The readability and audience acceptance of printed health promotion materials used by environmental health departments. (International Perspectives).

Introduction

A significant part of the work of an environmental health professional is the communication of information to clients, customers, and the public. The information may be conveyed in the context of health promotion, where the specific purposes include informing and changing individual and collective behavior. Information also may be conveyed as an adjunct to enforcement activities in which the environmental health professional is advising managements or individuals on legal compliance.

Information can be conveyed through a variety of means: verbally in person; on the telephone; through letters and reports; in lectures, talks, and presentations; on radio and television interviews; through Internet sites; and by e-mail. In whichever context and by whatever primary means the information is conveyed, it is common in environmental health departments to have printed brochures available for use as a written reinforcer to verbal inputs or as an adjunct to enforcement activity

The use of printed brochures by environmental health departments in the United Kingdom, as in other countries, is widespread. Table 1 shows the variety of titles the authors found in a sample of environmental health departments. A city council had 205 separate titles, and a mainly rural district council had 87 titles available for use or recommendation by environmental health officers. Printed brochures form a significant aspect of the communications methodology of environmental health departments, either by planned strategy or traditional practice, and commonly the local environmental health department is the gatekeeper between brochure producers and the public. The brochures found in this survey were from a wide range of sources, including central government, charities, trade unions, and commercial enterprises; some were produced "in house."

In a more general survey of professional groups, Murphy and Smith (1992) found that each group thought there would continue to be an important use for printed brochures in their work. In subsets of the wider field of health promotion, such as cancer education, brochures provide written reinforcement for verbal and audiovisual health promotion inputs both at the professional-client interface and in wider mass-media strategies (Borland, Hocking, Godkin, Gibbs, & Hill, 1991; Kaufman, Worrell, Bain, Jones, & Winfield, 1990; Mackie & Hole, 1992). They also can be used as primary sources of health information (Fielding, 1990; Funnel, Donnelly, Anderson, Johnson, & Oh, 1992).

A number of studies have shown that brochures are best used to produce an increase in knowledge (Lame, Shulman, Bartholomew, Gardner, Reed, & Cole, 1989; Sandler, Mitchell, & Fellows, 1989). This knowledge gain has been shown in several studies to be effective in the short term (Spaulding & Kugler, 1991) and the longer term (Watkins, Papacosta, Chinn, & Martin, 1987).

Some evidence also shows that brochures can play a role in effecting attitude change (Meyerowitz & Chaiken, 1987). In a review of studies on brochures designed for individual client/patient attitude change in relation to treatment experiences, Paul and Redman (1997) found that five out of six brochures had effected attitude change. This evidence must, however, be treated with caution as it focuses on a much more personal use than that which might be intended in a significant proportion of environmental health situations.

The production of user-friendly texts thus can be somewhat complicated because of the plethora of purposes for which brochures may be used. Simply because a brochure is easily understood does not mean that it will automatically result in behavior change (the core of common misperceptions regarding leaflets). It may also prove impossible to reduce all topics to a basic reading age as a leaflet may deal with issues that involve highly technical language or multilayered concepts. It may be necessary to consider these issues of reception if the topic either is controversial or necessitates precise instructions. Furthermore, the nature of the language and identity of the brochure are affected by the context within which the leaflet use is in tended. Some publications are intended for a studied, detailed consideration in a highly structured situation while others may be produced for more casual, opportunistic use.

While brochures can be efficacious in promoting knowledge gain and attitude change, there is little evidence that they have a strong role in behavior change. This fact does not seem to deter the ongoing and widespread use of brochures in the United Kingdom; Frazer and Smith (1997) have indicated that the demand for printed material remains high, despite other methods of communication becoming available.

Much has been written about how to produce effective health promotion leaflets or brochures. Hartley and Burnhill (1977) described how layout and design can improve information flow, Secker and Pollard (1995) discuss the use of readability tests to help to produce straightforward and understandable texts, and Frazer and Smith (1997) explain the importance of reflecting the values, language, and concerns of the target group in the brochures. Thus the technical information needed to produce brochures effective for communication is available. To what extent then have these factors been taken into account in the production of the brochures that are commonly used by environmental health departments in the United Kingdom?

