Patient Education and Counseling 99 (2016) 284–286

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Health promotion

The readability and suitability of sexual health promotion leaflets

Nova Corcoran* , Fatuma Ahmad
Faculty of Life Sciences and Education, University of South Wales, Lower Glyntaf Campus, Pontypridd, CF37 1DL Wales, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To investigate the readability and suitability of sexual health promotion leaflets.
Received 7 July 2014 Method: Application of SMOG, FRY and SAM tests to assess the readability and suitability of a selection of
Received in revised form 18 June 2015 sexual health leaflets.
Accepted 26 September 2015
Results: SMOG and FRY scores illustrate an average reading level of grade 9. SAM scores indicate that 59%
of leaflets are superior in design and 41% are average in design. Leaflets generally perform well in the
Keywords: categories of content, literacy demand, typography and layout. They perform poorly in use of graphics,
Readability
learning stimulation/motivation and cultural appropriateness.
Suitability
Sexual health
Conclusion: Sexual health leaflets have a reading level that is too high. Leaflets perform well on the
Leaflets suitability scores indicating they are reasonably suitable. There are a number of areas where sexual health
Health promotion leaflets could improve their design.
Practice implications: Numerous practical techniques are suggested for improving the readability and
suitability of sexual health leaflets.
ã 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction promote comprehension, for example, layout, graphics and

Sexual health knowledge is important for the promotion of safe
sexual health behaviors. The UK Department of Health [1]
advocates accurate, timely and high quality education to encourage
informed decision making in sexual health. Written materials are
frequently used in sexual health education to increase knowledge.
Whilst it is recognized that knowledge does not necessarily lead to
behavior change, increasing awareness of sexual health risks
encourages informed choice and may promote health seeking
behaviors [2].
Health literacy is the capacity to obtain, process and understand
health information [3]. Literacy levels influence sexual behavior
and knowledge [4] and those with lower literacy levels are less able
to understand and process health information [5]. Health
practitioners need to be able to design written materials that
are suitable for low literacy levels to promote comprehension and
understanding of sexual health topics.
Readability is the main guide to measuring reader comprehen-
sion [6,7]. Readability formulas calculate the number of formal
years of schooling needed to comprehend written material. They
are also a guide for practitioners to aid the development of literacy
sensitive health information [8]. However improving the readabil-
ity of written material without accounting for techniques that
* Corresponding author.
E-mail address: nova.corcoran@southwales.ac.uk (N. Corcoran).
cultural suitability [9] is likely to meet limited success. Best
practice guidance suggests a range of strategies to improve
readability and suitability of written materials [10–12] yet many
written materials remain inadequate for their intended audience
and assume a high reader ability [10,13].
There are a range of tools that can be applied to written
materials to assess the readability and suitability for a target
audience. To establish reading grade levels two commonly used
tools are SMOG (simplified measure of gobbledygook) and the FRY
readability formula. To establish the suitability of sexual health
leaflets the SAM (suitability assessment of material) tool assesses
demand of literacy, layout, graphics, motivation and cultural
specificity [14]. All three tools can be applied by a health
practitioner simply using pen and paper.
2. Method
Sexual health leaflets were collected in 2013 from a number of
city based health centers, family planning clinics and from the
largest sexual health organizations in the UK. Inclusion criteria
stated leaflets had to be paper based, free of charge, written in
English, contain a minimum of 30 full sentences and focus on
sexual health only. In organizations that published multiple
leaflets a maximum of 8 were randomly selected. 37 leaflets
met the inclusion criteria from 12 different organizations.
To assess readability the SMOG and FRY test was applied to each
leaflet. To assess suitability of materials the SAM test was applied

