guide the speaker. As a result, more attention can be paid to the audience, allowing the speaker to better connect with them and make adjustments as necessary. This is the style we want you to use for your presentation assignment in RCM 200.

Attributions

This chapter is adapted from “ Communication for Business Professionals ” by eCampusOntario (on Open Library ). It is licensed under Creative Commons Attribution-ShareAlike 4.0 International License .

This chapter is also adapted from “ Speak Out, Call In: Public Speaking as Advocacy ” by Meggie Mapes (on Pressbooks ). It is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License .

a speech delivery method where a short message is presented without advanced preparation

a speech delivery method where a message is read word-for-word off a written page or autocue device

a speech delivery method where a message is presented after being committed to memory by the speaker

a speech delivery method where the presentation is carefully planned and rehearsed, but spoken in a conversational manner using brief notes

the experience of feeling judged, or feeling that people do not recognize us as we perceive ourselves to be

Effective Professional Communication: A Rhetorical Approach Copyright © 2021 by Rebekah Bennetch; Corey Owen; and Zachary Keesey is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Four Methods for Delivering Oral Presentations

How to Establish Credibility in an Informative Speech

You never know when you might be asked to give a speech or presentation. Whether job or school related you will probably have to give a presentation. What about a toast at a wedding? Or even a roast! The important thing to remember is that it's a matter of when, not if, therefore, there are a few things to learn that will help in your delivery. You should always have a clear understanding of your audience and your purpose. Also, knowing the types of delivery and which to use when can add to your success.

The manuscript method is a form of speech delivery that involves speaking from text. With this method, a speaker will write out her speech word for word and practice how she will deliver the speech. A disadvantage of this method is a person may sound too practiced or stiff. To avoid sounding rehearsed, use eye contact, facial expressions and vocal variety to engage the audience. Use frequent glances at highlighted key points instead of reading the speech word for word.

Memorization

The memorization method is a form of speech delivery that involves fully memorizing a speech, from start to finish, before delivering it. This method of delivery allows a speaker to move around the stage or platform and maintain eye contact with the audience without relying on a script or notes. For speakers who deliver their speeches by memorization, add inflection to the voice and keep notes nearby to avoid forgetting an important key point.

The impromptu speech is spur-of-the-moment, with little to no time to prepare for this type of speech. For this method, you may be asked to give a few remarks, or share your thoughts with the group. The important thing to remember with this type of speaking is to know your main point, limit your thoughts to two to three ideas, and wrap it up with a conclusion. If you can think well enough on your feet, your conclusion will connect to your opening remarks or main idea. Impromptu speeches are best kept brief.

Extemporaneous

The extemporaneous method is ideal for most speaking situations. While it requires a great deal of preparation, it allows for great flexibility for the speaker, often delivering a much more engaging speech. For this method, a speaker will organize a speech with notes or an outline, and practice the delivery, but not word-for-word. A speaker may highlight key points in the speech and memorize a few portions of the speech, but will also speak in a more conversational tone. The extemporaneous method of delivery gives a speaker the flexibility to deliver a speech in a natural manner while maintaining eye contact and engaging an audience.

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• Westside Toastmasters: The 4 Delivery Methods
• Four Types of Speech Delivery

• Presentation Science

4 Presentation Delivery Styles You’ll Want to Consider

• By: Amy Boone

“Never speak from a manuscript.” Those were the words my public speaking professor drilled into us in college. She led us to believe it was perhaps the worst thing we could do. And for many, it probably was. But for me, when I stood up to speak, I needed the words. All the words. I wasn’t going to read them verbatim, but just having them there gave me a boost of confidence during my presentation delivery.

Many people just end up reading the notes in front of them, so having a manuscript isn’t a good idea for lots of speakers. But how do you choose? When it comes time to deliver your big presentation, you have at least 4 major delivery styles you can choose from: memorized, manuscript, impromptu, and extemporaneous. Each of these styles has advantages and disadvantages that you’ll want to weigh when choosing which style to use.

Memorized delivery is perhaps one of the toughest there is. Way, way back at the beginning of the field of public speaking (rhetoric), memorization was one of the 5 main components. So students of public speaking were incredibly skilled in the art of memorization and their memorization skills were put to the test as they recited long orations.

But communication has changed a lot. These days audience members like to feel like they are part of the message in some way, like their presence matters. But memorized delivery doesn’t allow for much interactivity because it makes it difficult to establish “a perception of give and take between the audience and the speaker.”

But that doesn’t mean there aren’t instances when memorization is good choice for delivery. If you are giving a press release or delivering an incredibly important speech that will be recorded and shared, it can be good idea to memorize what you want to say. Just keep in mind how difficult it can be to commit to memory long works. Make sure to leave yourself enough time to both learn the piece and then to learn how to deliver it naturally. Here are the advantages and disadvantages of memorized delivery as outlined in the book Between One and Many .

• Allows for constant eye contact with the audience
• Gives more freedom of movement
• Allows for precise and correct wording

Disadvantages

• Easy to forget
• Appears “canned” and cold
• Requires extensive preparation time
• Does not allow for spontaneity

Delivering from a manuscript is similar in many ways to memorized delivery. In this case, you have your presentation written out word-for-word on speaker’s notes that you then reference or read from during your presentation. Manuscript delivery can be useful if you need word precision but don’t have time to commit your presentation to memory.

It can also help if you’ll be delivering words that someone else wrote. We see this style most frequently today through the use of teleprompters that are used for newscasts and many political speeches. Every president since Ronald Reagan has made use of the teleprompter , which makes sense given that every word they utter will inevitably come under scrutiny.

Just remember that manuscript delivery is all about offering a comfortable experience for the speaker—taking the pressure off of him/her. But it doesn’t offer much to audience in the way of entertaining delivery or eye contact. So you’ll want to weigh the risk of boring or losing your audience with the reward of an “easier” delivery style which has these advantages and disadvantages :

• Accuracy and precision
• Transcript can be released quickly/simultaneously
• Less pressure to read than to deliver
• Allows for high control over outcome
• Allows for limited eye contact
• Tends toward written rather than oral style
• Can be easy to lose your place

Impromptu delivery is speaking with little to no preparation. It is “winging it” or speaking “off the cuff.” I know very few accomplished speakers who would willingly choose to use this delivery style. Even those speakers who feel energized by the thrill of impromptu delivery and can perform well under that kind of pressure know that preparation and practice will always result in a better end product.

For that reason, we never encourage a speaker to make impromptu delivery his or her chosen method of delivery. But you may need to deliver an impromptu message if the situation arises–like a job interview question you weren’t expecting, being put on the spot in a meeting, or having to fill in if the prepared speaker is unable to make it. In those cases, keep these advantages and disadvantages in mind.

• Allows for spontaneity
• Allows for lots of eye contact
• Gives speaker freedom to adapt freely to any given context/situation
• No time to prepare
• Can lead to high levels of anxiety
• Allows for low control over outcome

Extemporaneous

The final presentation delivery method is the one we recommend and use most frequently. Extemporaneous delivery can be defined as practiced and prepared, but flexible. The story of “Goldilocks and the 3 Bears” can help us here. With memorized and manuscript delivery, we are in Papa Bear territory where everything feels a bit too rigid, too hard, too confining. Impromptu delivery is Mama Bear’s stuff–too mushy and too soft. But with extemporaneous delivery, like Goldilocks finding Baby Bear’s possessions, there’s a happy medium. It feels just right.

So how does it work? With extemporaneous delivery, you develop your content–researching, editing, and revising until you get it right. Then, you move into the practice and preparation stage. Here’s where you’ve got flexibility for how you handle it. Some people like to practice from a nearly complete manuscript—hitting the main points, referencing notes as needed, but allowing for varied phrasing as it naturally occurs.

Others might prefer to practice from a very scant outline. So instead of having a story written out word-for-word, they might prefer just to have “tell story about first day on the job” written in their notes. This doesn’t mean that they don’t practice telling the story over and over again. It just means the words aren’t on the page directing them to tell it exactly the same every time. Your speaker’s notes should always come down to your personal preference.

The goal of extemporaneous speaking is to marry the best of memorized and manuscript delivery—the ability to use beautiful and precise language that moves the audience—with the best of impromptu delivery—the ability to deliver a message with warmth and character. And we know from research that both precision and warmth matter to the audience. Scientific research shows that speakers who use great eye contact come off as more “believable, confident and competent.” That said, here are the advantages and disadvantages of this, our favorite style:

• Combines the best of preparation and spontaneity
• Allows speaker to use notes but also maintain regular eye contact
• Allows speaker to be both adaptable and precise
• Overuse of notes can limit eye contact and gestures

When I deliver, I use an extemporaneous style. I don’t read what I’ve written word-for-word, but I like to have notes prepared like I was going to deliver from a manuscript. You may be like me and find a system that is a mix of categories that works for you. There may be parts of your presentation that you want to have memorized so you get the words exactly right. And you may want to deliver other parts of your speech more freeform, having prepared and practiced, but feeling free to change things up if the context or mood of the moment calls for it.

Whatever you decide, keep working and adapting and trying to new methods to find what works best for you. And realize that there will probably be situations in which time constraints or other factors keep you from being able to practice, prepare, and deliver like you’d prefer to. That’s okay. That’s the beauty of presentation delivery. It’s a little bit different every time. But it’s always a worthwhile adventure.

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9.1 Methods of Presentation Delivery

The importance of delivery.

Delivery is what you are probably most concerned about when it comes to giving presentations. This chapter is designed to help you give the best delivery possible and eliminate some of the nervousness you might be feeling. To do that, you should first dismiss the myth that public speaking is just reading and talking at the same time. Speaking in public has more formality than talking. During a speech, you should present yourself professionally. This doesn’t necessarily mean you must wear a suit or “dress up”, but it does mean making yourself presentable by being well groomed and wearing clean, appropriate clothes. It also means being prepared to use language correctly and appropriately for the audience and the topic, to make eye contact with your audience, and to look like you know your topic well.

While speaking has more formality than talking, it has less formality than reading. Speaking allows for flexibility, meaningful pauses, eye contact, small changes in word order, and vocal emphasis. Reading is more or less an exact replication of words on paper without the use of nonverbal interpretation. If you think about great presentations you have seen and heard, you will realize that speaking provides a much more animated and engaging message.

Methods of Presentation Delivery

There are four methods of delivery that can help you balance between too much and too little formality when giving a presentation.

Impromptu Speaking

Impromptu speaking is the presentation of a short message without advance preparation. You have probably done impromptu speaking many times in informal, conversational settings. Self-introductions in group settings are examples of impromptu speaking: “Hi, my name is Steve, and I’m an account manager.” Impromptu speaking also occurs when you answer a question such as, “What did you think of that report?” Your response is unplanned, so you are constructing your arguments and points as you speak. Now envision yourself going into a meeting when your boss suddenly says, “I want you to spend a few minutes talking about the last stage of the project….” Although you are not prepared to present on that topic, experience and practice may allow you to do so with relative ease.

The advantage of impromptu speaking is that it’s spontaneous and responsive in an animated group context – your audience is not expecting perfection. The disadvantage, is that with little or no time to contemplate the central theme of your message, it may come out disorganized and difficult for listeners to follow. Although perfection is not possible, you will want to deliver a sound and coherent message, remembering that impromptu presentations are generally most successful when brief and focused on a single point.

