Health Literacy Project: Oral Contraceptive Patient Education Materials
Cardea, in collaboration with Sage Words. Funded by Department of Health and Human Services, Office of Population Affairs, Office of Family Planning, Region VI, Grant number 6 FPTPA060022.
Overview
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. For family planning clients, such inability to understand and interpret information regarding correct use of oral contraceptives (OCPs) can result in unintended pregnancies. A study in one public health clinic found while 93% of OCP users understood what to do when they missed one pill, the percentage dropped to 19% when two pills were missed, and 13% for three.
More than 10 million women (28% of all women using birth control methods) currently use oral contraceptives (OCPs) in the U.S. While perfect pill use would result in a .1% failure rate, actual pill use is associated with a 3-8% failure rate--or about 300,000 to 800,000 unintended pregnancies each year. Rosenberg, Waugh, and Long estimate that "pill discontinuation and compliance difficulties...account for 20% of the 3.5 million annual unintended pregnancies in the United States." Compliance issues are directly related to the complicated “missed pill” protocol involving multiple conditions and logic steps to ensure continued pregnancy prevention. Providing low literacy materials with easy-to-follow instructions is essential in reducing the unintended pregnancy rate and its associated annual costs of $2.6 billion.
In 2009, the Region VI Title X grantees requested Cardea to develop low literacy materials regarding proper use of OCPs. With funding secured by DHHS Region VI, CHT collaborated with Sage Words (www.sagewords.org) to conduct a literature review, hold focus group interviews with clients and staff regarding current materials, draft new materials, and conduct usability testing with clients to determine comprehension and ease-of-use.
The literature review and analysis of current materials used in clinics found no existing materials meeting clients’ needs. As a result, the Region IV grantees decided to create and test new materials to meet both client and clinician’s needs. These materials are now available for free download with the goal of creating better-informed clients, decreased need for emergency contraception, and reduced unintended pregnancies among users.
This process moved the project in unexpected directions and innovations in how OCP use is presented both in written materials as well as with a clinician or health educator. In terms of written materials, analysis of current information and discussions with clients indicated reading level alone was insufficient to ensure clients' ability to read and understand. Just as important was an "intimidation factor" preventing clients from attempting to understand the information provided. For example, most clients reported not reading or understanding package inserts except in emergencies (such as a missed pill). Graphics, white space, and information organization played important roles in leading clients through the information presented. At the same time, clients in the focus groups indicated a need for a quick reference when pills are missed. This observation led to the conception of business-card-sized instructions providing the same information, but without graphics as a handy reference tool.
Clinicians indicated they did not use current materials as educational tools in the exam room for a number of reasons. The printing on the brochures or fact sheets was too small for both client and clinician to follow along at the same time, and the appropriate information was not easy to find. During the focus groups, staff indicated a poster-sized version of the materials would allow for an interactive discussion.
Development of the poster, however, also led to training in its use. Sage Words also created a stand-alone, self-directed training manual, also available for free download. A webinar - Health Literacy and OCPs: Helping Your Clients to Understand and Remember Instructions for How to Use OCPs Correctly - was conducted on November 9, 2010, and is available here.
The materials we developed include (see the column to the right for PDF downloads):
- Missed pills business card – 4 pdfs (front and back, English and Spanish)
- Missed pills flyer – 2 pdfs (English and Spanish)
- Starting pills flyer – 2 pdfs (English and Spanish)
- Side effects flyer – 2 pdfs (English and Spanish)
- Training manual – 1 pdf
Instructions for Printing OCP Materials
Factsheets
The 8 x 11 factsheets are very easy to print. First, you'll want to open the pdf on your computer and enter your clinic's phone number in the box at the bottom right hand corner. Just put your cursor in that box and type in your number. (You can't save this number in the pdf, so you will have to enter it each time you print more.) Then, print as many copies as you need at any one time.
You can print them double sided—that is easy to do on most printers—so you can have English on one side and Spanish on the other. Or you can print “How to Start” on one side, and “Missed Pills” on the other, in the same language.
