Simplified, Picture-Enhanced Texts Boost Sexual Health Literacy in Ghanaian Teens

A school-based experiment in Ghana has delivered a strikingly simple message with potentially far-reaching consequences: when it comes to teaching adolescents about sexual and reproductive health, the way information is written matters as much as what is written. In a quasi-experimental study conducted in the Effutu Municipality of Ghana’s Central Region, researchers found that adolescents who read simplified and picture-enhanced educational materials made substantially larger gains in functional sexual and reproductive health (SRH) literacy than peers who received a standard textbook-style text. The findings, published in Public Health in Practice, suggest that dense, formally written health materials may be quietly undermining school-based sexuality education across sub-Saharan Africa.

The study, led by Jacqueline Nkrumah, focused on functional SRH literacy, a concept adapted from Nutbeam’s health literacy framework and Mancuso’s conceptualization of health literacy. In practical terms, it measures whether a young person can read, process, and understand SRH information, including numerical details such as menstrual cycle calculations, well enough to make informed decisions. Low SRH literacy leaves adolescents vulnerable to misinformation, hampers their use of health services, and is linked to poorer reproductive health outcomes. It also reflects a failure of health and education systems to communicate in developmentally and linguistically appropriate ways.

The setting was carefully chosen. Effutu Municipality, home to 83,695 people including 20,433 adolescents aged 10 to 19, reports adolescent sexual activity above 60 percent and awareness of modern contraceptives at just 27 percent. National assessments indicate that most Ghanaian adolescents aged 10 to 14 read below grade level, yet textbooks and SRH resources are rarely adapted to their comprehension abilities. Although Ghana’s Adolescent Reproductive Health Policy, the National HIV and AIDS, STI Policy, and the Adolescent Health Policy and Strategy all endorse school-based SRH education, implementation has been hampered by sociocultural resistance, misinformation, and debates over content, leaving a persistent gap between policy and classroom reality.

To test whether literacy-sensitive materials could close that gap, the researcher developed three versions of an SRH educational resource, each containing six core lessons on pubertal changes, sexual activities, abstinence, friendship, sexually transmitted infections, and contraceptive methods. The standard text, serving as the comparison material, scored 66.0 on the Flesch Reading Ease scale. The simplified version was rewritten to achieve a mean score of 82.0, indicating easy readability, and a third version added pictures to the simplified text. All materials were compiled from existing digital and print sources, synthesized into a standard text, and then adapted to adolescents’ cognitive and reading levels, with the development process validated and published separately.

The trial enrolled adolescents aged 11 to 15 in grades 7 and 8 across 13 communities and schools spanning all four sub-municipalities. Schools were clustered by sub-municipality to prevent contamination between study groups: Winneba East continued routine school activities as the comparison group, Winneba West received the standard text, Essuekyir/Gyahadze received the simplified text, and Kojo-Beedu North received the picture-enhanced version. Before enrollment, participants passed a three-stage screening covering foundational literacy, visual acuity, and color perception. Foundational literacy was assessed with a 526-word passage adapted from the Progress in International Reading Literacy Study, plus numeracy items from the Trends in International Mathematics and Science Study, graded according to Ghana’s Basic Education Certificate Examination system.

Comprehension was measured with a purpose-built instrument, the Test of Functional Literacy in SRH (TOFL-SRH), a multiple-choice cloze-based tool modeled on validated approaches such as TOFHLA and OHL-AQ. It included 35 cloze items drawn from a 682-word passage and five numeracy questions requiring menstrual cycle calculations based on a two-month calendar. Two parallel forms with reshuffled item order minimized recall bias, and pretesting with 76 adolescents demonstrated acceptable reliability. The intervention itself ran for six weeks of weekly peer-supported reading sessions, with adolescents reading at home and then joining gender-segregated groups of 4 to 20 for one-hour sessions combining 40 minutes of guided reading with 20 minutes of questions and discussion, facilitated by trained near-peer research assistants aged 21 to 25.