Here is a step-by-step guide that may be useful if you are called upon to give an impromptu presentation in public:

• Take a moment to collect your thoughts and plan the main point you want to make.
• Thank the person for inviting you to speak. Avoid making comments about being unprepared, called upon at the last moment, on the spot, or feeling uneasy.
• Deliver your message, making your main point as briefly as you can while still covering it adequately and at a pace your listeners can follow.
• If you can, create some structure, using numbers if possible: “Two main reasons . . .” or “Three parts of our plan. . .” or “Two side effects of this drug. . .” Timeline structures are also effective, such as “past, present, and future or East Coast, Midwest, and West Coast”.
• Thank the person again for the opportunity to speak.
• Stop talking (it is easy to “ramble on” when you don’t have something prepared). If in front of an audience, don’t keep talking as you move back to your seat.

For additional advice on impromptu speaking, watch the following 4 minute video

Video: Impromptu Speaking by Toastmasters International  [4:00] Transcript available

Manuscript Presentations

Manuscript presentations  are the word-for-word iteration of a written message . In a manuscript presentation, the speaker keeps their attention on the printed page except when using visual aids. The advantage of reading from a manuscript is the exact repetition of original words. In some circumstances this can be extremely important. For example, reading a statement about your organization’s legal responsibilities to customers or announcing a new policy pertaining to maternity leave may require that the wording be exact.

A manuscript presentation may be appropriate at a more formal affair (like a report to shareholders), when your presentation must be said exactly as written in order to convey the proper emotion or decorum the situation deserves, ho wever there are costs involved in manuscript presentations. First, it’s typically an uninteresting way to present. Unless the presenter has rehearsed the reading as a complete performance, animated with vocal expression and gestures, the presentation will tend to be dull. Keeping one’s eyes glued to the script prevents eye contact with the audience. For this kind of “straight” manuscript presentation to hold audience attention, the audience must be already interested in the message and presenter before the delivery begins.

It is worth noting that professional speakers, actors, news reporters, and politicians often read from an autocue device, commonly called a teleprompter, especially when appearing on television, where eye contact with the camera is crucial. With practice, a presenter can achieve a conversational tone and give the impression of speaking extemporaneously and maintaining eye contact while using an autocue device. However, success in this medium depends on two factors: (1) the presenter is already an accomplished public speaker who has learned to use a conversational tone while delivering a prepared script, and (2) the presentation is written in a style that sounds conversational and in spoken rather than written, edited English.

Extemporaneous Presentations

Extemporaneous presentations are carefully planned and rehearsed presentations, delivered in a conversational manner, using brief notes . By using notes rather than a full manuscript, the extemporaneous presenter can establish and maintain eye contact with the audience and assess how well they are understanding the presentation as it progresses. Without all the words on the page to read, you have little choice but to look up and make eye contact with your audience.

Watch the following 10 minute video of a champion speaker presenting his extemporaneous speech: 2017 International Extemporaneous Speaking National Champion — Connor Rothschild Speech

Video: 2017 International Extemporaneous Speaking National Champion — Connor Rothschild Speech by Jennifer Rothschild [10:40] Transcript available

Presenting extemporaneously has some advantages. It promotes the likelihood that you, the speaker, will be perceived as knowledgeable and credible since you know the speech well enough that you don’t need to read it. In addition, your audience is likely to pay better attention to the message because it is engaging both verbally and nonverbally. It also allows flexibility; you are working from the strong foundation of an outline, but if you need to delete, add, or rephrase something at the last minute to adapt to your audience, you can do so.

The disadvantage of extemporaneous presentations is that it in some cases it does not allow for the verbal and the nonverbal preparation that are almost always required for a good speech.

Adequate preparation cannot be achieved the day before you’re scheduled to present, so be aware that if you want to present a credibly delivered speech, you will need to practice many times. Because extemporaneous presenting is the style used in the great majority of business presentation situations, most of the information in the subsequent sections of this chapter is targeted toward this kind of speaking.

Memorized Speaking

Memorized speakin g is the recitation of a written message that the speaker has committed to memory. Actors , of course, recite from memory whenever they perform from a script in a stage play, television program, or movie scene. When it comes to speeches, memorization can be useful when the message needs to be exact and the speaker doesn’t want to be confined by notes.

The advantage to memorization is that it enables the speaker to maintain eye contact with the audience throughout the speech. Being free of notes means that you can move freely around the stage and use your hands to make gestures. If your speech uses visual aids, this freedom is even more of an advantage. However, there are some real and potential costs.

First, unless you also plan and memorize every vocal cue (the subtle but meaningful variations in speech delivery, which can include the use of pitch, tone, volume, and pace), gesture, and facial expression, your presentation will be flat and uninteresting, and even the most fascinating topic will suffer. Second, if you lose your place and start trying to ad lib, the contrast in your style of delivery will alert your audience that something is wrong. More frighteningly, if you go completely blank during the presentation, it will be extremely difficult to find your place and keep going. Obviously, memorizing a five to seven minute presentation takes a great deal of time and effort, and if you aren’t used to memorizing, it is very difficult to pull off. Realistically, you will probably not have the time necessary to give a completely memorized speech. However, if you practice adequately, your approach will still feel like you are being extemporaneous.

“ 39. Methods of Presentation Delivery ” from Communication for Business Professionals by eCampusOntario is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Talking Business Copyright © 2023 by Laura Radtke is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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5 Effective PowerPoint Delivery Methods for Presentations

September 16, 2015 / Blog, PowerPoint, Rick Enrico Blog experts, investor presentation, PowerPoint Experts, powerpoint presentation design, PowerPoint presentation design experts, ppt designs, presentation design, presentation style, Rick Enrico, SlideGenius

Most presenters barely notice what particular presentation technique they’re using whenever they take the stage. This is because they’re not fully aware of how it could influence both their performance and their audience. When you prepare your pitch, decide whether you want to use a fast-paced approach or spend more time discussing your main points.

This provides a guide for organizing your ideas and translating them to your slides. While there are many presentation styles which work best for different speakers, there are also PowerPoint delivery methods that they can use to optimize their slides. Here, we’ll define some techniques introduced and practiced by popular presenters:

The Takahashi Method

Named after Masoyoshi Takahashi, this approach relies heavily on keywords with one main point placed per slide. Instead of using images, bullet points, or other visual elements , words are used as visuals.

This method requires many slides (depending on your content) since each one only has a few words displayed. Applying this method encourages your audience to pay more attention to you as the speaker, since you are the one explaining what’s projected on-screen.

The Kawasaki Method

Named after Guy Kawasaki, and also known as the “10-20-30” method (10 slides, 20 minutes, 30 font size). This approach is commonly used for investor presentations where a short yet impactful approach is needed to stand out among the competition.

This allows you to give brief but understandable messages within a limited time.

The Lessig Method

Used by Lawrence Lessig, this style has a limited use of images, relying more on words, similar to Takahashi’s style. Concise words or statements are used and slides are changed around, depending on the words the presenter delivers.

This focuses more on telling a story and injects a more synchronized approach, generating interest and allowing audiences to be more attentive.

The Godin Method

Seth Godin’s technique is a combination of texts and images, where the speaker uses striking photos to let the pictures speak for themselves. This lets him explain what he’s trying to point out and reiterate his main ideas through images.

This approach differs from Takahashi and Lessig’s, since they’re more focused on conveying their message primarily with text. The advantage? Using this appeals to the audience’s passions and establishes an emotional connection with them.

The Steve Jobs Method

Steve Jobs’ style concentrates on large images and texts, focusing on one statement per slide and combining it with visual elements. This gives the presenter the chance to offer demonstrations and allow a more interactive way of communicating his ideas.

This method enables your performance to be more interesting and powerful, allowing the audience to get the message easily for maximum impact.

In Conclusion

Let your objectives dictate your manner of presenting. Situations requiring brevity and conciseness might require the Kawasaki Method. The Takahashi and Lessig methods favor a confident presenting style to better focus attention on the speaker. The Godin and Jobs methods use strong images that create strong emotional connections.

The key is to understand and identify your objective as a presenter. Once you know this, you can then decide on what presentation style to use. Choose which one of the delivery methods suits you the most. Let SlideGenius experts help you out!

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5 keys to perfecting your presentation delivery in a hybrid world

Josh Storie

If I were to ask you to describe the average hybrid presentation, what words would you use? Clunky? Awkward? Disjointed? Distracting? There’s a good reason for that: Presenting to both in-person and virtual teams is still somewhat new.

Sure, years ago we had a few lone rangers who worked from home and dialed in virtually. But most of us were used to being in the same room with our colleagues. So, we were well versed on how to nail a live presentation from the front of the room. We knew where to stand, when to move, how to keep our hands from flailing about, and how to read the room to increase audience engagement.

Then COVID happened.

Overnight, our orientation and perspective changed. We all had to become online presenters—and video producers. We had to quickly learn how to frame our bodies within the camera lens, share our screen, engage with audience via chat threads and breakout rooms—all while trying to hold the attention of listeners who were balancing dogs, diaper changes, and doorbells.

And just when it feels like we’re starting to perfect those virtual presentation skills , the world is opening back up. Now we have to navigate another new world of hybrid communication.

Suddenly we must find ways to connect with hybrid audiences in new ways. We must move an audience that is both six feet away and six states away. No wonder we think of hybrid presentations as clunky and awkward. They present significant communication challenges.

Here are some simple tips to help you improve your hybrid presentation delivery.

#1: Level the Playing Field

In some ways, hybrid environments bring audiences together. But in other ways, it can make some groups feel isolated. We suggest adopting this rule:

If one person is virtual, the entire group is virtual.

In fact, the Duarte Strategy and Content team made this decision for our own weekly meetings. We found that when some of us were in-person and only one or two team members were virtual, we inevitably overlooked the virtual folks. And while we never intended to leave anyone out, those meetings made everyone feel disconnected. We encourage you to consider this policy for small groups and teams. If you’d prefer to maintain a hybrid workplace, at least adopt a virtual-first mindset.

#2: Acknowledge Both Audiences

It would be painfully awkward for a live speaker to neglect the people sitting right in front of them. Yet, speakers can easily forget to acknowledge the presence of a virtual audience when presenting in a hybrid environment. Go ahead and greet your live audience with a great big “Hello! It’s so nice to see many of you in person!” But don’t forget to greet your virtual audience, too. “And thanks to those of you joining us virtually.” Let them know that you’re not only aware they exist, you’re thrilled they chose to give you their time. A simple acknowledgment goes a long way.

#3: Treat the Camera as a Participant

Make sure you talk to the camera as if it were a person in your live audience. It can be hard to make this look fluid in a way that doesn’t distract the folks in front of you. But here’s a piece of advice that’s fairly easy for your brain and eyes to coordinate: Say one sentence to one person and then pause briefly. Direct the next sentence to another person and so on. Depending on the size of your audience, deliver a sentence to the camera about every four to six sentences. The people at home will feel seen and involved.

#4: Use a Producer

If the stakes are high and downplaying your virtual audience feels like a bad business move, recruit a colleague to pay attention to them when you can’t. This person doesn’t have to be a professional producer, just someone who can focus solely on the needs of your virtual audience—monitor chats, answer questions, respond to technical difficulties, and implement creative ways to include virtual participants. The producer might even lead a virtual breakout while the in-person audience segments into small groups themselves. This will allow you to focus on the in-person audience without neglecting your virtual audience.

#5: Rehearse with Your Tech Setup

We’ve all witnessed presentations where the speaker was thrown for a loop when their technology didn’t work as expected. WiFi goes out. Laptops crash at the most inopportune time. Luckily, these tech problems are typically the exception, not the rule.

