therefore , to increase the effectiveness of health education , information given to patients verbally should be supplemented and reinforced with written materials . some advantages of written materials are consistency of message , ready availability of the required information , and ability to share this information . these materials can be used to underpin the information obtained verbally from health care providers . however , to influence health behaviors , it is important to ensure that health education materials are suitable for their target audience . to maximize their suitability , a number of factors , such as content , layout , and cultural appropriateness of these materials should be taken into account . in spite of a range of benefits of written material , the means of acquiring health information are changing in this era of advancing electronics ; people rely more on electronic devices such as television and internet . therefore , printed materials should be made to suit the audience by making them attractive and useful . the development of effective health education materials requires formative research as well as evaluation , which systematically obtains information to be used to improve these materials . written education materials in the form of posters and brochures are common in the kingdom of saudi arabia ( ksa ) . however , we were unable to find any study conducted to determine the suitability of written health education materials disseminated in ksa in the literature review . consequently , it is expected that there is a lack of awareness of the factors that make written education material suitable . however , the evaluation of these brochures for their suitability is not conducted in a systematic manner . the purpose of our study was to formally evaluate the available health education brochures , designed and disseminated by government health care institutions in the qassim province , ksa . this was a cross - sectional review of health education brochures developed by the ministry of health ( moh ) institutions in the qassim province . qassim , a central province of ksa , has 174 health care facilities belonging to saudi moh . the majority of these health care facilities carry out health education activities , including the distribution of written health education materials . we invited all health care institutions under the moh , in the qassim province to send written health education materials available in their facilities for evaluation . all health education materials received were classified as leaflets , booklets , brochures and posters . we defined a health education brochure as a single page , two - sided , folded document designed to communicate health - related information to the community or patients . the brochures were further classified as two - fold , three - fold and four - fold . only brochures in arabic structured evaluation form composed of two sections , was designed and used as a research instrument . the first section of the evaluation form asked for general information while the second section was the suitability assessment of materials ( sam ) score sheet . this information included the title of the brochure and credentials of the authors , publication date , and citation for the sources of the contents . sam is used by researchers for the evaluation of printed materials , as well as web - based ones . the sam uses six factors to assess the suitability of materials : content , literacy demands , graphics , layout and typography , learning stimulation / motivation and cultural appropriateness . each criterion is scored on a maximum of two points and a minimum of zero point . a score of two points is rated as  superior ,  one point as  adequate ,  zero point as  not suitable . if the criterion does not apply to the material , it is labeled as  not applicable . scored items are summed up and the percentage ( excluding n / a items ) is calculated . the material is then classified according to percentage as either superior ( 70 - 100% ) , adequate ( 40 - 69% ) or not suitable ( 0 - 39% ) . the sam criteria use readability formulas to assess the  reading level  of written material for the factor on literacy demand. as readability formulas are not available for arabic , this item was omitted . amendments were also made in the criteria for  typography .  the criteria of  uppercase and lowercase serif or sans serif , and  no all caps for long headers or running text  were omitted , as they are not applicable to arabic typography . font size of at least 14 points was used as a criterion , instead of size 12 standard set by sam criteria . leonard doak and cecilia doak , authors of the original sam , were consulted through e - mails about the modifications in the sam instrument . two qualified consultant family physicians from the local community who were trained in a workshop arranged for this purpose did the evaluation . each brochure was independently evaluated and scored by each evaluator . data were entered and analyzed using epi info version 3.4 statistical package ( centers for disease control and prevention , atlanta , georgia , usa ) . the mean of percentages by the two evaluators , of all six sam factors and overall sam percentage were used to designate the categories of  superior ,   adequate  and  not suitable  to each brochure . for individual criterion , the scores assigned by the two evaluators were summed up and the categories re - defined . the criteria which attained four points were labeled as  superior ,  while those attained two or three points were labeled ,  adequate  and those with zero or one point were labeled as  not suitable . a total of 110 brochures were evaluated , out of which 59 were three - fold , 45 were two - fold and six were four - fold . of the brochures evaluated , 75 ( 68.2% ) were designed and disseminated by hospitals while 35 ( 31.8% ) were made by various departments in the public health administration , qassim . the most common subject written on was mental health ( 21.8% ) , followed by chronic diseases ( 12.7% ) , and the least common addressed topic was ophthalmology ( 1.8% ) . although the institution 's name was mentioned in all ( 100% ) brochures , the names of the authors ( 36.4% ) and reviewers ( 5.5% ) were mentioned in only a small proportion of the brochures . salient features of evaluated health education brochures ( n=110 ) seventy - four ( 67.3% ) brochures scored