This question is clearly important to the effective use of printed material in the delivery of environmental health services in all countries and may also be significant to the "best value" philosophy that is current in British local authority environmental health services and is based on the quest for maximum effectiveness and efficiency within defined economic parameters (Department of the Environment, Transport and the Regions [DETR], 1999). Here the ad hoc selection of printed brochures, which form a significant component of educational and enforcement activities, may be hard to justify on economic grounds. Even in circumstances in which the brochures are obtained at no cost, environmental health departments are accountable, at the very least, for justifying their use of those brochures. Effectiveness is particularly important if the brochure is to be used as an adjunct to enforcement activity. In a study of health and safety leaflets, Harvey, Fleming, Cregan, & Latimer (2000) found that 44 percent of sma ll and medium-sized businesses obtained their health and safety leaflets from enforcement officers.

The Method

The study was conducted through a series of case studies (Sturman, 1999) in five environmental health departments in England, Scotland, and Northern Ireland. In each location an environmental health professional acted as a coordinator. The brochures to be evaluated were selected locally with the objectives of providing as much diversity in terms of sources, targets, and topics as possible and of including one locally produced brochure and one with national distribution.

The case study design was chosen to facilitate the investigation of this contemporary issue within its real-life context (Robson, 1993). Each case study was an embedded case study (Yin, 1994) that contained two interlinked subunits of evaluative data. The subunits are characterized in this study as stages: a readability test and a target-audience questionnaire survey. In addition, coordinators acting as participant-observers gathered further observational data about the reactions of colleagues who were the prime users of the brochures (Figure 1).

Stage 1--Standardized Readability Test

A standardized readability test is designed to provide a quantitative measure of the ease with which a written text is comprehended, or read. A number of formulas have been developed for this purpose; Bradley, McCusker, Scott, & Li Wan Po (1994) compare several in a study of the readability of patient information brochures. For the study reported here, the SMOG formula, devised by McLaughlin (1969) was selected for its simplicity of application in practice. The formula is based on the theory that texts with a high proportion of polysyllabic words require a higher reading ability than texts with words mostly of one or two syllables. A high proportion of polysyllabic words is a fairly obvious obstacle, but it is easy to overlook, and if it is not taken into account, it may prevent the very people to whom the message of the brochure is directed from understanding that message. The SMOG formula produces an indicative reading age needed to read and understand the text. Table 2 gives the results of the SMOG test fo r the brochures involved in the case studies. The SMOG formula was applied to the brochures by the environmental health professional leading each case study and checked externally for accuracy of application.

Stage 2--Audience Reaction Survey

Hastings and Hayward (1991) describe how the best intentions of those who produce brochures can fall foul of the target audience and how pretesting can help to avoid this pit-fall. The SMOG test does not permit participation by the target audience in the evaluation of a brochure. Thus the questionnaire survey was designed to complement SMOG by providing a simple means of gauging the target-audience reaction to the brochures.

Careful consideration was given to the definition of the target audience. In some cases, the brochures were intended for distribution to the general public. Other brochures were for restricted distribution to those who had experienced an illness from a causative agent such as Campylobacter or a problem like dampness in homes. Some brochures were directed at companies and organizations that have to comply with specific laws enforced by the environmental health department. In each case, the demographic characteristics that might affect reading ability also were considered. Thus, issues of gender, ethnicity, age, and social background were taken into account, as was the question of whether English was the first language of the readers.

Once the target audience was established, a convenience sample of eight to 12 people was selected. Respondents were recruited in some sites when they visited the offices of the environmental health department, and in others their cooperation was sought through postal contact. The responses were analyzed by the case study coordinators and subjected to content analysis to identify emergent themes. The questionnaire survey consisted of questions relating to the following criteria: layout, content, presentation, language, general suitability It was recognized that these criteria were in themselves somewhat subjective (Figure 2). Feedback from participants observed by coordinators, however, indicated that there was a generally similar understanding of the criteria across all respondent types.

Overall, this case study method, with its eclectic data-gathering approach, provides an excellent opportunity to understand a phenomenon like the acquisition of health promotion material in its natural setting. What the method does not do, however, is provide a valid, reliable tool, in terms of scientific method, for leaflet selection. Such an approach would require the study of randomly selected, representative samples of target populations and the in-depth validation of research instruments--undertakings beyond the scope and resources of the majority of those who procure or use health promotion materials. This study also does not claim to have accessed all available resources in the relevant area.