Oftentimes, the fluidity of a presentation is interrupted by completely preventable technical mishaps. That’s why you should plan ahead and rehearse with your presentation technology for both your in-person and virtual audiences. Test what your live audience sees and hears and test what your virtual audience sees and hears. And have a backup in case anything goes wrong. Having the confidence that your tech is working correctly for both audiences will give you the freedom to focus on your content.

In many ways, the key to improving hybrid presentation delivery mirrors the same best practices we’ve taught for years: take time to plan ahead, connect with your audiences on their terms, develop compelling content, and practice your delivery . Because we predict that hybrid presenting isn’t going away any time soon.

Check out these related resources

3 lessons learned from the return to hybrid presenting

Practical delivery tips to improve your command of the virtual environment.

Crafting content for virtual communication: Keep it short and interesting

Here are 5 simple ways to adjust your virtual content and keep people engaged.  

Get more from your virtual platform: Confessions of an accidental platform expert

When it comes to using virtual platforms, most users have reached the “OK plateau.” The antidote is deliberate practice.

This paper is in the following e-collection/theme issue:

Published on 12.6.2024 in Vol 11 (2024)

Enabling People With Intellectual and Sensory Disabilities to Trigger a Tablet’s Delivery of Task Instructions by Walking to the Tablet: Proof-of-Concept Study

Authors of this article:

Original Paper

• Giulio E Lancioni 1 , PhD   ; 
• Nirbhay N Singh 2 , PhD   ; 
• Mark F O’Reilly 3 , PhD   ; 
• Jeff Sigafoos 4 , PhD   ; 
• Gloria Alberti 1 , MA   ; 
• Isabella Orlando 1 , MA   ; 
• Valeria Chiariello 1 , MA   ; 
• Lorenzo Desideri 5 , PhD  

1 Lega F D’Oro Research Center, Osimo, Italy

2 Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA, United States

3 College of Education, University of Texas at Austin, Austin, TX, United States

4 School of Education, Victoria University of Wellington, Wellington, New Zealand

5 Department of Psychology, Sigmund Freud University, Milan, Italy

Corresponding Author:

Giulio E Lancioni, PhD

Lega F D’Oro Research Center

Via Linguetta 3

Osimo, 60027

Phone: 39 3408323465

Email: [email protected]

Background: People with intellectual and sensory or sensory-motor disabilities tend to have problems performing multistep tasks. To alleviate their problems, technological solutions have been developed that provide task-step instructions. Instructions are generally delivered at people’s request (eg, as they touch an area of a computer or tablet screen) or automatically, at preset intervals.

Objective: This study carried out a preliminary assessment of a new tablet-based technology system that presented task-step instructions when participants with intellectual and sensory disabilities walked close to the tablet (ie, did not require participants to perform fine motor responses on the tablet screen).

Methods: The system entailed a tablet and a wireless camera and was programmed to present instructions when participants approached the tablet, that is, when the camera positioned in front of the tablet detected them. Two instructions were available for each task step. One instruction concerned the object(s) that the participants were to collect, and the other instruction concerned the “where” and “how” the object(s) collected would need to be used. For 3 of the six participants, the two instructions were presented in succession, with the second instruction presented once the required object(s) had been collected. For the other 3 participants, the two instructions were presented simultaneously. Instructions consisted of pictorial representations combined with brief verbal phrases. The impact of the system was assessed for each of the 2 groups of participants using a nonconcurrent multiple baseline design across individuals.

Results: All participants were successful in using the system. Their mean frequency of correct task steps was close to or above 11.5 for tasks including 12 steps. Their level of correct performance tended to be much lower during the baseline phase when they were to receive the task-step instructions from a regular tablet through scrolling responses.

Conclusions: The findings, which need to be interpreted with caution given the preliminary nature of the study, suggest that the new tablet-based technology system might be useful for helping people with intellectual and sensory disabilities perform multistep tasks.

Introduction

People with intellectual disabilities tend to have problems carrying out multistep tasks, largely due to difficulties in remembering the different steps included in the tasks and the order in which they should be performed [ 1 - 5 ]. The problems may be even greater in situations where intellectual disabilities are combined with sensory or sensory-motor impairments [ 6 - 8 ]. In spite of the difficulties encountered, fostering the ability to carry out multistep tasks remains a main rehabilitation objective, vital for ensuring that people will be able to achieve functional occupation and have a constructive role within their daily contexts and possibly within vocational contexts [ 1 , 9 - 12 ]. Such achievement is considered critical for advancing their condition, offering them new socially adaptive opportunities, and improving their quality of life [ 8 , 11 , 13 - 19 ].

Given the relevance of enabling people to manage the performance of multistep tasks, a large variety of studies have been conducted with the aim of reaching this goal with the support of technological solutions [ 1 , 4 , 20 ]. These technological solutions, designed to provide instructions for performing task steps correctly and in the right sequence, present several differences [ 10 , 21 ]. The most obvious differences concern (1) the characteristics of the instructions provided (eg, static pictorial images vs video clips illustrating the steps with or without an accompanying verbal phrase describing the steps) and (2) the way those instructions are made available [ 1 , 4 ].

With regard to the latter aspect (ie, the way instructions are made available), two main approaches can be pointed out. The first approach relies on the use of computer or tablet devices that present instructions for the task steps based on participants’ requests. Typically, participants initiate the request by performing a specific action such as touching an area of the computer or tablet screen [ 5 , 9 , 22 - 24 ]. The second approach relies on computer, tablet, or smartphone devices presenting the instructions automatically, at preset time intervals, eliminating the need for participants to produce specific request responses [ 7 , 25 , 26 ]. The intervals between instructions are decided by staff personnel familiar with the participants and the time they require for carrying out the different task steps.

The second approach may be considered advantageous for participants who cannot successfully use the first approach due to challenges in providing appropriate responses on computer or tablet screens (eg, inaccuracy in executing touch and scroll responses required to operate these devices) [ 27 , 28 ]. On the other hand, the presentation of instructions at preset time intervals may not always be consistent (in synchrony) with the participants’ performance. Although staff may have estimates of the times required by the participants for carrying out the task steps, the participants’ response speed and efficacy may fluctuate within and across days, making the intervals programmed based on those estimates too long or too short [ 8 , 16 ]. This may lead to participants missing some instructions and related task steps or having to wait for the instructions.

A possible way to bypass the shortcomings of the aforementioned approaches may involve the development of a technology system that (1) presents instructions without requiring the participants’ performance of fine motor responses on the computer or tablet screen and simply (2) associates instruction presentation with participants’ walking toward the system [ 8 , 16 , 27 ]. Such a system would ensure that participants who struggle with performing accurate motor responses on a computer or tablet screen do not need to use those responses. At the same time, this system would guarantee that instructions are delivered at the appropriate time (directly linked to people’s actions) rather than at preset time intervals [ 8 , 16 , 29 ].

This study aimed to set up such a system and carry out a preliminary evaluation of it with 6 participants with intellectual and sensory disabilities. The system consisted of a tablet and a wireless camera and was programmed to present instructions when the participant approached the tablet, that is, as the participant was spotted by the camera positioned in front of the tablet. Two instructions were available for each task step. One instruction concerned the object(s) that the participants were to collect, and the other concerned the “where” and “how” the collected object(s) were to be used. For 3 participants, the two instructions were presented in succession, with the second instruction displayed after the required object(s) had been collected. For the other 3 participants, both instructions were presented simultaneously. Instructions consisted of pictorial representations combined with brief verbal phrases. For each of the two groups of participants, the study was conducted following single-case research methodology.

Participants

Table 1 lists the participants included in the study (categorized into two groups of 3 based on their use of the task-step instructions) and reports their chronological ages and their Vineland age equivalents for daily living skills (personal subdomain) and receptive communication. The participants, who have pseudonyms ( Table 1 ), were between 23 and 62 years of age. All of them were diagnosed with sensory disabilities. Specifically, Allie had severe hearing loss. Sylvie, Rowan, Demi, and Jolene had serious impairments of their neurovisual system, leading to severe limitations in their visual acuity. Emory presented with severe limitations in her visual acuity as well as severe hearing loss. The use of eyeglasses allowed all participants to discriminate pictorial images of familiar objects on a tablet screen and to navigate easily within familiar contexts. Vineland age equivalents (measured via the second edition of the Vineland Adaptive Behavior Scales [ 30 , 31 ]) ranged from 4 years to 5 years and 3 months for personal daily living skills and from 3 years and 4 months to 4 years and 3 months for receptive communication. All participants attended rehabilitation and care centers, where the psychological services classified their level of functioning within the moderate intellectual disability range. However, no IQ scores were available.

The participants were recruited for the study based on a number of general criteria. First, they were unable to carry out multistep tasks without staff guidance or specific step instructions. Second, they could use pictorial representations alone or in combination with simple verbal phrases as instructions for the performance of task steps. Third, they expressed their willingness to use the technology system adopted in this study (and shown to them in advance) for carrying out multistep tasks involving familiar material and areas within their daily contexts. Fourth, they had poor fine motor skills and were considered unable to reliably use a tablet for accessing a series of task-step instructions. Fifth, staff supported their involvement in the study and considered technology-aided task engagement a positive goal for the participants and their contexts.

a Age equivalents are based on the Italian standardization of the Vineland scales [ 30 ].

Ethical Considerations

The study was approved by the Ethics Committee of the Lega F. D’Oro, Osimo (Ancona), Italy (P072820235). All procedures performed were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

As mentioned above, the participants had expressed their willingness to use the technology system to carry out tasks involving familiar material. Moreover, staff had indicated that the participants would enjoy performing the tasks provided that difficulties and errors (and thus frustration) would be largely avoided, which was the expectation within this study. While these two points suggested the study would be a positive experience for the participants, it was not possible for them to read and sign a formal consent document. Consequently, their legal representatives were directly involved in the consent process, reading and signing the consent forms on the participants’ behalf.

Setting, Sessions, Tasks, Instructions, and Research Assistants

Familiar rooms within the participants’ daily environments constituted the setting for the study. Sessions were typically carried out 1 or 2 times per day, 4 to 6 days a week. During each session, the participants were asked to perform 1 task. Tasks consisted of combinations of 12 steps. Each step involved 2 simple actions, which were familiar and meaningful to the participants, for example, “take the toilet paper” and “bring the toilet paper to the men’s room.” The combinations of steps (and related actions) led to a recognizable and practically relevant outcome, such as setting up a bathroom and cleaning the entrance, arranging the living room and putting away papers and books, and preparing or cleaning the dining room [ 16 ]. Tasks could be flexible, that is, they could include different combinations of steps on different days based on practical and environmental conditions [ 16 ]. Moreover, a number of steps could be used across different tasks. In total, 9 tasks were available to each participant. Textbox 1 provides a combination of 12 steps that could be included in a task such as supplying the bathroom and arranging the kitchen.

The instructions the tablet provided for the 2 actions involved in each task step consisted of 2 pictures ( Figure 1 and Figure 2 ) accompanied by brief verbal phrases (explained further under the Technology System section below). For the first 3 participants listed in Table 1 (ie, Rowan, Allie, and Sylvie), the 2 pictures were presented separately (ie, one at a time in sequence), and each picture was accompanied by a verbal phrase matching it. For the other 3 participants (ie, Jolene, Emory, and Demi), the 2 pictures were presented simultaneously (ie, one next to the other, as shown in Figure 1 and Figure 2 ), accompanied by a verbal phrase matching them (explained under the Technology System section below).

The presentation of the two instructions available for each task step in sequence or simultaneously was based on the participants’ history, that is, their use of the pictures within their daily contexts, under the supervision of regular staff personnel. The research assistants were 4 women who held a master’s degree in psychology and had experience with the implementation of technology-aided programs with people with intellectual and multiple disabilities as well as with data collection strategies.

