Getting the Word Out: Maximizing Health Messages

    Getting the Word Out:  Maximizing Health Messages Without

    Compromising Quality

    Nancy Clifton-Hawkins, MPH, CHES, CLE

    As health care providers, you are in a unique position - you need to maximize your health care messages in shortened encounters.  Health education brochures/fliers are tools that you can use to support the information you have given your patients.  Unfortunately, brochures that do not follow the 3-E’s of health education design:  Excellent Flow, Effortless to Read, and Easy to Comprehend are as ineffective as triplet photocopies of photocopies.    You can easily fix challenges, like these by having a clean copy or e-copy ready for reproducing, integrating more white space and color font into the document, keeping the topic focused, and ensuring that the literacy level is best for your reader.   Since it can sometimes mean the difference between life and death, this article is going to focus on the comprehension aspect of the 3-E’s.  

    It is not practical to assume that a patient is able or willing to take notes on their visit with you.    It is also not practical to assume that your patient has a level of health literacy that will enable them comprehend what you are saying to them.    For you to ensure that your patient is leaving with the information you have given them, a written health education tool is a great way to reinforce clinical visit information and instructions.  The goal is to create something that the patient values and can return to for clarification of their condition and a resource they can go to when they need help.   One way to improve patient comprehension and to make your educational brochure valuable is to invest time in developing your content at the most appropriate literacy level.   While you have a great literacy level tool readily available, via Microsoft Word © readability statistics, the only way you can reduce literacy level is by knowing the manual method.  The method employed here is the Simple Measure of Gobbledygook (SMOG) for literacy level testing (McLaughlin GH, 1969).  This particular method can help you to find areas that increase the literacy level in your document.  Usually these will be in the areas of sentence length and use of polysyllabic (words with more than three syllables).  Keep in mind, the key is to decrease length of your words and sentence length without compromising the reader’s intelligence.  To make the process easy I am going to provide you with the steps I have used for over 17 years.

    SMOG Literacy Level Testing Steps (Hopp H, 1993)

    Step One:  Select three sample sections of 100 words each in different parts of the document.  Write 100 next to the sample section.

    Step Two:  Count the number of sentences in each sample section.  Write the number of sentences next to that sample section. 

    Step Three:  Count the number of words that have more than three syllables.  Write the number of larger words next to that sample section.  Do not count words that are names or words that are normally less then three syllables but become longer because it changes form.  For example, respectable, strengthening, assessment, instructions, etc.

    Step Four:  Now for the math.  For each section –

    1. Divide 100 by the number of sentences. 

    2. Add that number to the total number of words with more than 3 syllables.

    3. After you have completed A and B add each of the sample sections together and get a sum. 

    4. Divide the total number by 3 (because there are three sections) and obtain a product.

    5. Multiply that number by .4 to get the literacy level.  That number represents the grade level.

    Step Five:     To adjust the literacy level you will need to do one or all of the following –

    • Shorten sentences.  The more sentences you have in a 100 word sample the lower the literacy level.

    • Decrease number of words with more than three syllables.  You do this by using a thesaurus and find more simple ways of describing a more difficult word.  For example: The efficacy of this statement has yet to be proven.  Change it to:  It is still not yet known if this statement is true and will work.

    • Do the math again to see if the literacy level has changed.  If not, continue to find ways to make document easier to read by shortening sentences and making words simpler.  Keep in mind that some words have more than three syllables but are well known by most populations so you will not have to change it.  Understand is one of those words.  As a result, the grade level may appear higher. 

    Step Six:  Check for acceptable reading level.  This is dependent on the target audience.  However, when working with low income and lower educational level populations, it is recommended that materials be written between the 4th and 6th grade reading level.  Keep in mind your audience and be sure not to offend intelligence if the level is too low. 

    Step Seven: Field test with target audience. 

    When giving health information to your patients it is important to make sure that they can understand you.   Part of improving their health literacy is to be mindful of the way you are presenting to information to them, in both verbal and written format.   Health Education materials are excellent techniques to support any verbal information or instructions you have given to your patient.   One of the most important ways to ensure that your materials can be used is by focusing on the 3-E’s of health education design:  Excellent Flow, Effortless to Read, and Easy to Comprehend.  This article focused on the comprehension aspect to materials development.   By employing the SMOG (McLaughlin GH, 1969) method, you were given the steps necessary to develop materials that can be delivered at an appropriate literacy level for your patients.   There are other methods and techniques that can help you improve clinician/patient encounters that will result in excellent patient compliance, comprehension and retention.  While I enjoy using the SMOG method, you should avail yourself to the various websites and toolkits available to you free.   The one’s listed below are specific to health care professionals. 

    California Health Literacy Initiative:

    Food and Nutrition Information Center - HealthLiteracy Resource List for Educators 2007:

    National Center for the Study of Adult Learning and Literacy -

    Agency for Healthcare Research and Quality:

    You are in the field of health care to make a difference in the lives of others.   By taking the time to ensure that your messages and instructions are reaching your patients, you can improve the quality of their lives.   When your patients are healthier and happier, the rewards for both are immeasurable. 


    Friedman DB, Kao K. A Comprehensive Assessment of the Difficulty Level and Cultural Sensitivity of Online Cancer Prevention Resources for Older Minority Men.  Prev. Chronic Dis. 2008 January 5(1);  A07.

    Hopp, H.  Health Education and Curriculum Design.  Loma Linda University. 1993. 

    McLaughlin GH. SMOG Grading: A New Reading Formula. J Reading 1969;12:639–640.

    **A extremely edited version of this article appears in the University of Phoenix – Faculty Articles section of their website**