A critique of a current health promotion leaflet (Level 2)

University Degree Subjects allied to Medicine

Health promotion is increasingly seen as a role of the NHS and its practitioners (Boyce 2009). Darzi (2008) recommended that the NHS should be equally active in promoting good health as it is in treating disease and therefore modern nurses require knowledge of effective health education materials to enhance health promotion. This assignment will seek to appraise a health promotion leaflet (Appendix 1) related to a current NHS health campaign and which for the purpose of this assignment will be referred to throughout as ‘the leaflet’. Appraisal of this leaflet will include: an explanation of why this leaflet was chosen; the source of the leaflet; the relevance of this leaflet to the role of the nurse in promoting health; an analysis of the design of the leaflet including effectiveness of both illustration and textual layout by way of reference to supporting evidence; an evaluation of the information content contained within the leaflet; a short critique of the overall readability of the information using a widely accepted readability test and supporting guidelines; a brief consideration of the target audience and subsequent ethical considerations and lastly an overview of the assignment with reference to application to practice and future research.

Firstly the leaflet was chosen as it is part of a current NHS health promotion campaign aimed at raising awareness of risk factors of hepatitis C contraction and to encourage at risk individuals to seek testing and treatment for the disease. Produced in 2009, the leaflet is an example of a current health promotion leaflet produced in the UK for the National Health Service. There are complimentary elements to the leaflet, such as a website where resources, for both patient and health care professionals, including current research on Hepatitis C can be accessed (NHS 2009); this was also a deciding factor in choosing this leaflet. Lastly, this leaflet was chosen as it highlights the complimentary role of patient information leaflets to the role of the nurse as educator (Boyce 2009b). As treatment for chronic hepatitis has become more effective and more widely available, it becomes more important that early prevention is facilitated by health service providers particularly nurses (Panou & Catt 2009). Panou & Catt (2009b) also suggests that as hepatitis C symptoms can go unnoticed while causing irreversible damage; nurses should be aware of the disease and the quality of written information which is available for patients in order to increase the uptake of testing among at risk individuals.

The leaflet was sourced in a sexual health clinic in Greater Glasgow, and since persons who engage in unprotected sex have been identified as a group who are at high risk of contracting hepatitis C (World Health Organisation 2009) this setting can be said to be an appropriate one to reach a section of the leaflet’s target audience.

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An important factor in whether health information will appeal to this target audience is design (Houts et al 2006). According to Hoffman and Worrall (2004) and supported by Demir (2008), a health education leaflet should be patient centred and designed with the principles of good health education material design in mind, including layout of both illustration and text. Often leaflets in clinical areas are ignored; however leaflets with pictures draw the attention of patients and encourage attention to the information contained within (Houts et al 2006b) and as the leaflet selected is vibrant and colourful it catches the eye. The colourful effect of the leaflet is produced by a photographic collage including items which may be linked to high risk behaviour or disease prevention, such as drug paraphernalia, body jewellery and condoms. It could be argued that these images could be considered unclear, open to interpretation; western based and therefore culturally biased which could reduce the relevance of the campaign on the desired audience (Griffin et al 2003). Images within this leaflet although colourful, do not support or help explain the leaflets key points. Evidence suggests that illustration in written health information can aid recall and promote understanding of the written material (Houts et al 2006c) while Godsell & Scarborough (2006) state that while people with varied literacy skills may find reading and understanding health information difficult, those with low literacy levels or learning difficulties can be aided significantly by the use of illustration or photographs combined with text. It could be argued that according to this evidence the producers of this leaflet have not capitalized on the use of illustration for readability purposes. Conversely inappropriate use of illustration can distract the audience and abstract graphics are not recommended as each picture should illustrate a single idea to reinforce the text (Hoffman and Worrall 2004b), further supporting the premise that, while the illustrations displayed on the leaflet are eye-catching, they do not support the factual content it contains. On further assessment of the leaflet, consideration was given to the effectiveness of the way text is laid out as advocated by Hoffmann and Worrell (2004c) and the NHS (2006) Toolkit for producing patient information. The leaflet uses paragraphs which may be less successful than alternative layouts such as bullet points; Paragraphs however are short communicating a single idea which maintains the clarity of the message. Text within the leaflet is of a recommended dark on light background in a 9.5 mm font which is smaller than the recommended 12 mm and could make reading the leaflet uncomfortable for people with visual difficulties (Briggs & Smith 2008). The nurse selecting appropriate health information should consider such influences on comprehension of health education materials (Carress 2003).