• Take the toilet paper and bring it to the men’s bathroom.
• Take the towel and bring it to the ladies’ bathroom.
• Take the toothpaste and bring it to the men’s bathroom.
• Take the toilet paper and bring it to the ladies’ bathroom.
• Take the deodorant and bring it to the ladies’ bathroom.
• Take liquid soap and bring it to the men’s bathroom.
• Take the aluminum and bring it to the microwave.
• Take paper towels and put them in the kitchen drawer.
• Take the chips and put them on the kitchen table.
• Take the flowers and put them in the kitchen sink.

Technology System

Basic components.

The technology included (1) a Samsung Galaxy tablet with an internet connection and MacroDroid and CloudEdge apps and (2) a DEATTI wireless (battery-powered) camera with a passive infrared sensor [ 32 ]. The tablet was also fitted with (1) pictures and verbal phrases used as instructions for the task steps; (2) positive-feedback pictures and praise words shown after the completion of each task step; and (3) videos with the participants’ preferred music, comic sketches, or food preparation presented after the completion of the last task step. The tablet was located in one of the rooms used for the tasks. The camera was positioned about 1.5 meters before the tablet. By walking to the tablet, the participants automatically activated the camera, making it send an input to the tablet via the CloudEdge app. This input was used by the MacroDroid app to make the tablet present task-step instructions.

Instructions Presentation

The first 3 participants (ie, Rowan, Allie, and Sylvie) received the two instructions available for each task step in succession (explained in the Setting, Sessions, Tasks, Instructions, and Research Assistants section). With a task step such as “bringing liquid soap from a store cabinet to the sink area of a specific bathroom,” for example, the instruction the participants received the first time they approached the tablet consisted of a picture showing the liquid soap inside a store cabinet (or simply the liquid soap) accompanied by the verbal phrase “take the soap.” The instruction they received the second time they approached the tablet for that step (while they were carrying the soap they had collected from the cabinet) involved a picture representing the soap on the sink of the red bathroom accompanied by the verbal phrase “bring the soap to the red bathroom.” Once a step was completed, approaching the tablet led to the tablet’s presentation of (1) positive feedback with a picture showing hand clapping, thumbs up, or another representation indicating approval and a praise word, and (2) the first instruction for the following task step. The process continued as described above for all other steps of the task and included the presentation of a 2.5-minute video of a preferred (music, comic, or food preparation) event following the completion of the last step. After the delivery of an instruction, the system had a brief period (15-25 seconds) of inertia to ensure that the participant could go back for a second look at the tablet screen without a change of instruction.

For the last 3 participants (ie, Jolene, Emory, and Demi), the tablet presented the two instructions available for each task step simultaneously. For example, for a step such as “bringing liquid soap from a store cabinet to the sink area of the red bathroom,” the tablet presented a picture showing soap (or soap in the cabinet) to the left and a picture showing soap on the sink of the red bathroom to the right and accompanied such presentation with a phrase like “take the soap and bring it to the red bathroom.” Returning to the tablet (ie, after completing a step) triggered the tablet’s presentation of positive feedback plus praise word followed by the presentation of the instructions for the next task step. The positive feedback and praise word after each completed step, the video of a preferred event at the end of the task, and the idleness of the tablet after the delivery of instructions matched those used for the first 3 participants.

Experimental Conditions and Data Analysis

The study started with a pretest verifying whether the participants could carry out the tasks independent of specific step instructions. After the pretest, each of the two groups of participants had a baseline phase followed by an intervention phase. These phases were implemented according to a nonconcurrent multiple baseline design across participants [ 33 , 34 ]. In practice, the participants of each group received different numbers of baseline sessions before the start of the intervention with the technology system. Pretest, baseline, and intervention sessions were implemented by the research assistants. To make sure that their application of the procedural conditions was accurate (that their level of procedural fidelity was high), two strategies were adopted. One involved their preliminary familiarization with those conditions while the other involved regular feedback on their performance [ 35 ]. Feedback was delivered by a research coordinator who had access to video recordings of the sessions.

The participants’ data concerning the correctly performed task steps were reported in graphic form. To simplify the graphic presentation, data points were made to represent blocks of sessions. The baseline and intervention frequencies of correct task steps were compared using the “Percentage of data points Exceeding the Median” method [ 36 , 37 ]. This method, which is one of the most practical tools to evaluate single-case research data, served to determine how many data points of the intervention phase were above the baseline median.

The pretest included 5 sessions. Each session started with the research assistant asking the participants to carry out a task. The request was made via a simple verbal statement and a general pictorial representation. The statement summarized what the participants were to do (eg, “you can supply the bathroom and set up the kitchen table”). The pictorial representation included a drawing of the areas (bathroom and kitchen table) involved in the task. The research assistant did not intervene if the participants carried out steps involved in the task. If the participants remained passive for 30-60 seconds or carried out a step not involved in the task, the research assistant provided guidance for a task step (eg, helped them to bring the toilet paper to a red bathroom). The session continued until the participants had carried out all task steps or had received the research assistant’s guidance for the performance of 2 steps. All the steps omitted as well as those carried out with the research assistant’s guidance were counted as noncorrect. At the end of a session, the participants were presented with a 2.5-minute video of preferred music, comic, or food preparation events.

The baseline included 7, 8, and 13 sessions for the participants of the first group and 6, 8, and 12 sessions for the participants of the second group. Those sessions served to determine whether the participants were able to use a tablet independently to obtain task-step instructions and then carry out those steps. Each session started with the research assistant placing a tablet on a desk and asking the participants to use it to get instructions for a specific task. Meanwhile, the research assistant demonstrated how to use the tablet (ie, operating horizontal scrolling) to receive the step instructions. If participants were unsuccessful or passive for 30-60 seconds, the research assistant provided guidance (ie, carried out the tablet scrolling for them and ensured that they performed the task step indicated by the tablet instructions). Two instances of guidance from research assistants were allowed per session. A session lasted until the participants had either carried out the last step of the task or failed to progress (eg, due to a new unsuccessful or passive period following the research assistant’s guidance instances or due to inaccurate scrolling leading them to skip the instructions or shut the presentation process). At the end of a session, the participants were presented with a 2.5-minute video of their preferred music, comic, or food preparation events.

Intervention

The intervention phase included 97, 83, and 88 sessions for the participants of the first group and 87, 64, and 69 sessions for the participants of the second group. During the intervention, the participants had the technology system that worked as described in the Technology System section. The objective was to determine whether the system was suitable to help the participants carry out the tasks correctly. Each session started with the research assistant accompanying the participants to the area where the tablet was available (ie, just before the camera). When the camera detected the participants, the tablet was triggered to produce the first instruction delivery. All the rest was as described in the Technology System section. The first 2 sessions served as introductory sessions in which the research assistant could provide guidance any time the participants showed signs of hesitation or difficulty. During the following (regular intervention) sessions, no research assistant’s guidance was available except if a participant asked for it.

Data Recording

Data recording concerned (1) the number of task steps performed correctly (ie, in line with the step descriptions and independent of the research assistant’s guidance) within the sessions and (2) the length of the sessions. Data were recorded by the research assistants responsible for the implementation of the sessions. Interrater agreement was assessed by having a reliability observer record the participants’ performance of the task steps and the sessions’ length in 21% to 23% of the participants’ sessions. The percentage of agreement (calculated by dividing the number of sessions in which the 2 raters reported the same number of correct steps and session lengths differing by less than 1.5 minutes by the total number of sessions in which agreement was checked, and multiplying by 100%) ranged between 91 and 100% across participants.

Figures 3 and 4 report the baseline and intervention data for the first group of participants (ie, Rowan, Allie, and Sylvie) and the second group of participants (ie, Jolene, Emory, and Demi), respectively. The black triangles represent mean frequencies of correct task steps over blocks of 2 sessions. Occasional blocks with 3 sessions (at the end of the phases) are marked with an arrow. The figures do not report the 2 introductory sessions carried out at the start of the intervention phase.

During the pretest, the participants’ frequency of correct task steps per session was (virtually) zero. Indeed, they could carry out a single step (not necessarily involved in the task presented) or remain inactive. All sessions were interrupted after they had received guidance for 2 task steps. The mean session length was below 10 minutes for all participants.

During the baseline, the participants’ mean frequency of correct steps per session varied between about 1.5 (Allie) and 6 (Emory) out of the 12 steps available for each of the tasks. Such frequency reflected their inaccurate (unreliable) use of the tablet (ie, skipping step instructions or blocking the scrolling process and closing the instructions’ presentation) with the consequent omission of many task steps. The mean session length was about 6.5 (Jolene) to 14.5 (Emory) minutes. The mean length across participants was about 11.5 minutes.

During the intervention, the participants carried out the tasks successfully, and the mean frequency of task steps performed correctly per session varied between near 11.5 (Jolene and Demi) and above 11.5 (all other participants). The mean session length varied between about 15 (Demi) and 29.5 (Allie) minutes. The mean length across participants was about 19.5 minutes. The session length reported for pretest, baseline, and intervention always included the 2.5-minute preferred video shown at the end of the sessions. The large differences in the session length observed during the intervention (when the frequency of correct steps was similar across participants) mainly reflected differences in the participants’ performance speed. The Percentage of data points Exceeding the Median method showed indices of 1 for all participants (ie, all their intervention data points were higher than their median baseline frequency value) confirming the strong impact of the intervention with the technology system on their task performance.

Principal Findings

The results suggest that the technology system used during the intervention was adequate to help the participants receive step instructions in a timely fashion and without the need to produce specific responses on the tablet. The participants’ high frequency of correct task steps and the stability of such frequency across the intervention phase suggest that the instruction process was suitable for them and that they had sufficient motivation to maintain their task performance over time [ 38 - 40 ]. In light of the above, a few considerations may be in order.

First, the new technology system seems to have the characteristics required to bypass the limitations of the two main instruction technology approaches typically used with people with intellectual and developmental disabilities, that is, the approach requiring the participants to seek the instructions through simple responses on the tablet or computer’s screen and the approach providing automatic presentation of the instructions, at preset time intervals [ 1 , 4 ]. Indeed, by avoiding the need for fine motor request responses, the new system can successfully help participants who, due to poor fine motor skills, would fail to benefit from the first approach. Moreover, by ensuring a timely presentation of the step instructions based on the participants’ walking to the tablet, the new system would avoid any reliance on prearranged instruction deliveries and related risks of instruction neglect in case of performance difficulties or slowness.

Second, the system can be flexible concerning the way the instructions are presented. As viewed in this study, for example, the system can be set to present the two instructions concerning each task step at successive times for people who can handle only one simple instruction at a time (people with poor working memory [ 41 , 42 ]). The system can also be set to present the two instructions of each step simultaneously for participants who are able to handle more complex instruction inputs. Technically, the system could also be set up to present the step instructions in small chunks with people who have a relatively high level of functioning or have become very familiar with the tasks on hand and no longer need an analytic step-by-step instruction process [ 43 - 46 ].

Third, the system can be easily used for supporting tasks that may change across days in terms of the steps included. The most direct and fast way to arrange the sequence of steps included in the task on any particular day is to provide the system with a sequence of numbers representing the codes for those steps [ 16 ]. To facilitate the use of the system by staff and caregivers who have limited familiarity with technology, the system could be fitted with a series of tasks and variations thereof that can be selected by writing their names or any other code used in storing them in the tablet memory.

