The quality and comprehensiveness of sex education varies greatly among young people in the United States. Whether it's information about one's own anatomy, or about birth control beyond condoms, young people indicate their sexual and reproductive health knowledge is incomplete.

Easy to comprehend, medically accurate information can be difficult for adolescents to locate. Young people indicate existing contraceptive counseling resources often do not show realistic bodies—varied in size, shape, or skin tone—nor do they share anatomical terms that could be helpful, or provide enough detail about how to access or use birth control on one's own.

Although the majority of adolescents is relatively healthy, the American Academy of Pediatrics suggests they receive regular preventative medical care which includes sexual and reproductive health care. However, data indicate that most adolescents and young adults do not receive preventative medical care, with even less receiving sexual and reproductive health care. For Black, Latinx, and low-income adolescents, this situation is further compounded by medical mistrust, biases, and coercion that affect the access, provision, and uptake of contraceptive care.

Young people want bodily autonomy—the power and agency to make decisions about their own body, life, and future—yet, they do not have all of the information they need or desire. The Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3) at the University of Chicago collaborated with adolescents ages 14 to 17 to co-design contraceptive counseling resources that incorporated design principles and criteria they prioritized. Iterative prototype making and testing in partnership with the Ci3 Youth Advisory Council, Ci3 Co-Design Fellows, and partnering clinicians, resulted in a distinctive step-by-step approach using a combination of visual and narrative storytelling that situates birth control methods in the context of whole and varied bodies and in the context of use.

Context

Most adolescents and young adults in the United States do not receive sexual and reproductive health care despite recommendations from the American Academy of Pediatrics on preventative medical care.

Inequalities in the distribution of infrastructure—housing, transportation, and hospitals—have a heightened effect on teenagers from low-income communities of color who often lack the time, money, and autonomy to seek medical care. Moreover, research indicates Black, Latinx, and low-income adolescents and young adults continue to experience medical mistrust, biases, and coercion that affect the access, provision, and uptake of contraceptive care.

Among adolescents who do receive sexual health care, there is evidence that those who experience patient-centered care—care that is respectful and responsive to individual values, needs, and preferences—are more likely to speak to their clinician about their concerns and select and continue to use a contraceptive method. Yet, the reality remains for all bodies across all ages, most contraceptive care currently being delivered in the United States lacks a patient-centered approach.

This evidence illuminates a failure to connect with and care for young people during an important developmental moment and calls for the dramatic redesign of adolescent sexual and reproductive health care with and for young people, especially those marginalized by the intersections of race, ethnicity, sexual or gender identity, and socio-economic class.

Hello Options: making contraception tangible and improving decision making experiences

Ci3 made an important first step in improving the provision of contraceptive care with "Hello Options," a tangible contraceptive counseling decision aid, co-designed with adolescents and healthcare clinicians. Organized around a central ring, Hello Options includes life-size, tangible models of the most commonly available contraceptive methods. This design ensures that young people have information about the full range of methods which they can see and touch—improving knowledge about how birth control works and busting commonly held myths. For instance, when one young person saw an IUD for the first time, they shared, "...my mom told me never get the IUD, ever, because she thought it was some type of huge contraption. Once we saw it [during our visit to the pediatric mobile health unit] it was really very small."

Though many decision aids have been designed and tested, few have demonstrated improvements in contraceptive behavior and satisfaction—with fewer still that are practical and concise enough to be used during the clinical visit. In a 2021 study, clinicians indicated Hello Options helped young people take a more active role in their decision making. Additionally, both clinicians and patients indicated Hello Options allowed patients to make more informed decisions.

To support the use of Hello Options, Ci3 wanted to create a set of print and digital resources to provide additional information about birth control methods.

Formative research

The design team began the first phase of design research by considering the contraceptive counseling "tear sheet," a common patient education tool. We collected analogous examples that provided a range of contrasting reference points, using these as a jumping-off point to prototype a variety of layouts and using iteration to start developing a point of view that synced to the meta-design principles and tone and voice of our brand—Hello Greenlight.