In terms of content of information, written material should contain accurate content and be written in a simple manner which can be understood easily (Hoffmann and Worral 2004d), (NHS 2006b). The information in the leaflet can be assumed to be relatively current as it has been issued by the department of health superseding a previous ‘2006’ health information leaflet (DOH 2009), it has been produced as part of a campaign strategy based on the Hepatitis C strategy for England, supported by current evidence as recommended in the NHS toolkit for producing patient information (NHS 2006c). The information contained in an A4 sized leaflet cannot cover all information; however the leaflet does refer the reader to further resources although it is, the opinion of the author, a weak point of the leaflet is that there is no direct link to the current campaign website. The information contained within the material can be seen to be comprehensible to readers of varied literacy skills where one accepts that material should be written at approximately aged 10 levels for optimum readability (Hoffmann and Worrall 2004e). McLaughlin (1974) describes readability as a quality of written material which encourages the reader to keep reading. One element of this readability is how easy the material is to understand, and to measure this the SMOG readability tool was developed (McLaughlin 1969), a tool used to calculate the comprehensibility of written material based on the number of words of three or more syllables contained within the text. The SMOG readability tool is often used to assess the quality of written healthcare information (Sand-Jecklin 2007). Using the SMOG readability tool, both manually and via McLaughlin’s online SMOG calculator (McLaughlin and Trottier 2009) it was possible to calculate an approximate reading age for the leaflet which indicates ‘some high school’ reading level (McLaughlin 1969b). Although the SMOG tool is generally accepted to be a reliable and simple way to calculate the readability of health education literature, the strict criteria may result in higher reading grade scores (Sand-Jecklin 2007b) for example in the leaflet where a key word of three syllables ‘Hepatitis’ is repeated, therefore this leaflet may be judged to be closer to the Hoffmann and Worrall (2004f) advocated reading age than the SMOG tool indicates. A possible criticism of the leaflet according to the recommendations put forward by Hoffmann and Worrall (2004g) is the use of judgmental language such as ‘Don’t start injecting drugs’ which may appear patronising to the reader (NHS 2006c). The voice of the leaflet however enhances the leaflet’s readability using an active, conversational style, which will both lower the reading level of the material and engage the reader (Godsell and Scarborough 2006b).

The leaflet aims to target high risk groups, however a growing number of hepatitis C cases are emerging from amongst the South Asian immigrant population which poses ethical considerations on the accessibility of hepatitis C awareness information (Panou 2009c) such as whether this leaflet is available in appropriate languages. This leaflet is available to print for display in multilingual formats (DOH 2009) however whether the leaflet is available in a clinical area is dependant on healthcare staff printing and promoting an appropriately translated version which was not evident at the source of this leaflet. This is important to note as Health messages can be easily missed due to language barriers, and therefore health information is recommended to be available in several languages (Smith 2006).

In conclusion the leaflet is appropriately placed, eye catching and appears to have an adequate readability level and current evidence based content. The leaflet does however appear to have some design flaws which may affect its impact on a target audience including poor use of illustration, font size and limited availability in formats aimed towards increasingly high risk minority ethnic groups. Further discussion in this assignment would have been welcomed by the author, though limited by the specified word count. Subsequently while researching health education leaflet design, the author perceived a significant gap in current research, specifically in terms of impact of text layout and engagement of the reader in written health education information and therefore would recommend or aim to undertake further research in this area. In terms of practice the author would suggest that awareness of simple readability tests, guidelines and the impact of appropriate graphics would inform the nurse in selecting written health education material which are appropriate for individual service users.

Appendix 1: Leaflet: Hepatitis C: Get tested,Get treated.

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