What the procedure described in this paper has done is to provide an accessible means of comparison between brochures by allocating a considered number score to each answer option within a specific topic stream. The number scores allowed an overall quantitative result to be calculated for each brochure (Table 2). While this approach is not intended to provide results with a high degree of external validity it does, along with the qualitative results, provide a means of comparing one brochure with another, and it may be a helpful means of communicating the results of such studies to busy environmental health managers.

The conduct of the study conformed to the normal professional ethical standards (SHEPS, 1993). Because participation was voluntary and the identities of participants were not needed at any stage of the process (in line with local ethical practice), it was not considered necessary to seek ethical approval from a research ethics committee.

Results and Discussion

The case study design yielded a range of data that helped researchers assess the usefulness of readability measures and of audience acceptance as indicators of the acceptability of printed health promotion material. Debriefing of coordinators regarding their observations of the process found that the environmental health professionals involved in the study expressed considerable levels of satisfaction regarding the usefulness and relevance of the process.

The first subunit of the case studies, reading age as determined by the SMOG formula, varied from nine years for the Scottish Office/Department of the Environment's "Keep Your Home Free From Damp and Mould' to 15 years for an in-house brochure on the same topic (Table 2). This result immediately raises the question of whether a locally produced brochure was necessary when a potentially more suitable one was already available nationally One case study leader commented that locally produced brochures carry with them a sense of pride and identity which may result in the brochure being used in preference to all others, however good the alternatives. This comment perhaps exemplifies how brochures sometimes optimize self-promotion rather than the conveyance of topic information for which they are primarily intended.

Results also indicated the importance of having some mechanism for making an objective evaluation of the brochures available on a subject of interest and of any brochures intended to be produced in house. The coordinator of Case Study 5, in which inhouse brochures were produced, pointed out that the environmental health department had estimated the reading age of the customers for the brochure to be nine years but that no evaluation of the brochure had previously been carried out. The SMOG formula indicated reading ages of 13 and 15 years, which suggests that most of those at whom the brochures were targeted would have serious difficulties in reading them. Not all locally produced brochures produced low scores. The highest audience score (98.3 percent) was given to the brochure "Campylobacter," produced by a Metropolitan Borough Council in association with the local health authority (Case Study 1).

The second subunit of the case studies, audience acceptance, was used in conjunction with the readability data for a Scottish Office/Department of the Environment brochure, "Keep Your Home Free From Damp and Mould," which was included in two case studies. It is interesting that the results of the target audience surveys for this brochure are remarkably close in both case studies--70.1 percent and 70.2 percent-- despite the authors' caution about the validity of the quantitative results. While the reading age for this brochure, at nine years, indicates suitability for purpose, the target-audience responses suggest a number of important reservations. Ten of the 11 respondents in Case Study 2 said that the text was too small, and some commented that the way in which the sections and pictures were organized was not of benefit to the reader. These comments were reinforced by the respondents in Case Study 3, who commented that they felt there was too much text and that the print was too small. These results indicat e that even if the brochure has the right mix of words and sentences, people can still have trouble with the volume of information, especially if the print is small and close together. On the other hand, this brochure scored substantially higher in the audience survey than did the in-house brochure on the same topic (which had a score of 51.0 percent) (Table 2). Respondents said that the latter brochure was not well laid out, that there was too much text on the pages, and that the text was too small for most customers. They suggested that the brochure could be understood by only a few customers and should be completely redesigned with more common words and phrases.

The popular brochure "Wise Up To Food Hygiene," from the Domestos Advisory Service, achieved a high score in the audience questionnaire survey and an acceptable reading-age score. Respondents commented that it was well designed, appealing to the eye, informative, and easy to read, and that it was likely to be very useful for the purpose intended. An issue raised by some respondents was that the word Domestos appears prominently; thus, in addition to promoting the food safety message, the brochure promotes Domestos products throughout. The reader could easily be led to believe that the environmental health department, through which the brochure was distributed, endorses Domestos products for the purpose indicated in the brochure. This situation may be in conflict with the ethos of the education/enforcement approach of the department and could potentially conflict with other environmental health issues--in this case, for example, safety in the use of chemicals in the workplace.