as  adequate ,  34 ( 30.9% ) were  not suitable  and two ( 1.8% ) were rated as overall , the average sam score for all brochures was 44.3% ( range : 20.0% to 70.0% ) , which is considered  adequate  based on the sam ratings . the suitability rating , across the six sam factors , are displayed in table 2 , while the suitability rating for individual criteria of the sam factors are shown in table 3 . suitability rating of the health education brochures in qassim ( n = 110 ) rating of sam factors for health education brochures in qassim ( n=110 ) rating of individual criterion of sam factors for health education brochures in qassim ( n=110 ) the content factor in the majority ( 74.5% ) of the brochures was categorized as  adequate . a large proportion ( 92.7% ) of the brochures stated their purpose , which warranted the classification as superior  or  adequate  according to sam scores . a succinct summary to emphasize important  take home  messages was absent in almost all brochures resulting in the rating of 107 ( 97.3% ) brochures as  not suitable . overall , the average sam score for the  content  factor of all brochures was 48.9% ( range : 13.0 - 75.0% ) , which placed them in  adequate  category . the  literacy demand  factor in 54.5% of the brochures was categorized as  adequate ;  only one ( 0.9% ) brochure was rated as overall , the average sam score for the  literacy demand  factor of all brochures was 42.0% ( range : 7.0 - 75.0% ) , which put them into the  adequate  category . the brochures were largely written in a passive , third - person using medical terms , thus rendering almost half ( 50.9% ) of them  not suitable  with regard to style of writing . approximately , two - thirds ( 68.2% ) of the brochures were rated as  not suitable  in graphics . overall , the average sam score for the  graphics  factor of all brochures was 25.9% ( range : 0.0 - 75.0% ) , which fell into the  not suitable  category . only 3 ( 2.7% ) brochures had covers with graphics that were rated as  superior . a sizable proportion of brochures ( 63.7% ) had illustrations that made them  not suitable . approximately , two - thirds ( 64.5% ) of the brochures were categorized as  adequate  in  layout and typography . overall , the average sam score for this factor was 48.7% ( range : 17.0 - 92.0% ) , which fell into the  adequate  category . most brochures used an appropriate font size ( 14 point or larger ) . however , in some brochures pages were text - dense , and watermarks used as background illustrations made the text difficult to read . more than one - third ( 41.0% ) of the brochures were categorized as  not suitable  in the  learning stimulation and motivation  factor . overall , the average sam score for this factor was 39.9% ( range : 0.0 - 75.0% ) , which fell into the upper limit of the  not suitable  category . none of the brochures used active interaction , and very few used passive interaction such as question and answer format for headings and subheadings . few brochures focused on practical , behavior - modifying steps for the reader ; 11 ( 10.0% ) brochures scored  superior  in this category . the cultural appropriateness of the majority ( 82.7% ) of the brochures was  adequate . overall , the average sam score for the factor for  cultural appropriateness of all brochures was 48.3% ( range : 25.0 - 75.0% ) , which fell into the  adequate  category . on the whole , the brochures in this study addressed a variety of topics including mental health , chronic diseases and infectious diseases . some topics such as mental health and cardiac health were addressed more frequently , as the institutions with these specialties had specific budgets for health promotion activities . author 's credentials are considered important to assure readers that the information provided was credible since the authors had the appropriate expertise in the field . the majority of our brochures ( 63.6% ) did not give the name of the authors or their credentials . however , all of them displayed the institution 's name as well as logo of the moh . this display of the name of the institution and logo of moh endorsed the information as credible . a record of the date of publication is important to assure readers that the information provided was up - to - date . brochures published within the past 2 - 3 years are considered up - to - date . however , a study conducted in the united kingdom found that some general practices were using information leaflets that were 6 - 13 years old for the education of patients . in our study , only a small proportion ( 15.5% ) of brochures mentioned the date of publication , which made it difficult to determine if they were current . in this study , the average sam score for all brochures was 44.3% , which is considered  adequate  on the sam ratings . in an evaluation of the written education materials for patients with prostate cancer , the mean overall sam rating was however , average scores were higher ( 63.3% ) in comparison to our study . our study found that approximately two - thirds ( 67.3% ) of brochures fell into the  adequate  category . this finding is similar to an evaluation of 31 information leaflets , 64.5% of which were rated as  adequate . , the researchers found that 22 ( 75.8% ) scored  adequate  for their overall suitability , while sam suitability scored six as  superior  ( 20.6% ) and one ( 3.4% ) as  not suitable . in an evaluation of 21 printed educational materials on human papillomavirus ( hpv ) , the average sam score was 37.4% , which is considered  not suitable .  