Fourth, the use of a webcam to trigger the tablet to present instructions can be considered a rather simple technology solution [ 47 - 50 ]. The webcam is a small battery-powered device connected to the tablet via Bluetooth, a device that is much simpler and easier to operate than conventional motion sensors, such as the Philips Hue motion sensors [ 51 ]. Moreover, the webcam’s cost (about US $60) is largely affordable [ 52 ]. When using the system within a daily context, one would be advised to locate the webcam and the tablet in a room corner. This would minimize the risk that people sharing the room with the participants can accidentally interfere with the system’s functioning.

Limitations and Future Research

The study presents 4 basic limitations, namely, the small number of participants, lack of generalization and maintenance data, lack of participants’ satisfaction data, and lack of social validation of the technology and its impact. The first limitation reflects the preliminary nature of the study, prevents one from making general statements about the findings reported, and underlines the need for new studies with additional participants [ 53 - 55 ]. The second limitation calls for new studies directed at (1) extending the number of sessions implemented and the intervention period to verify whether the intervention effects last and consolidate over time and (2) carrying out the sessions in different settings (provided these were familiar to the participants) to determine how extensively and profitably the system could be used within daily contexts [ 39 , 55 - 57 ].

The third limitation necessitates assessing how the participants perceive the intervention program. The assessment could consist of having the participants choose between the sessions with the system and other types of daily occupation. Large levels of preference for the sessions over other types of occupation would suggest participants’ satisfaction with the sessions [ 58 - 61 ]. The fourth limitation underlines the need for new studies to include staff and caregivers in the evaluation of the technology and its impact, as these personnel are finally responsible for applying the program and its technology in daily contexts. A practical way to include these personnel in the evaluation could involve (1) the personnel’s access to videos reporting the performance of different participants during intervention sessions and (2) the personnel’s rating of the videos on points such as the participants’ comfort during the sessions, the relevance of their task performance, and the overall acceptability and applicability of the intervention program [ 62 , 63 ].

Conclusions

In conclusion, the results of this study suggest that the technology system used for the intervention program implemented with 6 participants was effective in helping them carry out fairly complex tasks independently and accurately. Although quite encouraging, these results are to be taken with caution, given the limitations of the study mentioned above. New studies should address those limitations and provide the evidence necessary to determine the applicability and impact of the present technology-aided program. New research may also assess the possibility of upgrading and optimizing the technology to facilitate and extend its use across settings and people.

Data Availability

The data sets generated during and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

GEL was responsible for setting up the study, acquiring and analyzing the data, as well as writing the manuscript. NNS, MFO, and JS collaborated in setting up the study, analyzing the data, and editing the manuscript. GA, IO, VC, and LD collaborated in setting up the study and the technology system, acquiring and analyzing the data, as well as editing the manuscript.

Conflicts of Interest

None declared.

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Edited by M Mulvenna; submitted 09.04.24; peer-reviewed by YS Hwang; comments to author 12.05.24; revised version received 15.05.24; accepted 15.05.24; published 12.06.24.

©Giulio E Lancioni, Nirbhay N Singh, Mark F O’Reilly, Jeff Sigafoos, Gloria Alberti, Isabella Orlando, Valeria Chiariello, Lorenzo Desideri. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 12.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive Technology, is properly cited. The complete bibliographic information, a link to the original publication on https://rehab.jmir.org/, as well as this copyright and license information must be included.

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Research Article

The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft

* E-mail: [email protected]

¶ ‡ RH and DR are co-first authors on this work.

Affiliation Division of Epidemiology, Berkeley School of Public Health Berkeley, University of California, Berkeley, California, United States of America

Roles Data curation, Formal analysis, Investigation, Writing – original draft

Affiliations Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, Syrian Public Health Network, London, United Kingdom

Roles Formal analysis, Methodology, Writing – review & editing

Affiliation Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Roles Formal analysis, Investigation, Writing – review & editing

Affiliations Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, Oregon, United States of America

Roles Investigation, Project administration, Resources, Writing – review & editing

Affiliation Syrian American Medical Society, Washington, District of Columbia, United States of America

Roles Conceptualization, Project administration, Resources, Writing – review & editing

Affiliations Assistance Coordination Unit, Gaziantep, Turkey, Syrian Public Health Network, London, United Kingdom

Roles Data curation, Formal analysis, Writing – review & editing

Affiliation Syrian American Medical Society, Gaziantep, Turkey

Roles Visualization, Writing – review & editing

Affiliation Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom

Roles Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing

Affiliations Syrian Public Health Network, London, United Kingdom, Department of Infectious Disease, Imperial College London, London, United Kingdom

• Rohini Haar, 
• Diana Rayes, 
• Hannah Tappis, 
• Leonard Rubenstein, 
• Anas Rihawi, 
• Mohamed Hamze, 
• Naser Almhawish, 
• Reham Wais, 
• Hesham Alahmad, 

• Published: June 13, 2024
• https://doi.org/10.1371/journal.pgph.0002967
• Reader Comments

Syria has experienced over a decade of armed conflict, characterized by targeted violence against healthcare. The impacts of these attacks have resulted in both direct and indirect attacks on health and reverberating effects on local communities. This study aims to explore the perspectives of health workers based in northern Syria who have experienced such attacks on health to understand the impacts on the health system as well as communities served. In-depth interviews were conducted with health workers in the northern regions of Syria where attacks on health have been frequent. Participants were identified using purposive and snowball sampling. Interviews were coded and analyzed using the Framework Method. Our inductive and deductive codes aligned closely with the WHO Health System Building Blocks framework, and we therefore integrated this framing into the presentation of findings. We actively sought to include female and non-physician health workers as both groups have been under-represented in previous research in northern Syria. A total of 40 health workers (32.5% female, 77.5% non-physicians) who experienced attacks in northern Syria between 2013 and 2020 participated in interviews in 2020–2021. Participants characterized attacks on health as frequent, persistent over years, and strategically targeted. The attacks had both direct and indirect impacts on the health system and consequently the wider health of the community. For the health system, participants noted compounded impacts on the delivery of care, health system governance, and challenges to financing, workforce, and infrastructure. Reconstructing health facilities or planning services in the aftermath of attacks on health was challenging due to poor health system governance and resource challenges. These impacts had ripple effects on the health of the community, particularly the most vulnerable. The impacts of attacks on health in Syria are multiple, with both short- and long-term consequences for the health system(s) across Syria as well as the health of communities in these respective areas. Though such attacks against healthcare are illegal under international humanitarian law, this and other legal frameworks have led to little accountability in the face of such attacks both in Syria and elsewhere. Characterizing their impacts is essential to improving our understanding of the consequences of attacks as a public health issue and supporting protection and advocacy efforts.

Citation: Haar R, Rayes D, Tappis H, Rubenstein L, Rihawi A, Hamze M, et al. (2024) The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. PLOS Glob Public Health 4(6): e0002967. https://doi.org/10.1371/journal.pgph.0002967

Editor: Veena Sriram, The University of British Columbia, CANADA

Received: November 13, 2023; Accepted: April 29, 2024; Published: June 13, 2024

Copyright: © 2024 Haar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The qualitative datasets presented in this manuscript are not readily available because of the sensitive nature of the data. There are ethical requirements that stipulate that qualitative data cannot be shared.

Funding: Funding for this project and all authors was provided by the Research for Health in Humanitarian Crises (R2HC, https://www.elrha.org/programme/research-for-health-in-humanitarian-crises/ ) program at ELRHA (Grant #35189, PI RH). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

I. Introduction

Violence against healthcare in conflict settings is a tragic yet common occurrence in recent years, with devastating consequences on healthcare providers, patients, and the entire health system [ 1 – 4 ]. These attacks can be characterized by direct violence, such as airstrikes on hospitals and assaults on health workers or patients. They also include arrests, threats, intimidation, and interference with health services, all of which violate International Humanitarian Law in armed conflict [ 5 ]. Indirect impacts include the effects on healthcare access due to damaged healthcare facilities and infrastructure, the forced exodus of healthcare workers (who are often the targets of direct attacks), underfunding, and a reluctance for patients to seek healthcare as they perceive health facilities to be unsafe [ 6 ]. Numerous and diverse attacks on healthcare have been recorded over the past two decades, with the most frequent violations reported in Afghanistan, the Central African Republic, Colombia, Ethiopia, Myanmar, Palestine, South Sudan, Syria, Yemen, and, most recently, Ukraine and Sudan, perpetrated both by internal and external armed actors and militaries [ 1 , 7 ]. Documentation of these attacks is critical, and mandated by the UN Security Council (Resolution 2286) [ 6 ]. In 2022 alone, the Safeguarding Health in Conflict Coalition and Insecurity Insight reported nearly 2,000 incidents of attacks on healthcare facilities and personnel in 32 countries, with 232 health workers killed and hundreds more kidnapped and arrested [ 3 ].

Syria’s brutal conflict began after peaceful uprisings in March 2011 were violently and disproportionately suppressed by the Syrian government with significant disruption to its health system [ 8 , 9 ]. The criminalization of the provision of medical care to those considered opposed to the government and the direct attacks and disruption to healthcare began soon after [ 10 ]. As the conflict progressed, hundreds of aerial bombardments of healthcare facilities were recorded over the years, mostly in parts of the countries opposed to the Syrian government, along with other forms of violence against healthcare including the interruption of healthcare access and supplies [ 11 ]. As of 2024, over 16.7 million people require humanitarian assistance in Syria, with over 5.5 million displaced worldwide [ 12 ].

Many involved parties, including the governments of Syria, Russia, the United States, and multiple non-state armed groups including the Islamic State, al-Nusra Front, and others, are implicated in such violence, however, the vast majority of strikes on health were conducted by Syrian government and aligned Russian forces in opposition-controlled areas, primarily the cities of Idlib and northern Aleppo [ 10 , 11 , 13 ]. According to Physicians for Human Rights, between 2011 and March 2022, there have been more than 601 airstrikes on at least 222 health care facilities, with evidence that these strikes were intentional and targeted [ 2 , 8 , 13 – 15 ]. Over 900 health workers have been killed directly in the conflict, many in the course of their work and countless more have suffered from physical and psychological injuries [ 15 , 16 ]. The number of patients affected is unknown but includes those with immediate injuries as well as many who avoided seeking healthcare, waited too long, were afraid to report stigmatized violence, or were deprived of regular treatment or preventative services; the impacts on those who never sought care are much harder to quantify [ 15 , 17 ]. Attacks on healthcare in Syria have also been an important driver of forced displacement within and outside of Syria’s borders as well as a key driver of the forced exodus of health workers [ 8 ].

The evidence available suggests that attacks on healthcare have wide-ranging impacts on the delivery of healthcare, including long-term health consequences, economic losses, and an erosion of trust in healthcare systems [ 8 – 11 ]. However, a detailed exploration of these impacts and their nature on the health system in Syria and elsewhere is limited, as are studies of the experiences of health workers subject to attacks [ 18 – 23 ]. The perspectives of health workers who have survived attacks are critical for gaining a deeper understanding of the impacts of violence on the many components of the health system in Syria.

This study aims to explore the complex and compounding impacts of violence on the health system, including its effects on the availability and accessibility of care, selected health outcomes, and the long-term stability of health resources. Employing a health systems approach facilitated organizing impacts within a structured framework that would facilitate a deeper comprehension of the impacts, both directly and in aggregate [ 24 , 25 ].

II. Methods

Research design.