The brochure "Food Safety: Hazard Analysis," examined in Case Study 1, was designed by a Metropolitan Borough Council to advise food managers on how to meet the hazard analysis requirements of the food law. Clearly the link with the law raises the stakes for any brochure given by an enforcement officer to those who must comply with the law and who could potentially be prosecuted by an enforcement officer or authority. In Case Study 1, the brochure showed an acceptable reading score (11 years) for the target audience of food managers; nevertheless, the target-audience responses in the questionnaire survey indicated a number of important reservations, and the brochure scored significantly less well than the other two brochures examined in this case study. The main concerns were that the brochure did not have a clear layout and that the information did not flow well. It was suggested by the target-audience sample that the brochure would he understood by only a few people. Hazard analysis is a difficult subject, and in this case it would appear that the brochure did not effectively convey the message to the target-audience sample. This result raises the question of the efficacy of printed brochures used as an adjunct to enforcement activity and whether there is potential for brochures that are "proven" to be ineffective to be used as defense evidence in any related legal proceedings.

In most cases, the target-audience respondents suggested improvements to the brochures through their comments, which are outlined below:

* layout:

--- "reduce the amount of text,"

--- "summarize the key points,"

--- "make the brochure bigger,"

--- "don't pack so much detail into such a small space," and

--- "highlight the key points";

* content:

--- "restrict the information to the key points only,"

--- "produce supplementary information referenced in the original brochure,"

--- "the brochure is short on the health effects of lead,"

--- "no contact number provided for further information,"

--- "too much information--condensation could be one brochure on its own,"

--- "single-column format would be better than up and down,"

--- "there are excessively large margins around very small text," and

--- "the last page contains too much";

* presentation:

--- "picture of what the mold looks like,"

--- "replace the pale-colored text,"

--- "increase the text size,"

--- "the cover is unattractive,"

--- "make the brochure brighter to be more eye-catching,"

--- "could you not use more common words and phrases,"

--- "improve the layout,"

--- "use bolder type to emphasize key points,"

--- "I don't like the mixed text styles,"

--- "older people find text on a shiny surface hard to read,"

--- "too small text," and

--- "not well laid out and too much text";

* language:

--- use more concise language and sentences to make the subject easier to comprehend,"

--- "use pictures more because words confuse,"

--- "an excellent brochure--comprehensive but expressed in simple, straightforward language" (Home Energy Efficiency Scheme [HEES] brochure),

--- "more common words and phrases needed," and

--- "the brochure was not very useful and could be improved";

* general suitability:

--- "the HEES brochure was the most user-friendly" and

--- "the brochure could be understood by only a few people."

These suggestions must be read in light of the limitations imposed by a relatively small audience sample and the low external validity of the exercise. Each study site chose its own audience sample to best reflect the potential users of the leaflet. Other sites may have potential audiences that differ in certain respects (e.g. ethnicity, age, gender, linguistic background), and therefore what may be acceptable or unacceptable in one location may elicit a very different response in another.

Conclusion

This study raised a number of questions about the effectiveness of environmental health promotion brochures in common use in the United Kingdom and about problems that could arise from simply assuming that the brochures are conveying the intended message to the target audience. Each of the sites that cooperated in the study observed that a more systematic approach to choice and provision of printed material, taking into account the expressed needs of the end users, was to be encouraged. The production of numerical scores was considered useful as a simple comparison tool for making a choice between brochures on the same topic.

Such a systematic approach addresses dilemmas such as whether there is a need to produce, or continue to produce, in-house material when well-designed materials are available from external sources. In-house production can be both time consuming and expensive, and a coherent process for brochure choice may help practitioners to challenge departmental policies if choices appear to have more to do with kudos and prestige for individuals or individual departments than with the provision of cost-effective environmental health promotion materials.