The pdfs are designed to print in black and white as well as in color, so you can use them even if you don’t have a color printer.
However, it is best to print them directly from the pdf on your computer, rather than photocopying them. The illustrations will not be as clear in a photocopy.
You can also choose the kind of paper you choose to print them on, colored paper or cardstock , for example.
Business Cards
You'll need to purchase two-side printable business cards from an office supply store. Set your printer for the Avery template 8371 or the equivalent, and make sure your printer setting for "page scaling" is set at "None." Print "Card Front" on one side, and feed it back to your printer to print "Card Back" on the other side. You can also have them printed for you at any online printing service (see below).
Posters
The pdfs for the 8 x 11 factsheets can be printed in poster size by any online printing service. All you need to do is give the printing service the link to the factsheet pdf you want, and they can print as many as you need, in a variety of sizes. There is no need to change any aspect of the pdf—but be sure you give the printing service your clinic phone number so they can type it in before they print.
Acknowledgements
Many thanks to all those who participated at various stages of this project, in various ways.
Those who envisioned the project from the start: Liese Sherwood Fabre and Evelyn Glass, DHHS, and Sandy Rice, Cardea, as well as the Title X project directors of DHHS Region VI: Wanicha Burapa, Sharon Ashcraft, Patrick Gillies, Elease Lewis, Marsha Maxwell, and Jill Nobles-Botkin.
Sage Words Accessible Health Communications who developed and implemented the project.
The five clinics that participated at every stage of the development of the materials:
- Luna Public Health Department, Deming, New Mexico
- Hempstead County Health Unit, Hope, Arkansas
- People's Community Clinic, Austin, Texas
- Jefferson Parish Health Unit, Metairie, Louisiana
- Oklahoma City County Health Department, Oklahoma City, Oklahoma
Those who were instrumental in setting up clinic visits and client discussion groups and facilitating along the way:
- Ragan T. Collins, MPH, Health Education and Outreach Coordinator, DHH/OPH/Family Planning Program, New Orleans, Louisiana
- Susan Browder, BA, CPM, Program Administrator, Reproductive Health/Family Planning, Oklahoma City County Health Department, Oklahoma City, Oklahoma
- Mary Jackson, RN, Luna Public Health, Deming, New Mexico
- Darlene Cannon, RN, MCHS, Nursing Service Specialist, Southwest Region, Arkansas Department of Health
- Dana Carpenter, MPH, Health Education & Special Projects Supervisor, Peoples Community Clinic, Austin, Texas
Those who reviewed materials for accuracy and health safety, and for health literacy:
- Sharon Ashcraft, RN, BSN, Women's Health Section Chief, Arkansas Department of Health
- Wanicha Burapa, MD, MPH, Medical Director, NM DOH Family Planning Program
- Philip Fabacher, MD, FACOG, Medical Director, LA Family Planning Program
- Evelyn Glass, MSPH, Regional Program Consultant, Office of Family Planning, Region VI
- Delia James, APN, Hempstead County Health Unit, Hope, Arkansas
- Janet Lawson, MD, FACOG, Medical Consultant, Division for Family and Community Health Services, Texas Department of State Health Services
- Velia Luna, CNP, Luna County PHO, Deming, New Mexico
- Moises Morales, Program Specialist, El Civics Adult Education, AISD, Austin, Texas
- Deborah Nettles, APRN, Jefferson Parish Health Unit, Metairie, Louisiana
- Jill Nobles-Botkin, MSN, CNM, Director, Perinatal & Reproductive Health Division, Oklahoma State Department of Health
- Glenda Lynn Rose, PhD, Austin Learning Academy, Austin, Texas
- Liese Sherwood-Fabre, PhD, Public Health Advisor, Office of Family Planning, Region VI
Those who were instrumental in creating the actual product:
- Photographer and information design expert Woody Packard
- Illustrator Ricky Colson III
- Translator Sandra Chada
- Writer and developer Kath Anderson, MPH, of Sage Words
Questions?
Please contact Sandy Rice at srice@cardeaservices.org