http://dx.doi.org/10.1016/j.pec.2015.09.003
0738-3991/ ã 2015 Elsevier Ireland Ltd. All rights reserved.
 N. Corcoran, F. Ahmad / Patient Education and Counseling 99 (2016) 284–286
to each leaflet. SAM categories were given additional guidance to
ensure consistency in scoring adapted from guidance by the
original authors [15]. SAM scores were calculated from judging
each leaflet in 21 specific categories and allocating a score to each
category: 2.0 = superior, 1.0 = adequate, 0.0 = unsuitable. The overall
total score was also calculated into score from 100. A score of 70–
100 is superior, 40–69 is adequate, 39 or less is unsuitable. Each
leaflet was assessed twice using two separate coders (the authors).
After the analysis of leaflets was complete the two scores for each
test were totaled and divided by two to give a single score. All
scores were collated and divided by the number of leaflets (37) to
produce one final average score. For SMOG and FRY this is an
average reading grade level. For SAM this is the average score for
each category.
3. Results
The average SMOG reading grade was grade 9, with grades
ranging from between 6th to 12th grade. The average FRY reading
grade was grade 9, with grades ranging from between 6th to 13th
grade. For all the leaflets combined this equates to an overall
average reading grade of grade 9.
The SAM test found 25 leaflets (59%) to be superior and 15 leaflets
(41%) to be adequate. No leaflets were scored as unsuitable. The
averagetotalSAMscorewas72.TheSAMtestfoundallleafletsshowed
their purpose via the title, content or cover (2.0), and nearlyall leaflets
were clear in their content focus (1.9). The literacy demand and
typography scores were generally high. These categories included
sentenceconstruction(1.9)enhancedlearningfeatures(1.9)andgood
writingstyle(1.7).Typographyandlayout(1.8)andcovergraphics(1.5)
werealsohigh.Thelowestscoreswerefoundinthetypeofillustrations
used (0.5) the use of lists, charts or tables (0.2) and captions for
illustrations (0.4). The scores for interaction with the reader were low
at 0.9, although performance was better in behavior modeling and
motivation (1.6 and 1.7). Although cultural matching was adequate,
the use of positive cultural images (0.7) and overall suitability for the
target population in relation to culture (0.7) was low.
4. Discussion and conclusion
4.1. Discussion
The readability of sexual health leaflets was poor as the average
reading grade was grade 9 with scores as high as grade 12 and 13.
As an average guide written materials should be between grades 6–
8 although some authors have recommended lower levels of
grades 5–6 [16]. This mismatch between reading grades of leaflets
and recommended reading grades is supported by older studies in
other health topics [16,17]. This is a major challenge as sexual
health leaflets do not match the reading levels of the population
they are designed for, yet health practitioners still continue to
design and distribute these leaflets. A range of reasons have been
suggested as to why health professionals continue to create
resources not fit for practice. These include organizational policy,
assumptions around who and how leaflets will be used, and lack of
knowledge of optimum readability levels [18].
The majority of leaflets performed well in a number of areas,
however 41% of leaflets were only deemed ‘acceptable’. Given the
amount of best practice guidance available [see 11,15,16] this
number is surprisingly high. As with readability, this figure
suggests either health practitioners find it difficult to locate
guidance on best practice, or the process of putting theory into
practice is challenging in some way.
Leaflets performed well in similar areas, for example, all leaflets
had explicit titles, used subheadings and had content aimed at
increasingknowledgeanddesirablereaderbehavior.Thewritingstyle
285
of the majority of leaflets used the active voice and this is consistently
recommended by practitioners as best practice in health leaflets
[11,15]. Cover graphics were predominately friendly, attracted
attention or portrayed the purpose of the leaflet. Layout and
typography were well-designed including the use of a readable font
size. Typographic and visual cues (i.e., bold type) were also common.
This is consistent with guidance that states simple and clearly
presented materials can improve understanding of content [16].
Leaflets performed poorly in the use of illustrations and
interactive content. Visuals such as pictures or drawings are useful
for communicating information to readers, especially when the
text and the image are closely linked [10]. There is also evidence to
suggest that pictures can enhance knowledge and comprehension
of health information [19]. Over half the leaflets focused on STIs
but few included any illustrations of a simple condom pictorial
demonstration or even written instructions. This could increase
knowledge of correct condom use.
The majority of leaflets chose to portray a culturally neutral
image or failed to use any relevant images altogether. This suggests
a reluctance to tailor information to specific cultural groups and
may mean that some populations do not perceive information to
be relevant to them. Reasons for this may include the desire to not
focus on one specific group, fear of stigmatizing audiences or lack
of consideration of alternative cultural norms. However, many
authors argue that health education is more effective if it is
culturally tailored [20].
Interaction scores were low and many leaflets neglected reader
engagement. This is supported by research that suggests reader
interaction is often absent from printed resources [21]. This
represents a missed opportunity in leaflet design especially when
interaction can promote engagement with leaflet content and may
appeal to readers with a lower literacy level.
4.2. Conclusion
Readability of sexual health leaflets is too high for the audiences
that they are designed for. Failure to consider this variable in the
design of future sexual health leaflets contributes to inequalities in
sexual health as leaflets favor those with high reading abilities. The
suitability assessment of these leaflets demonstrates areas of good
practice however the majority of sexual health leaflets underutilize
techniques that could be used to promote reader engagement and
comprehension.
4.3. Implications for practice
Health practitioners designing print materials could consider
the following; Change complex words to words with fewer
syllables. This immediately lowers the reading grade level. Include
techniques that encourage engagement with written text, for
example true/false quizzes to promote reader interaction. Include
graphics and images where appropriate that support written text.
Review cultural suitability of written materials and tailor to
specific cultural groups where appropriate.
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