All of these considerations point to the need for further research. For instance, could a regional or national organization provide the funding and expertise necessary to conduct ongoing research that would draw on larger samples and would use targeted professional expertise in communications technology? Such research should be able to address message imperatives, societal trends, and conditions while also monitoring the acceptability of material at the local level as required by organizations such as those who participated in the case studies reported in this paper. Further work also needs to be undertaken with respect to the creation and selection of written environmental health promotion materials. The functioning of these materials as educators, behavior changers, reinforcers of verbal health education, and aids to enforcement needs to be challenged afresh.

Overall, this study has shown that the application of a well-structured method for brochure selection is an indispensable element of best practice in environmental health departments and contributes to effective resource management in environmental health promotion. The method described here provides an accessible and realistic tool for this purpose.

Acknowledgements: The authors thank the following environmental health professionals who acted as local case study coordinators: Shiela Bell, Penny Marsh, Jane Prosser, Nicky E. Brichard, and Anne Donaghy.

TABLE 1

Numbers of Printed-Leaflet Titles Available in U.K. Environmental Health
Departments

General Topic                            Number of
                                      Different Titles
                                      City Council

Health and safety                          51
Food safety                                42
Environmental protection                   36
Housing                                     5
General public health (including            6
 pest control)
Infectious disease control                  8
Home safety                                26
Consumer safety                            15
Promotion of the department's              16
 Services
Totals                                     205

General Topic                         Number of
                                   Different Titles
                                  District Council

Health and safety                        15
Food safety                              18
Environmental protection                 38
Housing                                   1
General public health (including          6
 pest control)
Infectious disease control                2
Home safety                               4
Consumer safety                           3
Promotion of the department's             0
 Services
Totals                                   87

TABLE 2

Selected Brochures and Test Results

Title                               Source



Case Study 1: English Metropolitan
 Borough Council
"Wise up to Food Hygiene"           Domestos Advisory Service (with
                                    "discrete" commercial advertising)




"Campylobacter"                     MBC and Local Health Authority
                                    (funded by the Health Authority)




"Food safety: Hazard Analysis"      MBC. Text drafted by Food Liaison
                                    Group and adapted by several LAs.



Case Study 2: Scottish District
 Council
"Food Safety: A Guide from HM       MAFF
Government"



Lead                                Environmental Health (Scotland) and
                                    Communicable Diseases (Scotland)
                                    Units



"Keep Your Home Free from Damp and  Scottish Office (central
Mould"                              government)




Case Study 3: English District
 Council
"We Give Grants to Help You Keep    HEES
Warm"




"Minor Works Assistance"            Borough Council ("in house")




"Keep Your Home Free from Damp and  Department of the Environment
Mould"                              (central government)





Case Study 4: English District
 Council
"Grant Applications: The Test of    District Council ("in house")
Resources"




"House Renovation Grants"           Department of the Environment




"We Give Grants to Keep You Warm"   HEES



Case Study 5: Group Environmental
 Health Committee, N. Ireland
"Food Safety and Your Barbeque"     The Foodlink Programme (government
                                    funded)



"Caution! Improperly Stored LPG Is  Group EH Committee ("in house")
a Serious Hazard"



"Condensation, Mould Growth and     Group EH Committee ("in house")
You"





Title                               Appearance and Purpose



Case Study 1: English Metropolitan
 Borough Council
"Wise up to Food Hygiene"           Glossy 8-page A5 brochure.
                                    Domestos" appears as a large-text
                                    watermark in the middle pages. Used
                                    in broad-sweep approach to raising
                                    food safety awareness.

"Campylobacter"                     Tri-fold glossy brochure. Black
                                    text on a light green background.
                                    Sent to people infected with
                                    Campylobacter in place of a home
                                    visit.

"Food safety: Hazard Analysis"      4 glossy pages in tri-fold format.
                                    Black text on yellow background.
                                    Targeted at food managers as part
                                    of routine visit activity.

Case Study 2: Scottish District
 Council
"Food Safety: A Guide from HM       A5 brochure with 12 text and
Government"                         graphics pages plus covers. Given
                                    to all people interviewed because
                                    they have food poisoning.

Lead                                4 sheets folded to provide an A5
                                    brochure. Black text on a white
                                    background. Given to clients who
                                    inquire about lead in water or who
                                    request sampling.

"Keep Your Home Free from Damp and  A 6-page tri-fold brochure in A5
Mould"                              size. Black text in red columns.
                                    Given to householders during
                                    inspections or on request for
                                    information.