The study was conducted by researchers at the University of California, Berkeley and Johns Hopkins University in partnership with two humanitarian organizations working directly on the humanitarian health response inside Syria: Syrian American Medical Society (SAMS) and Assistance Coordination Unit (ACU). We used a qualitative research design with in-depth, semi-structured interviews with Syrian healthcare workers who had experienced attacks on healthcare during the conflict. We developed the interview guide based on previous research on attacks on health carried out by members of the study team in Syria, Myanmar, and Colombia and in coordination with our local partners with a content analysis orientation [ 18 , 19 , 26 ]. Drawing from our prior research and comprehensive literature review, we developed a preliminary conceptual framework for our study to demonstrate that attacks on hospitals can influence the health system, generating cumulative effects on community well-being. As we progressed with the study, we refined and expanded upon this model to deepen our understanding of participants’ experiences and enhance the overall analysis. The overall research question guiding this study was: What are health worker perceptions of the impact of violence on healthcare based on their personal experiences and knowledge of attacks?

Partner organizations

The Syrian American Medical Society (SAMS) was established in 1998 and its humanitarian arm has provided health and humanitarian care in Syria and Syrian refugee-hosting countries since the onset of the uprisings in 2011 [ 27 ]. ACU, established in 2013, manages the Early Warning Alert and Response Network (EWARN) surveillance program as well as several other key health and Water Sanitation and Hygiene (WASH) monitoring and information systems across areas in Syria that are outside of government control. Both organizations maintain ongoing programs in Syria and have established networks of health workers in Syria [ 27 ]. Partnering at the conceptualization, execution, and analysis phases of the study was intentional and aimed to support the co-design of the study from researchers who themselves had experienced attacks on health in Syria.

Setting and participant selection

Study participants were recruited through purposive and snowball sampling through SAMS’ and ACU’s professional networks. This approach enabled us to promote interviews with female and non-physician health workers as both groups are under-represented in conflict research. We defined the term health worker broadly to include physicians as well as midwives, nurses, pharmacists, dentists as well as technicians (e.g. anesthetic, dialysis), and those who held administrative or management roles. Other inclusion criteria included personal experiences of attacks on healthcare in northern Syria between 2011 and 2020, ability and willingness to consent, and an internet connection.

Participants were included from governorates within northwest Syria including parts of Aleppo, Idlib, Hama, and Homs governorates, and to a lesser extent, northeast Syria including parts of Al-Hasakah, Aleppo (Menbij and Ain Al Arab), Deir Ez Zor, and Raqqa. These governorates were selected based on the high frequency of attacks in these areas as well as the accessibility, connectivity, and security of health workers available for interviews [ 9 , 15 , 16 ].

Data collection

All interviews were conducted in Arabic by Syrian-American team members (DR and AR) using Zoom (version 5.0) for accessibility and safety reasons. We developed a protocol in collaboration with the data management department at UC Berkeley in compliance with ethical and privacy guidelines. Both interviewers were fluent in Syrian Arabic, experienced in conflict research, and practiced reflexivity throughout the process. Most interviews were conducted by a female researcher (DR) to encourage female participation. Following oral consent (for security and confidentiality purposes, we did not do written consent), participants were asked to describe their roles and responsibilities as well as their experiences of the Syrian conflict, particularly violence against healthcare. After the interview, participants were asked to refer additional potential participants to the research team. Data collection was terminated once participants were no longer presenting major additional concepts and thematic saturation was achieved.

Most interviews were audio-recorded for the transcription of interviews and to maintain the accuracy of information shared. In a few cases, handwritten notes were taken instead of recording based on participant comfort and preference. Interviews were transcribed in Arabic and translated to English by native Arabic speakers for coding and analysis. We extracted participants’ demographic data including profession, location, gender, and specific incidents of violence they described. Data were analyzed using Dedoose (version 9.0) qualitative software.

Data analysis

We analyzed the translated English transcripts using the Framework Method, which is well-suited to analyze health research using a multi-disciplinary approach [ 28 ]. One key distinction of this approach is that it permits both inductive and deductive approaches to thematic analysis. We followed the steps proposed by the Framework Method including familiarization with transcripts, initial coding, developing an analytical framework (set of codes that are mutually agreed upon), and charting data into a framework matrix. A codebook was developed using Dedoose qualitative software based on the broader study objective of exploring the short- and long-term impacts of attacks on a) healthcare facilities, b) health services, c) community health, d) health workers, and e) the health system.

We found that our deductive and inductive codes aligned closely with the WHO Health System Building Blocks framework and therefore integrated this framing into our analysis [ 29 , 30 ]. We focused on five out of the six existing WHO Health System Building Blocks: (1) service delivery (2) health workforce, (3) essential medicines and infrastructure, (4) governance, and (5) financing. Consistent with recent guidance on adapting health system components for context-specific research, we replaced the sixth building block (Health Information Systems) with the domain of (6) security and protection, as these concepts are particularly relevant to the humanitarian context [ 29 , 30 ]. We approach governance as it relates to health in a similar vein to WHO in terms of stewardship, ‘oversight, regulation, incentives, and accountability [ 31 ]. The connection between the building blocks and the clinical experience varies which could influence the analysis given impacts are examined via the perspective of health workers in this study.

Interviews were both deductively and inductively coded by at least two individual coders (DR, AR, RH, HT) and compared and discussed for discrepancies. Coding and subsequent interview results were discussed iteratively among the qualitative research team regularly, identifying potential themes of interest and areas for further exploration. Themes were developed based on the perceptions of health workers regarding the various impacts of violence against healthcare as well as in alignment with the WHO Health System Building Blocks framework. We identified key patterns, and correlations among the responses and highlighted quotations germane to the analysis. Emerging findings from the qualitative data were also discussed with our research team to probe deeper, ensure consistency, and explore any incongruous data.

Ethical considerations

The University of California, Berkeley’s Human Subjects Protection Program reviewed and approved this study (Protocol # 2020-03-13069). The researchers also consulted with and received approval from the Idlib Health Directorate and other local leadership in lieu of a formal ethical review board in Syria.

Comprehensive informed consent procedures took place at the start of each interview. Participants were able to terminate the interview at any time and to withdraw their participation until the time at which the analysis was started. Given that some topics covered may be sensitive or cause distress, a reference to a mental health professional was available should this be needed by the participants.

III. Results

Between June 2020 and November 2021, a total of 40 health workers participated in remote in-depth interviews. Participants included 27 males (67.5%) and 13 females (32.5%) and represented a variety of health professions, including nurses (25%), physicians (including dentists, surgeons, and medical doctors) (22.5%), technicians (laboratory, surgical assistants, and anesthetics) (15%), health administrators (10%), first responders (10%), pharmacists (5%), medical students (7.5%), a midwife (2.5%), and a psychologist (2.5%) ( Table 1 ). All participants experienced attacks on healthcare facilities between 2013 and 2020, most of them experienced more than one.

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Participants were mainly based in northwest Syria, in Idlib and Aleppo governorates, followed by a smaller number from northeastern Syria, including Raqqa and central Syria, including Eastern Ghouta, and Hama. They worked in facilities experiencing attacks including general hospitals (46%), surgical centers (33%), primary care centers (13%), and specialty hospitals (8%). Numerous medical facilities, clinics, and ambulances were named as sites where health workers were working or experienced attacks. Almost all health workers had experienced more than one attack and had been displaced several times over the course of the conflict. All the participants were still working in the health sector in some capacity; however, at least 5 of the participants were not working in the profession that they had initially received training in.

Health workers described that violence against healthcare in Syria resulted in intersectional and compounded impacts that affect all parts of the health system. Adapted from the WHO Health System Building Blocks framework, we outline both direct and indirect impacts under the following themes: 1) severe constraints on health service delivery, 2) challenges in health workforce retention and morale, 3) compounding loss in essential medicines and infrastructure, 4) weakened health governance, 5) uncertainties in health financing, and 6) compromised security and protection. Collectively, these health system impacts had cascading impacts on community health.

Health system impacts

1) severe constraints on health service delivery..

All participants emphasized that the quantity and quality of health service delivery was affected by attacks on healthcare in both the short- and the long-term. This was due to a combination of direct damage to healthcare facilities, as well as increased health needs and demand on facilities due to the direct and indirect impacts of the conflict. At times of an acute increase in violence leading to forced displacement, participants reported that there could be a sudden and significant population growth in some areas, leading to a spike in demand.

Irreparable damage to health facilities . One participant observed that “if this destroyed hospital was providing healthcare services to a particular area of half a million people, then that half a million people would be without healthcare for a month. They may also have to go to other areas and their diagnosis may be delayed, as well as having complications and many other problems” (Administrator) Participants noted disparities between urban and rural facilities; in rural areas, when attacks on health facilities occurred resulting in closures, those communities had more limited options for alternative healthcare.

Even when health facilities were re-opened, “all services were not always fully reinstated” stated a participant who highlighted this reality with an example of a pediatric unit that remained closed to prioritize the reopening of the trauma unit (Physician). Chronic and preventative care, as well as care requiring specialized or high-resource equipment, took longer to reinstate. Another participant noted that early discharges of admitted patients were frequent when the facility was felt to be at higher risk of being attacked or had been attacked recently. In many cases, attacks also impacted the quality of care. “If we want to give each patient five minutes, the patient does not [get what they need] but these are the available capabilities (Lab Technician).

Ripple effects on nearby facilities . The reduction in services had ripple effects on other health facilities in the patient catchment area and their ability to meet demand, often overburdening still-functioning or partially functioning facilities. Several participants described that patients were transferred to or advised to go to alternative facilities, especially those outside city centers when attacks occurred. One participant described the scale of redistribution of patient loads: “The hospital has recently become the one to serve the entire south of Idlib. If you know southern Idlib, all hospitals were bombed before us, then all hospitals were stopped, so [our] hospital received patients from Ariha, rural Ariha, and southern rural Idlib; even northern rural Hama and southern rural Aleppo…. The workload—it was intense” (Nurse).

Irretrievable loss of specialized services . Specialized services were particularly affected if provider facilities were damaged; this included services for chronic conditions, including cancer, kidney failure (dialysis) and mental health conditions. Mental health needs among the community increased significantly due to the conflict and were noted by participants to be unmet due to the lack of mental health specialists (which also pre-dated the conflict, but was exacerbated by attacks,) and the fear among patients of visiting hospitals. Cancer services were also noted to be a particularly scarce resource in these areas.

A participant described the difficult decisions that patients need to make, “For example, cancer patients now have two options: either to head towards Damascus or towards Turkey” (Lab Technician) which is not always an option for all patients. This is particularly due to social factors which, as one participant noted, particularly affected widows or people living with a disability because they could not travel as easily (Physician).

2) Challenges in health workforce retention and morale.

Attacks on healthcare were described to result in a precipitous drop in the availability of workers through forced displacement, and a lack of training opportunities, among other reasons.

The lack of trained health workers had catastrophic effects on some services. One participant illustrated this experience:

“We still did not have skilled general practitioners who knew how to use the triage system and how to treat 90% of the common diseases in the community… The number of gynecologists was also very, very few compared to the number of women in the community… That is why a lot of complications and mortality were occurring. This is what we have… there are not enough physicians… What can we do?!” (Physician)

Displacement and unemployment . Many health workers experienced forced displacement, often more than once. The wide-ranging impacts of this were noted to affect the quality of care for patients as well as the work experiences of health workers. Several participants described disruption to their ability to develop long-term rapport with their patients and strong relationships with their colleagues. A participant also noted the critical importance of establishing a long-term relationship with patients, particularly in settings where clinical records are absent, poorly kept, or destroyed. Other participants described that being unable to continue working with well-established and familiar colleagues was challenging. Some also described a different culture in different cities in Syria or that they felt like outsiders. “In Idlib, the culture is different. They call us nazeheen (displaced)–but we did not leave by our own choice,” said one participant who had been displaced more than 15 times (Nurse).

