Low-literacy material targets correct OC use

Your physician has just reviewed instructions on proper oral contraceptive (OC) use with the patient, a 22-year-old mother of three. The physician asks if there any questions, and send her to the front desk with a supply of pill packs and written instructions. But how do you know she received the information she needs to take her pills properly?

Providing low literacy materials with easy-to-follow instructions is essential in reducing the U.S. unintended pregnancy rate and its associated annual costs of $2.6 billion.1 However, clinicians face an uphill battle. The National Center for Education Statistics estimates that 88% of the adult U.S. population lacks the literacy skills needed to maintain health and prevent disease.2

In response to a request by Title X family planners, a cooperative effort among the Region VI Department of Health and Human Services Office of Family Planning, the Center for Health Training in Austin, and Sage Words Accessible Health Communications in Austin has yielded an oral contraceptive health literacy project to help providers and patients communicate more effectively regarding correct, consistent pill-taking. The project, "On the Same Page," features a training manual written for publicly funded family planning clinic staff, as well as posters designed to help clinicians and patients stay "on the same page" during instructions. Patient materials include a missed pills business card and flyers on missed pills, starting pills, and side effects, all available in English and Spanish. The project was funded by a grant from the Department of Health and Human Services, Office of Population Affairs, Office of Family Planning, Region VI.

How does it work?

Clinicians are accustomed to thinking of written materials as something to hand to patients. The posters and fact sheets in the "On the Same Page" project work together as a tool, something that is used interactively, much in the same way clinicians use the pill packet for demonstration, say project officials.

The poster concept came directly from staff discussion groups, explains Kathryn Anderson, MA, executive director of Sage Words Accessible Health Communications. Anderson served as writer and developer for the project. "When we asked what format would be useful to them, staff indicated that posters were a useful and familiar format. Staff often used posters in an exam room setting, especially to communicate visually," she explains. "We also learned from staff discussion groups that they rarely use written materials like brochures or the pill packet insert in the exam room when explaining pill instructions."

Materials with small fonts, a significant amount of text, and no graphics simply can't be shared, says Anderson. A poster, on the other hand, is visually accessible to provider and patient. Graphics and text can be seen at the same time, so the patient is a participant in the provider's explanation.

A second important aspect of using the posters in the exam room is that the patient has access to the same information more than once, Anderson notes. Repetition is essential in processing unfamiliar information and in retaining and acting on that information, she explains. If the patient has been sitting in the exam room looking at the poster, it might serve to elicit questions. Anderson says it also might serve as an "advance organizer" in which the patient might already have begun the process of organizing and understanding the information before the provider discusses it with her. The patient can see the poster ahead of the provider's visit, looks at it while the provider discusses the information, and has the same information at home on the fact sheet, Anderson states. Having exactly the same information in the same format at home might help a patient trigger recall of the exam room discussion, which can be helpful in comprehending the written information, explains Anderson. Patients tested drafts of the text in a process called usability testing, which enabled developers to pinpoint and revise areas of misunderstanding.

Title X grantees in Region VI, which encompasses Arkansas, Louisiana, Oklahoma, New Mexico, and Texas, have been excited about the materials included with the project, says Sandy Rice, MEd, vice president of the Center for Health Training. Project funding allowed developers to be able to provide a year's worth of hard copies of the "missed pills" fact sheets and posters to grantee clinics in the region. "Although we are pleased and proud that we have made these materials available online for free download, we recognize that Title X and other publicly funded clinics face severe budget restrictions that may prohibit their abilities to make copies," says Rice.


1. Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. J Reprod Med 1995; 40:355-360.

2. White S. Assessing the Nation's Health Literacy: Key concepts and findings of the National Assessment of Adult Health Literacy (NAAL). Chicago: American Medical Association (AMA) Foundation; 2008.


The manual and project materials for "On the Same Page," an oral contraceptive health literacy project, are available for free download at the Center for Health Training web site, www.centerforhealthtraining.org. Under "Projects," select "Current Projects," then under "Region VI," select "Health Literacy Project: Oral Contraceptive Patient Education Materials." Clinicians also can take advantage of a free webinar on the project. To access the webinar, go to www.centerforhealthtraining.org. Under "Training + Events," select "Online Training." To access the webinar, click the link under "Health Literacy and OCPs: Helping Your Clients to Understand and Remember Instructions for How to Use OCPs Correctly."

• Oral contraceptive health literacy materials also are available at www.sagewords.org.