Case Study 3: English District
 Council
"We Give Grants to Help You Keep    A six page tri-fold brochure in A5
Warm"                               size, printed red, blue and black
                                    inks on white paper. Sent to people
                                    over 60 years old and likely to be
                                    eligible for a grant.

"Minor Works Assistance"            4 sheets folded to produce A5
                                    brochure. Black text on white
                                    background. Sent to people likely
                                    to be eligible for a grant.

"Keep Your Home Free from Damp and  6-page tri-fold brochure in A5
Mould"                              size, printed color with black text
                                    in red columns. An information
                                    brochure for householders who are
                                    experiencing dampness in their
                                    home.

Case Study 4: English District
 Council
"Grant Applications: The Test of    8 A5 pages printed in black and
Resources"                          white. Aimed at potential grant
                                    applicants. An officer may work
                                    through the brochure with a
                                    client if requested.

"House Renovation Grants"           45 A4 pages printed in two colors.
                                    Aimed at potential grant applicants
                                    and made available at the Councils
                                    reception.

"We Give Grants to Keep You Warm"   Glossy single-sheet folded to
                                    produce A5 brochure. Targeted
                                    mainly at the elderly.

Case Study 5: Group Environmental
 Health Committee, N. Ireland
"Food Safety and Your Barbeque"     4 A5 pages with large color
                                    cartoons and mostly black text on
                                    a white background. Aimed at
                                    householders.

"Caution! Improperly Stored LPG Is  A4 page in tri-fold format. Mostly
a Serious Hazard"                   blue text on white background with
                                    captions highlighted in red. Aimed
                                    at business and householders.

"Condensation, Mould Growth and     A4 page folded once to form a
You"                                brochure. Black text in numbered
                                    paragraphs on a white background.
                                    Aimed at people known to have
                                    dampness in their homes.


Title                                  SMOG Formula     Average Survey
                                    Result 'Equivalent    Score (%)
                                       Reading Age'

Case Study 1: English Metropolitan
 Borough Council
"Wise up to Food Hygiene"                11 years           96.5%





"Campylobacter"                          12 years           98.3%





"Food safety: Hazard Analysis"           11 years           75.9%




Case Study 2: Scottish District
 Council
"Food Safety: A Guide from HM            11 years           83.9%
Government"



Lead                                     11 years           70.3%





"Keep Your Home Free from Damp and        9 years           70.2%
Mould"




Case Study 3: English District
 Council
"We Give Grants to Help You Keep         10 years           84.0%
Warm"




"Minor Works Assistance"                 13 years           82.3%




"Keep Your Home Free from Damp and       9 years            70.1%
Mould"





Case Study 4: English District
 Council
"Grant Applications: The Test of         13 years           70.3%
Resources"




"House Renovation Grants"                13 years           81.0%




"We Give Grants to Keep You Warm"        10 years           90.3%



Case Study 5: Group Environmental
 Health Committee, N. Ireland
"Food Safety and Your Barbeque"          10 years           79.3%




"Caution! Improperly Stored LPG Is       13 years           66.2%
a Serious Hazard"



"Condensation, Mould Growth and          15 years           51.0%
You"





HEES = Home Energy Efficiency Scheme (government-funded not-for- profit
organization)

LAs = local authorities.

MAAF = Ministry of Agriculture, government).

MBC = metropolitan borough council.

Although most of the information presented in the Journal refers to situations within thc United States, environmental health and protection, know no boundaries. The Journal periodically runs an International Perspectives Column to ensure that issues relevant to our international constituency, representing over 60 countries worldwide, are addressed. Our goal is to raise diverse issues of interest to all our readers, irrespective of origin. Also, by offering perspectives from abroad, whet her research or commentary, this column helps keep our U.S. members informed about international environmental health concerns--and their solutions.

REFERENCES

Borland, R.M., Hocking, B., Godkin, G.A., Gibbs, A.F., & Hill, D.J. (1991). The impact of a skin cancer control education package for outdoor workers. Medical Journal of Australia, 154(10), 686-688.