An important but paradoxical workforce challenge was that in the wake of an attack, despite increased needs for services, health workers could become unemployed if funding to a facility was interrupted or redirected, which often occurred following attacks. One participant said, “Physician retention is difficult as the hospital is rebuilding and [health workers] need to find work in the meantime and then come back” (Medical Technician). This resulted in unstable and inconsistent work as a direct result of attacks that severely damaged health facilities. Another participant explained that “health workers live in an ambiguous future—[the] near future and far future are both not clear” (Physician).

Skills and training . Staff shortages resulting from the targeting and the exodus of health workers have led to an increase in task-shifting, a phenomenon which was uncommon before the conflict. Health workers were forced to take on roles that they were not prepared or trained for, causing undue stress among health workers and their colleagues, and potentially leading to suboptimal quality of care for patients. One participant highlighted this gap, particularly concerning maternal health as there were too few obstetricians, stating, “…and midwives have only basic training so [we] have far more home births and maternal mortality than before the war” (Physician).

Feelings of resistance and solidarity allowed health workers to carry on . Despite the challenges noted by participants, there were also many examples of coping, survival, resistance, and solidarity among health workers. Participants stayed in Syria despite the risk it posed to their lives and their well-being and continued to provide services, motivated by duty towards their respective communities and wanting to meet ongoing needs. However, many participants rejected narratives of “hero” or “victim,” rather than just feeling an obligation to help. One participant described this sentiment as “The feeling that dominates me most is that there is a wounded person in need of rescue. He’ll die if I don’t do my job, its possibility is 100%, whereas the probability of my death in targeting is 5%, the feeling of rescue always prevails over me” (Physician).

Health workers were motivated by a sense of solidarity felt among other health workers undergoing similar circumstances and fighting for the Syrian cause. Many health workers described that they communicate via groups on phone messaging applications to stay connected with colleagues, support patients, share stories, and find mutual strength. Some participants worked in Syria and visited their families weekly or monthly in Turkey, who lived there for safety reasons, to find a balance between work and family. Participants also described feelings of resistance against the Syrian regime that drove them to continue working. One participant described, “For me, I absolutely refuse to leave Syria. In my opinion we must do anything that can support the Syrian revolution, God willing” (Administrator).

3) Compounding loss of essential medicines and infrastructure.

Damaged infrastructure . Participants discussed the extensive destruction of infrastructure in Syria due to attacks, including hospitals, mobile clinics, ambulances, and supply trucks. Damaged facilities were assessed in the aftermath of attacks and health workers supported the repair efforts and continued to see patients. However, compounded damage from multiple attacks made reconstruction efforts more costly. One participant noted, “If it was minor damage, [we] can build back in 2–3 weeks. But with severe damage, especially cumulative—it would be hard to ever build back” (Physician) The perceived high risk of future attacks often made funders and organizations reluctant to rebuild health infrastructure.

Scarcity of medical resources . Participants reported that interrupted medical supplies and medications presented challenges for the health system. This was not only due to the direct effects of attacks on health on pharmacy stocks but also damage to transport infrastructure and relevant hospital infrastructure such as electricity, particularly affecting medications that required refrigeration. Even if classes of medications were available, specialist medications or specific dosages and formulations were scarce. As a result of severe shortages, the cost of medications rose sharply, leaving many medications out of reach for many people who may have needed them. While health workers described a range of strategies to fill the gaps in medication coverage, including free pharmacies within facilities and negotiated discounts on medications coordinated among pharmacists, many patients were still unable to access their medications regularly, also out of fear of visiting health facilities to do so. One participant explained the downstream impacts of attacks on healthcare on medication shortages: “Many people cannot buy medicine because it is so expensive…Many people are displaced and in need, have left their jobs, lands, and livelihoods, and yet they are compelled to buy this drug” (Physician).

4) Weakened health governance.

Hindered effectiveness . Participants shared some glimpses of their experience with health governance in northern Syria. Several of them described that the Syrian government’s violence against healthcare includes deliberately undermining the establishment and effectiveness of local health governance and leadership in northern Syria. Attacks on healthcare have thus left both local and international humanitarian organizations to fill this gap. However, given the enormous challenges of building a new health system in the setting of war as well as targeted violence and the lack of executive authority, health governance actors in northern Syria faced numerous challenges, some of which participants touched on in the interviews. Challenges included managing security, ensuring that health facilities stayed open, staffed, and equipped, equitable and efficient policy making and procedures for rebuilding, and prioritizing limited resources. One participant noted that “the main infection in society [is that] there is no direct health authority, there is no security authority … Unfortunately, things have become random, …there is no regulation, and there is no one to impose curfews, stabilize markets, and regulate the work” (Administrator).

Limited planning and coordination . Participants noted that one of the key challenges for local governance actors (which include health directorates and humanitarian organizations) in northern Syria is the rehabilitation of health facilities damaged by attacks on health. Participants noted that they, as health workers, were also required to make challenging decisions, for example, around fortifying hospital buildings, locations of health facilities to minimize the risk of attacks, and where to prioritize resources. Several noted that prioritizing protection from attacks had trade-offs: more secure locations could restrict access. Participants described that health facilities were increasingly fragmented or siloed in some parts of opposition-controlled Syria. While peacetime structures are often built in central and accessible areas of communities, new health facilities were built away from the centers of town to protect civilians in case they were targeted. One participant described why: “Hospitals cost a lot to build. And one bomb can destroy the whole thing, so it is better to build smaller ones. We deliberately increased the medical points to reduce the damage” (Physician). Fragmentation of the health system(s) often resulted in inequities in healthcare services for different communities. For instance, one participant stated that “physicians and health care workers were not distributed evenly—[there were] more in safer areas, and fewer in dangerous areas” (Physician).

When rebuilt, services were also divided into separate facilities to ensure that a strike on one facility would not affect too many people or services. While this was effective for keeping some services accessible, it made holistic and coordinated medical care for patients challenging.

5) Uncertainties in health financing.

Both the direct airstrikes on health facilities and the indirect impact on services were associated with a high cost of healthcare system(s) in northern Syria, as referenced above regarding the increasing cause of medications. According to participants, increasingly limited financial resources over the protracted conflict resulted in tensions around broader medical resource allocation among the different actors and communities, as well as significant dependency on unstable donor funds and international aid (often restricted because of anti-terrorism regulations), and frequent interruptions of funding streams to health service organizations, facilities and staff. In addition, participants perceived that funders were reportedly reluctant to fund health facilities or services at high risk of repeat attacks.

Several participants described challenges with resource allocation both at administrative and clinical levels. Administrators noted that with restricted funds and ongoing losses of infrastructure, rebuilding facilities was not a priority, especially when the risk of re-attack was high. One participant noted, “The cost of establishing … a hospital was more than two or three million dollars… It is too costly… And in the end, after you pay all these costs, the regime with just one missile can destroy the entire hospital” (Physician). One participant noted that the persistence of attacks over the years also limited healthcare actors and donors from investing in establishing more sophisticated specialized services for tertiary care, concerned that health facilities continued to be targeted.

Interrupted funding streams . Unstable donor funds, top-down decisions on funding priorities (without consideration of local needs), and political or technical restrictions on funding resulted in unreliable and frequently interrupted funding streams for the health system. Several participants highlighted that salary delays caused by shifts in donor priorities, coupled with the absence of health and life insurance for workers, demotivated healthcare professionals from staying in perilous conditions and prompted them to contemplate migration. When funding was reduced or interrupted, and health workers were unemployed, participants described how this negatively impacted their livelihoods: “Costs actually go up—distance to work from a secure area, diesel costs, rent since [they] can’t live in their own home, food prices are up… all while employment goes down” (Medical Technician).

Increasing unaffordability of care . Further downstream, the limited resources caused by physical attacks and defunding led to increasing costs of health services, which disincentivized patients from accessing preventative care. For example, major transportation issues due to long distances and transportation costs led to the inaccessibility of hospitals among civilians, exacerbating conditions that require follow-up (particularly for those living in mountainous or rural regions). Numerous private health enterprises emerged to fill this gap, but participants reported that they were not consistent, and the resulting financial pressure was then on patients themselves to pay directly for services, a grim challenge when the conflict disrupted so much employment in the area. Participants mentioned that patients frequently had to choose between two risky options: fear of being in a public hospital that is being bombed or significant financial risks from seeking care in a more expensive private facility. For example, one participant said, “Private hospitals were $50 per day which is a lot. Bombing of big or public hospitals drove people to private smaller facilities but the financial pressures drove them back to the public hospitals. …and they became afraid and began to suffer from phobia from the intense and focused bombing on the medical centers” (Pharmacist).

6) Compromised security and protection.

In response to attacks on health, administrators, professionals, and patients were required to make constant calculations of security risks and plans. Many participants noted that security risks deeply impacted patients’ choice to even seek healthcare, often resulting in a chilling effect on health-seeking behavior. “Even the threat of violence limits health services,” said one participant, suggesting that frequent attacks on healthcare services cause some sick people to avoid seeking health services (First Responder). Several participants spoke about the deconfliction mechanism in Syria, the decision to share coordinates of hospitals with UN Member States and armed actors in a (failed) attempt to ensure respect for IHL. One of these participants said, “We did everything we had to do, and we told them that those locations were medical centers, but we were regarded as enemies and then were attacked…. No one… no one stopped these attacks” (Physician). The deliberate targeting of medical facilities by the Syrian government and its allies despite consensus from health actors in northern Syria to participate in the deconfliction mechanism was particularly galling for most participants, causing deep mistrust of the UN and the international response in Syria.

Fortifications and contingency measures . At the facility level, insecurity resulted in adaptations and restructuring that did not always provide added protection. Fortifications of community hospitals, building hospitals outside of the community and in caves and underground, were novel adaptations to high-intensity aerial attacks. While there was hope among participants that these fortifications would better protect patients and providers, this was not always the case. One participant pointed out that several fortified facilities have since been targeted and destroyed with even stronger weaponry. Beyond infrastructure modification, facilities also took steps to invest in air raid alarm programs, removing the medical emblem from their frontage, and employing armed guards to monitor the entrances to mitigate attacks.

Despite these efforts, protections were fragile and limited by the broader conflict and violence in the region. One participant explained “We built this hospital underground, which made us feel very safe because the airstrikes that targeted the perimeter of the hospital and the hospital itself did not damage at all. However, it was not very safe because the road leading to the hospital was dangerous”(Nurse). Transportation to or between health centers was especially fraught, “There is no public transportation. Even private transportation is dangerous. When a person moves at night, he is afraid of being sniped by a gun plane. The gun plane as soon as it sees a light at night, snipers it, regardless of whether there are children, women, or injured people” (Administrator).

Health workers themselves also attempted to mitigate the risk to themselves and their patients. Several participants described that offices would shorten visits or send patients home quickly to mitigate risks. They also developed staggered schedules to spare staff and patients if attacks occurred.

