Evaluating Information on Oral Contraceptive Use

Published in Human Reproduction (Vol. 21, No. 12, pp. 3137-3145), this paper presents research designed to explore strategies for helping women understand what to do when they forget to take their daily contraceptive pill. Funded by the United States Agency for International Development (USAID) and carried out by Family Health International (FHI), this study found that unintended pregnancies could be reduced if instructions explaining the steps to take when pills are missed are communicated in graphic format, featuring simplified information.

As reported here, it was estimated that globally in 2001 more than 2 million women became unintentionally pregnant due to improper use of oral contraceptives. In response, and in recognition that missed pill instructions have been deemed confusing and complicated, many organisations and institutions working in family planning have developed guidance, in the form of educational leaflets, to supplement the patient package inserts (PPIs) that are provided by the companies that produce the contraceptive. This study compares missed pill instructions created by the World Health Organization (WHO) and the Johns Hopkins University Center for Communication Programs (JHU/CCP), organisations that provide evidence-based guidance to wide audiences in both developed and developing countries. The 4 instructions all contained 8 directives, presented in different ways. The directives include:

• Take a pill as soon as you remember
• Throw away any (remaining) pills that were missed
• Take the next pill at the usual time
• Continue to take pills as usual, one each day
• Avoid sex or use condoms for 7 days/use back-up until 7 active pills have been taken in a row
• Skip the next pill-free week/inactive pills and go straight to the next pack
• Use emergency contraception
• Consult a health provider

A randomised controlled trial was conducted with 864 current and past pill users of 21- and 28-day oral contraceptive pill packs at 12 sites in Kingston, Jamaica, to assess the comprehensibility of 4 types of instructions in graphic and text formats. Each participant was provided with scenarios of missed pills and one version of the instructions; they were then asked what they should do to avoid pregnancy. More than 60% of respondents knew what to do when one pill was missed, but most did not give correct answers for missing 2 or more pills in a row, regardless of the instruction type. This suggests that, "as instructions incorporate more steps or as each step becomes dependent on the previous, instructions become less understandable to pill users. This is particularly noteworthy as these pill users, and Jamaican women in general, tend to be well educated. It certainly revealed that these instructions were too complicated, even for highly literate women."

Notably, WHO's simplified graphic instructions were rated as the most comprehensible and user-friendly of the 4 types of instructions, with <5% of women mentioning having difficulty with absorbing all the information presented. In contrast, 31% of 21-day users and 21% of 28-day users in the PPI text group reported having difficulty due to the multitudinous instructions to follow. The authors stress that graphic instructions are easier to understand than text-only instructions, and that scaling back on the breadth of medical information results in better comprehension. In short, providing women with simplified instructions for what to do when pills are missed, as well as counseling women on the need to follow these instructions, gives women who use oral contraceptives greater control in avoiding unintended pregnancies.

As a result of these findings, the WHO's expert working group modified its Selected Practice Recommendations for Contraceptive Use (SPR), a version of which was used in the study. The modified SPR has been disseminated in the United Kingdom by the Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit and by USAID through an email distribution list for Pearls of Contraception.