Bradley, B., McCusker, E., Scott, E., & Li Wan Po, A. (1995). Patient information leaflets on over-the-counter (OTC) medicines: The manufacturer's perspective. Journal of Clinical Pharmacy & Therapeutics, 20(1), 37-40.

Department of the Environment, Transport and the Regions. (1999). New duty of best value for local authority services. London: Author. http://www.local-regions.odpm.gov.uk/bestvualue/bvindex.htm (9 Sept. 2002).

Fielding, J.E. (1990). Worksite health promotion survey: Smoking control activities. Preventive Medicine, 19(4), 402-413.

Frazer, J., & Smith, F (1997). Pretesting health promotion leaflets--A case study. International Journal of Health Education, 35(3), 97-101.

Funnell, MW, Donnelly, M.B., Anderson, R.M., Johnson, PD., & Oh, MS. (1992). Perceived effectiveness, cost and availability of patient education methods and materials. The Diabetes Educator, 18(2), 139-145.

Hartley J., & Burnhill, P (1978). Fifty guidelines for improving instructional text. In J. Hartley & I.K. Davies, Contributions to an educational technology (pp. 182-194). London: Kogan.

Harvey, H.D., Fleming, F, Cregan, K,, & Latimer, E. (2000). The health promotion implications of knowledge and attitude of employees in relation to health and safety leaflets, International Journal of Environmental Health Research, 10(4), 315-329.

Hastings, G., & Hayward, A. (1991). Social marketing and communication in health promotion. Health Promotion International, 6(2), 135-145.

Kaufman, A.J., Worrell, J., Bain, R.S., Jr., Jones, H.W., III, & Winfield, A.C. (1990). American Cancer Society's breast cancer detection awareness program: The 1988 middle Tennessee experience. Southern Medical Journal, 83(6), 618-620.

Lame, L., Shulman, R.J., Bartholomew, K., Gardner, P, Reed, T., & Cole, S. (1989). An educational booklet diminishes anxiety in parents whose children receive total parenteral nutrition. American Journal of Diseases of Children, 143(3), 374-377.

MacKie, R.M., & Hole, D. (1992). Audit of a public education campaign to encourage earlier detection of malignant melanoma. British Medical Journal, 304, 1012-1015.

McLaughlin, G.A. (1969). SMOG grading--A new readability formula. Journal of Reading, 12(8), 639-646.

Meyerowitz, B.E., & Chaiken, S. (1987). The effect of framing on breast self-examination attitudes, intentions and behaviour. Journal of Personality and Social Psychology 52, 500-510.

Murphy, S., & Smith, C. (1992). An examination of the use of health education leaflets by health promotion officers. Health Education Journal, 51(4), 266-275.

Paul, C.K., & Redman, S. (1997). A review of the effectiveness of print material in changing health-related knowledge, attitudes and behaviour. Health Promotion Journal of Australia, 7(2), 91-99.

Robson, C. (1993). Real world research. Oxford: Blackwell.

Sandler, D.A., Mitchell, J.R.A., & Fellows, A. (1989). Is an information booklet for patients leaving the hospital helpful and useful? British Medical Journal, 298, 870-874.

Secker, J., & Pollard, R. (1995). Writing leaflets for patients: Guidelines for producing written information. Edinburgh: Health Education Board for Scotland.

Society of Health Education and Promotion Specialists. (1993). Code of practice. London: Author.

Spaulding, S.A., & Kugler, J.P. (1991). Influenza immunisation: The impact of notifying patients of high-risk status. Journal of Family Practice, 33, 495-498.

Sturman, A. (1999). Case study methods. In J.P. Keeves & G. Lakomski (Eds.), Issues in educational research (pp. 103-112). Oxford: Elsevier Science, Ltd.

Watkins, C.J., Papacosta, A.O., Chinn, S., & Martin, J. (1987), A randomized controlled trial of an information booklet for hypertensive patients in general practice. Journal of the Royal College of General Practitioners, 37(305), 548-550.

Yin, R.K. (1994). Case study research: Design and methods (2nd ed.). London: Sage Publications.

Corresponding Author: Harold D. Harvey, Director, Environmental Health Protection and Safety Centre, 4F10, University of Ulster, Jordanstown, Northern Ireland BT37 0QB. Email: <[e-mail]>.