Cumulative impacts on the health of the community

Participants reported that the cumulative impacts of attacks had dramatically weakened the foundation of healthcare across northern Syria, leading to significant and adverse consequences for population health outcomes including overall health behaviors, the sense of well-being among the community, and ultimately, mortality and morbidity ( Fig 1 ). Participants described numerous outcomes on their patients and communities, with the most prominent themes of forced displacement, avoidant health-seeking behaviors, and a reported increase in various disease outcomes. Participants described that because of violence against healthcare and its wide health system impacts, people living in northern Syria had far fewer options to seek care, either for prevention or treatment, resulting in more illness severity, frequency, and prevalence compared to before the conflict.

https://doi.org/10.1371/journal.pgph.0002967.g001

Forced displacement . Protracted attacks on healthcare were reported to be a direct driver of forced population displacement. One participant explained that “After the hospital was targeted, the town became empty” (Reception Officer). The resulting displacement also resulted in overburdening health systems not designed for mass population movements. A participant noted that “the camps put a lot of pressure on the (border) hospital which was already providing its services to people who live there” (Technician). Those with chronic conditions also had to make difficult decisions between staying in their communities and potentially risking their health or relocating nearer to health services. When a hospital closed, a person with chronic illness “had to leave the area for any medical problem, or any tiny wound would lead to death, he would not be able to get to the hospital” (Physician).

Avoidant health-seeking behaviors . Civilians who stayed in northern Syria had to navigate between the practical need for health care services and the fear of getting injured or killed if they sought health services at the wrong time. One participant described his patients’ thought processes the following way: “It’s okay, let me feel sick a little longer [rather] than lose my life in the hospital” (Nurse). Many participants suggested that attacks on health directly lead to worsening health outcomes because of the hesitation expressed by patients, exacerbating their health conditions and contributing to worsening health outcomes or death.

Perceived increase in disease prevalence . Many participants observed increases in the prevalence of communicable diseases and chronic diseases in the aftermath of attacks, possibly because diseases were left untreated in their early stages and became more severe. Chronic diseases such as heart disease and diabetes require consistent medication management, regular clinic visits, and supervision. Several participants perceived that because trauma care frequently took precedence after attacks on health, preventative and chronic care were therefore underprioritized and their severity increased. One participant noted that aid agencies and donors also influenced this change, as “they started to focus primarily on war-related injuries and casualties at the expense of the communicable and chronic diseases, which increased terrifyingly, especially after 2017” (Physician). Participants noted that attacks on health played a role in the declining workforce, displacement, and lack of medications and other resources which in turn impacted communicable diseases particularly. One participant described that “Several kinds of diseases have prevailed in our areas such as leishmaniasis, scabies, tuberculosis, and polio. This was all because of the lack of medical staff [to respond to these issues]” (Nurse). Participants pointed to both direct and indirect relationships between attacks on healthcare and worsening mortality and morbidity. Attacks on health were strongly associated with civilian violence in this area as well. When an attack occurred, the number of wounded and sick people would increase, just at a time when hospital services were destroyed. The incongruity between the rising need for care and the declining availability of services resulted in worse outcomes.

IV. Discussion

This study examines the multifaceted impacts of targeted violence against healthcare on northern Syria’s health system, where frequent and repeated airstrikes on health facilities over the past decade have been well-documented as deliberate and strategic, a clear violation of International Humanitarian Law [ 2 , 8 – 11 , 13 – 18 ]. The resultant damage to every level of the health system has cumulative effects on the population of northern Syria. This is especially pertinent in the wake of the February 2023 earthquakes, which caused further devastation to a health infrastructure already weakened by violence against healthcare [ 32 ]. As airstrikes targeting health facilities are being increasingly seen in other conflicts, including in Ukraine, Myanmar, and Sudan in 2023, these impacts have unfortunate echoes elsewhere [ 1 – 3 ]. Insight into both the characteristics and the impacts of violence against healthcare is critical to better protecting health workers, patients, and all civilians.

Analyzing our research through the lens of the WHO Health System Building Blocks provided some structure to our findings: all pillars are essential to a functioning health system and were profoundly affected by violence against healthcare [ 33 ]. Medicines and infrastructure were destroyed by the airstrikes; the lack of resources and concerns around repeat attacks made replacing them challenging. Health service delivery was disrupted both in the long and short-term, with substantial impacts on service delivery in attacked facilities as well as neighboring ones. Workforce impacts were notable not only for displacement, reductions in available workers, and task shifting, but also for paradoxical challenges with finding employment in the aftermath of an attack. With regards to governance, our findings specifically relate to how health professionals experienced governance, including the perception that health governance in northern Syria was weakened in the face of attacks, leading to a fragmentation of service provision [ 17 , 34 – 36 ]. Other research has considered the impacts of attacks on healthcare on governance in greater detail [ 37 – 42 ]. Financing disruptions have also resulted in some misalignment between local needs and international donors with unstable funding streams [ 37 ].

Several cross-cutting findings also emerged. First, violence against one component of the health system had impacts on others. For example, governance challenges made the rebuilding of the workforce more difficult [ 38 , 39 ]. Medicines were destroyed by the airstrikes and the lack of financing made replacing them challenging. Health infrastructure was disrupted both in the long and short term, with substantial impacts on service delivery in attacked facilities as well as neighboring ones. Also, impacts were compounded over time, as we hypothesized in conceptual work [ 31 , 36 ]. For instance, health workers noted that the repeated nature of attacks on health in Syria over prolonged periods resulted in impacts far greater than each individual attack. Third, the study exposed several complex causal pathways between the attack and the outcome, suggesting that there are multiple opportunities to intervene and ameliorate population health impacts. For example, the growing burden of chronic illness resulted from several layered processes including donors sometimes prioritizing funding for trauma care (resulting in fewer chronic care services) and patients who were afraid of violence against healthcare waiting longer to seek care (an adaptive response which has been identified in previous studies) and task shifting of health workers towards emergency care [ 8 – 11 ]. Interventions at any of these steps in the cascade could mitigate the burden of disease. This study also found that knock-on effects reached far beyond the health outcomes, with impacts on population displacement as well as social cohesion. Collectively, strong health systems ensure that the community has robust health care services and that population health outcomes are positive. Finally, the findings touch on the concern that while impacts were severe for virtually all the attacks participants reported, the experiences and impacts were not homogenous. Often, the most vulnerable communities (children, chronically or severely ill, rural communities) suffered disproportionately, particularly those that had experienced several displacements or continued to be internally displaced [ 1 – 3 , 8 – 11 , 34 ].

Our research adds to the growing literature on the impacts of conflict and targeted attacks on health. For example, our findings on increasingly siloed health programs and fragmented leadership are also explored by Alkhalil et. al., who note that the multiple Health Directorates were established soon after the withdrawal of the Ministry of Health [ 37 ]. Our study underscores the Douedari et. al. finding that a key constraint of health system reconstruction is the ongoing targeting of health facilities and health workers [ 43 ]. This has been compounded by the exodus of health workers with many of those leaving among the more senior, experienced, and more able to leave due to having recognized degrees and sought-after experience [ 44 ]. While the interviews only gave a glimpse of health worker perspectives on governance issues, they support extensive literature on the complexities of northern Syria’s governance challenges including the evolution and performance of the local health directorates, the competition between humanitarian structures and the directorates, and the refusal of Syria’s health ministry to engage [ 40 – 42 ].

Although deepening our understanding of the impacts of violence against healthcare on health systems from the perspectives of affected health workers is critical, it is essential to operationalize this knowledge with more targeted and concrete strategies to engage local health workers, support them, seek accountability, and protect them from attacks. The health workers we interviewed were able to share their perspectives not only as direct targets but also as wider members of the community, underscoring a need for better protection and support. The impacts of attacks on the personal and professional lives of health workers is explored in a separate study published by our study team and expand upon the psychological harms including moral distress and moral injury [ 23 ]. Of importance is that non-physicians and women health workers must be equally centered in these conversations. The health workforce remains the foundation of the health system; policies and frameworks that protect and safeguard their physical, psychological, and financial well-being are essential. Steps to concretely achieve this goal may include encouraging existing, local, quasi-governmental bodies and funders to support formal arrangements for salary protection in the wake of attacks or insurance should they be injured or killed, supporting training initiatives such as the Syrian Board of Medical Specialties, and continuing to have health workers engaged in broader decision making regarding the health system [ 12 , 21 , 37 , 45 ]. For the international community, supporting health systems in conflict-affected Syria should involve stabilizing funding streams for equipment, medicines, and infrastructure that prioritize local needs, supporting local governance, ensuring long-term and sustainable care delivery systems, and developing sustainable pipelines for training new professionals across various professions [ 21 ].

The health system impacts resulting from attacks on healthcare that have been explored in this study are complex and to an extent entrenched; they will last decades, if not generations. Knowing this, the prevention of attacks must be strengthened. Such attacks are violations of International Humanitarian Law. Given current paralysis in accountability mechanisms, states’ abdication of responsibility for implementation of UN Security Council Resolution 2286, and the scale of such attacks, insights from this and similar work are essential to stimulate the political will to prevent violence against health, hold perpetrators to account and to mitigate their impacts [ 46 ]. Our work emphasizes the need for research beyond counting the number of attacks and the quantitative extent of damage resulting from violence against healthcare. Taking a health systems approach and exploring the structural impacts through the voices of health workers directly affected (and, where possible civilians and patients) is essential to build our understanding of the multiple, compounding, and intersecting aspects of this topic. This is increasingly relevant where current, active conflicts in Myanmar, Sudan, and Ukraine, among others, necessitate this approach to support a nuanced and contextualized understanding of the impacts [ 29 ].

Further research could include more diverse voices, including community members and health workers both from Syria as well as the many other contexts where healthcare is targeted [ 32 , 34 , 36 ]. Next steps may also consider mixed-method or quantitative analysis of the health system impacts identified in this study; a more granular analysis could identify differential impacts based on the type and severity of attack on specific communities and their respective health systems.

Limitations

As in all studies involving interviewers and interviewees, there is a risk of recall and reporting bias, or bias introduced by the researchers. The sampling approach, including only health workers and those living in primarily northern Syria, limited our understanding of the perspectives of the local community, other aid workers, leadership, and those not directly experiencing violence. This may particularly limit analyses of some health system components such as governance and financing where health workers may not play a direct role and administrators and other stakeholders may be able to give a fuller picture. We interviewed health workers who remained and continued working in Syria and did not include the perspectives and experiences of those who left or stopped working in healthcare. Though we had a diverse set of participants, including students, technicians, and mid-level providers, we sampled fewer female health workers than we hoped, despite active efforts to recruit female participants and ensure a female interviewer was available. This was largely due to hesitations expressed by female health workers to participate in a research study citing safety and confidentiality. We hope future studies expand the sampling frame, include more women, and expand on the understanding of the many impacts of conflict and targeted violence.

This study provides compelling evidence of the profound and far-reaching consequences of violence against healthcare in Syria and its multilateral impacts on the health system. Our findings highlight the compounding, cumulative nature of these impacts, which have reverberating effects on the health of the communities served by directly and indirectly affected health facilities. It is crucial for efforts to protect health in conflict settings to address not only the attacks themselves but also the devastating repercussions they have on vulnerable individuals and systems, emphasizing the need for accountability, resource prioritization, and prevention of attacks.

Supporting information

S1 checklist..

https://doi.org/10.1371/journal.pgph.0002967.s001

Acknowledgments

We thank Syrian American Medical Society, Assistance Coordination Unit, the Researching Impacts of Attacks on Health Consortium and Physicians for Human Rights their invaluable contributions to this research, including Houssam Alnahhas and Christian DeVos at PHR, Larissa Fast and Christina Wille with RIAH, Qasim Yagizi, Mohamad Rami Kawas and Aya Aksh at ACU, Ahmad Tarakji and Randa Loutfi at SAMS. We thank the Idlib Health Directorate for supporting this study. We would also like to thank the dedicated health workers across northern Syria who generously shared their experiences and insights with us.

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