in another assessment of 35 brochures and eight worldwide web education materials for neurology patients , 14% of the materials were  superior , in that study , well - known organizations had brochures with an average rating in the  adequate  category . a concise summary , interactive format , and motivation content help people to adopt the desired behavior . in our study , few brochures ( 13.6% ) most of the brochures mainly had scientific information , but no practical guidance for behavior change . other studies have also found similar limitations in the written health education materials . in our study , 97.3% of brochures had no summary of the contents which is more than was found in another study in which 86% of the materials were without a summary statement . an evaluation of 101 written documents for novel h1n1/09 influenza published on the cdc website , showed that not a single document had a summary . many of our brochures needed to be more focused on the information which was in the category of  needed to know ,  rather than another area of considerable weakness in our brochures was the absence of interactive techniques such as question and answer format . evaluation of the use of common vocabulary in the brochures showed that our study had only 2 ( 1.8% ) that could be rated superior  in comparison to 4 ( 14% ) that were  superior  in another study . several studies have found that written materials with graphics are well - received by the target audience because they can help to reinforce messages . in our study , approximately 68% brochures were rated as  not suitable  compared to 82% of the brochures in another study that required improvements to their illustrations . in evaluating the cover graphics for each brochure , only 3 ( 2.7% ) were rated  superior . this is in contrast to another study in which the researchers rated the majority of cover graphics as  superior . captions are helpful in conveying the message of the graphics . in our study , only 10 brochures ( 9.1% ) had captions to explain the information in the graphics , in contrast to another study in which there were captions to the illustrations of 24% of the written materials . though the brochure must be visually appealing and well - formatted , the main message can be obscured with the use of several bright colors and stylish borders . in our study , 76.4% were  adequate  in typography , but in another study , the font used in 51% of the brochures was appropriate . in our study , 25.5% of the brochures needed improvement in layout , while in the study by arnold et al . subheadings were required in 45.5% of our brochures to shorten the paragraphs and make them easier to understand , compared to 51% in another study that needed shortening of paragraphs . other researchers also had issue with the paragraphs , text - dense pages and the lack of subdivision of complex information into smaller pieces of written materials . in evaluating content for behavior modeling , adequate  in another study . in that same study , evaluation of the materials for motivation showed that 72.3% of the materials were  adequate  or  not suitable ,  while all of our brochures ( 100% ) fell into these two categories . in our study , as was also found by weintraub et al . our brochures were culturally sensitive with no offensive illustrations or examples , as was also noted in other studies . this study was limited to the evaluation of health education brochures designed by government institutions . the brochures from private health care institutions , and those written in languages other than arabic , were not evaluated . as the brochures were selected from qassim province only , the findings of this study may not be generalized to cover those produced and disseminated in other provinces of saudi arabia . therefore , the evaluator 's attitudes , cultural and professional background may have influenced the outcome of this evaluation . this study was limited to the evaluation of health education brochures designed by government institutions . the brochures from private health care institutions , and those written in languages other than arabic , were not evaluated . as the brochures were selected from qassim province only , the findings of this study may not be generalized to cover those produced and disseminated in other provinces of saudi arabia . therefore , the evaluator 's attitudes , cultural and professional background may have influenced the outcome of this evaluation . to sum up , this study showed that although two - thirds of the health education brochures were  adequate  in terms of their overall suitability the majority needed improvements to be made to their graphics , learning stimulation and motivation . the lack of a summarized statement , and interactive features , insufficient use of graphics , the absence of instructions to model desired behavior , and a crowded layout were some of the weaknesses also found in other studies that used sam to evaluate written materials . moreover , health care workers who prepare the health education brochures should be properly trained for the purpose . the health care professionals should strive to ensure that the quality of the written education materials is appropriate for the target audience .
background : health education is the cornerstone of primary health care . 
 health education materials distributed to the community should , therefore , be suitable and effective . 
 the purpose of this study was to evaluate the health education brochures , designed and disseminated by ministry of health institutions in the qassim province.materials and methods : the study was a cross - sectional review of health education brochures . 
 we used a structured evaluation form , comprising general information on the brochures and a modified suitability assessment of materials ( sam ) score sheet . 
 the sam consisting of 22 criteria in six groups , includes content , literacy demands , graphics , layout / typography , learning stimulation / motivation , and cultural appropriateness . 
 sam criteria categorize written material into 
 superior ,   adequate  and  not suitable . 
 two qualified consultant family physicians evaluated the brochures . 
 data were analyzed using epi info version 3.4 statistical package.results:we evaluated 110 brochures , the majority of which addressed chronic health conditions such as mental health , diabetes mellitus and hypertension . 
 seventy - four ( 67.3% ) brochures were evaluated as  adequate ,  34 ( 30.9% ) as  not suitable  and 2 ( 1.8% ) as  superior .   cultural appropriateness  was the highest scoring factor , with 92 ( 83.6% ) brochures falling into either the  superior  or  adequate  category . 
 with regard to  content ,  88 ( 80.0% ) brochures fell into either the  superior  or  adequate  category . 
 this was the second highest scoring factor . 
 graphics was the factor that scored the least . 
 seventy - five ( 68.2% ) brochures were rated in this factor as  not suitable.conclusions:although two - thirds of our brochures were considered  adequate ,  the majority needed improvement to their graphics and learning stimulation factors . 
 we recommend that guidelines for designing health education brochures should be formulated to improve the quality of health education brochures .