The results were unambiguous. Of 408 projected participants, 317 completed baseline assessment and 249 completed the intervention, a 78 percent completion rate. At baseline, inadequate functional SRH literacy ranged from 68.4 to 95.4 percent across arms; by end-line it had fallen to between 19.7 and 72.7 percent. In difference-in-differences analysis, adolescents given the standard text showed no statistically significant gains over the comparison group (5.77 points; 95 percent CI: -2.42 to 13.97; p = 0.166). Those reading the simplified text gained 12.29 points (95 percent CI: 6.79 to 17.77; p = 0.001), and the picture-enhanced group gained 10.26 points (95 percent CI: 4.37 to 16.14; p = 0.001). A fixed-effects regression model, which accounts for stable participant and group differences, told the same story: gains of 13.87 points for simplified text and 13.06 points for picture-enhanced text, both highly significant, against a modest 7.11-point background learning effect in the comparison group.

Domain-specific analyses added nuance. Simplified texts produced the strongest gains in textual comprehension (14.59 points; p = 0.001), while picture-enhanced materials also drove significant improvements (13.49 points; p = 0.001). Numerical comprehension, however, improved significantly only among adolescents exposed to simplified texts (10.46 points; p = 0.027). The picture-enhanced group’s weaker numeracy gains may reflect the cognitive burden of its menstrual cycle chart, which required simultaneous interpretation of colors, day numbers, symbols, and cycle phases, or simply the difficulty of numeracy concepts for adolescents with weak foundational math skills. The author cautions that these explanations were not directly tested, but the practical implication is clear: visual elements must be carefully integrated with numerical information to avoid overwhelming young readers when explaining concepts like menstrual cycles, contraceptive effectiveness, and pregnancy risk.

Not everything went smoothly, and the study’s obstacles are themselves instructive. Attrition between baseline and end-line reached 21 percent, driven primarily by school-level withdrawal rather than individual dropout. In three schools, participation ceased after teachers raised concerns about condom- and sexuality-related content, reflecting the sociocultural resistance, stigma, and religious opposition that have long constrained SRH education in Ghana and similar settings. The study was also limited to a single municipality, and uneven distribution of public and private schools across arms may have introduced residual confounding. Still, baseline equivalence across the four arms was confirmed statistically, and standardized procedures, validated tools, and rotation of implementors during end-line data collection helped reduce bias. An eight-week follow-up of 215 participants showed significant differences in literacy across groups persisting over time, though retention patterns were similar across intervention formats.

The broader implications reach well beyond Effutu. Multivariable analysis revealed that foundational literacy was the only participant characteristic consistently associated with functional SRH literacy, meaning that even literacy-sensitive materials favor adolescents with stronger reading skills. Scaling up such interventions, the study suggests, may require complementary investment in basic literacy education, particularly for the most disadvantaged learners. For policymakers, the message is to shift focus from simply providing SRH information to designing and delivering it appropriately, especially in underserved communities where national data show reading levels lag far behind the materials meant to inform them. As Ghana and its neighbors grapple with how to make comprehensive sexuality education a lived classroom reality, this evidence points toward a deceptively simple lever: rewrite the materials so the students who need them most can actually read them.

Subject of Research: The effect of literacy-sensitive sexual and reproductive health educational materials on adolescents' functional SRH literacy in Ghana

Article Title: Literacy-sensitive sexual and reproductive health education for adolescents in Ghana: Evidence from a school-based quasi-experimental study

Article References: Nkrumah, J. (2026). Literacy-sensitive sexual and reproductive health education for adolescents in Ghana: Evidence from a school-based quasi-experimental study. Public Health in Practice, 12, Article 100854. https://doi.org/10.1016/j.puhip.2026.100854

Image Credits: AI Generated

DOI: 10.1016/j.puhip.2026.100854

Keywords: adolescent health, sexual and reproductive health, health literacy, Ghana, comprehensive sexuality education, health education materials, school-based intervention, quasi-experimental study, readability, numeracy, sub-Saharan Africa, public health