Next, we engaged young people ages 14 to 17 in a series of workshops to co-design contraceptive counseling resources to complement the use of Hello Options before, during, and after a patient visit.

Exploring and critiquing the current state of contraceptive tear sheets

To kick-off the first workshop, in keeping with the positive youth development framework that informs Ci3's research ethos, the Ci3 design and communications teams discussed the different properties that make up visual communications and related careers such as copywriters, illustrators, art directors, and creative directors who expertly craft communications. Next, Ci3 staff discussed the importance of giving feedback and iteration in crafting effective communications and invited workshop participants to evaluate and critique tear sheets for two birth control methods—the ring and the external condom. Ci3's prototypes were included in the mix, but not explicitly identified. After participants spent time reviewing and ranking print materials independently, the group discussed their reactions and feelings on a range of topics, including what information was most important to them; what kinds of visualizations helped, hindered, or prevented them from engaging; and what was missing.

Design principles and criteria

Thematic analysis of the workshop transcript by the Ci3 team yielded two primary design principles to guide the next phase of prototyping:

Design Principle 1: The quality and comprehensiveness of sexual health education varies greatly among young people. Therefore, sexual health patient education materials for adolescents must feel welcoming and engage young people no matter their level of sexual and reproductive health knowledge.

Design Principle 2: Step-by-step guidance for how to properly use birth control methods should be explained through visual and narrative storytelling rather than without any background information (for instance, birth control methods represented without context of use—in the body or an environment—or abstract line drawings of anatomical parts).

Each principle was supported by a set of design criteria that were used to guide and evaluate the iterative development of patient education materials in subsequent workshops with young people as well as one-on-one feedback sessions with young people and clinicians.

Doing justice to the design criteria

Iterative prototyping revealed myriad opportunities to thoughtfully attend to the nuances deemed essential by young people and to allay concerns raised by clinicians. Two vignettes below, organized by design criteria that map to the accompanying project imagery, provide a sense of the deliberations involved in achieving the standards delineated by young people.

Criteria Area 1.2: Promote curiosity and exploration, not fear. Unfortunately, some adolescents describe sexual health education experiences that continue to emphasize fear—of disease, pregnancy, or specific birth control methods. Finding a birth control method that works for your body and life can be a process because everyone's body is different; that means a method that works great for a friend might give you headaches or nausea. For all of these reasons, using matter-of-fact language is critical to presenting birth control information and considerations. For instance, though smiley-face-icons may seem to warm up the tone and provide visual cues, they are misleading. Categories are important framing mechanisms that set expectations: should it be "common side effects," or "benefits/disadvantages"? In the end, we landed on simply, "additional information."

Criteria Area 2.2: Show birth control within the external (surface and regional anatomy) anatomical context of the body. External visualizations of the body must be realistic, specific, and varied in their depiction to foster belonging and debunk myths and stereotypes. For instance, pubic hair and skin tones of the vulva, labia majora, labia minora, and anus should vary. Iterative prototyping of pubic hair styles and skin tones for cisgender female anatomy sparked robust support for specificity by young people. In contrast, a clinician noted their concern that the desired level of detail may be too graphic or scary for younger adolescents and deter them from seeking care. In the final version, the level of detail was retained with the rationale that tear sheets would be used in a clinical setting if and when a young person expressed interest in a specific method. Alternately, a carousel feature was used to display illustrations on the web version so that a user could see an introductory image about a method before deciding to explore in more detail.

Scaling with Hello Options

The next production run of Hello Options will ship with a QR code printed on the back of the birth control pill pack directing to the web-based version of the adolescent patient contraceptive tear sheets. Another QR code on the insert included in the Hello Options travel case directs clinicians to individual PDF-version tear sheets that can be uploaded and used with corresponding dot phrases for use as handouts or in electronic health record messaging. Together these Hello Greenlight tools provide adolescents with the information they need and desire to make decisions about their own bodies, lives, and futures.