From Standard Text to Simplified Learning: A Conceptual Framework for Developing Adolescent-Friendly Sexual and Reproductive Health Resources in Ghana

From Standard Text to Simplified Learning: A Conceptual Framework for Developing Adolescent-Friendly Sexual and Reproductive Health Resources in Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Standard Text to Simplified Learning: A Conceptual Framework for Developing Adolescent-Friendly Sexual and Reproductive Health Resources in Ghana Jacqueline Nkrumah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7879931/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted 16 You are reading this latest preprint version Abstract Background Adolescents in low-resource settings often lack access to sexual and reproductive health (SRH) materials that match their literacy levels. In Ghana, despite policy support for adolescent SRH education, implementation gaps persist due to the complexity of available texts. This paper presents a conceptual framework for developing simplified, culturally appropriate SRH resources tailored to the cognitive and literacy needs of adolescents. Methods This framework was developed through an iterative process, including a baseline needs assessment, resource design, stakeholder validation, and evaluation of quasi-experimental methods. A review of existing materials and a literacy assessment identified major gaps in comprehension and vocabulary demands. Content was synthesized from six SRH themes and simplified into formats: a text-only version and a picture-enhanced version with static illustrations. Validation was conducted with educators, health officials, adolescents, and academic experts. Results The resources were piloted with 317 adolescents aged 11–15 over six weeks. A total of 249 participants completed the study. Compared to the control group, users of the simplified and picture-enhanced texts showed significant improvements in SRH decision-making skills (+ 11 points, p < 0.01) and print literacy scores (+ 13–14 points, p < 0.01). A 21% dropout rate, linked to stigma and sociocultural resistance, highlighted the need for greater community and parental engagement. Conclusion The framework offers a stepwise, theory-informed approach to developing adolescent-friendly SRH materials. By reducing cognitive load and improving readability, it supports equitable access to SRH education. adolescent SRH literacy simplified text instructional design cognitive theory Ghana Figures Figure 1 Figure 2 Background Health literacy (HL) encompasses the cognitive and social skills needed to access, understand, appraise, and apply health information for informed decision-making [ 1 – 3 ]. While individual capacity has traditionally been emphasized, contemporary definitions highlight a shared responsibility between individuals and the health system. Organizations are expected to create enabling environments through policies, services, and communication practices that support people of all literacy levels in making informed health decisions [ 4 – 5 ]. This principle of organizational health literacy aligns with the Sustainable Development Goal (SDG) 3.7, which calls for universal access to sexual and reproductive health (SRH) information. Prior literature demonstrates that institutional support for health literacy fosters comprehension, engagement, equity, and informed decision-making, particularly among low-literate populations [ 3 , 6 ]. In Africa, health communication is challenged by limited language accessibility, low functional literacy, and weak information navigation skills, which hinder the understanding of both print and digital materials [ 7 ]. A growing body of research in Sub-Saharan Africa (SSA) consistently reports low health literacy levels among adolescents and the general population [ 3 , 8 ]. Ghana reflects these patterns, with studies showing limited awareness of health literacy and poor literacy outcomes [ 9 – 10 ]. Most research in the region has focused on individual-level health literacy, while the role of institutions in reducing literacy barriers and fostering accessible communication environments remains underexplored [ 11 – 12 ]. In adolescent SRH, the literature in SSA has primarily emphasized knowledge, awareness, and information sources, with limited assessment of adolescents’ ability to comprehend, evaluate, and apply SRH information meaningfully [ 8 ]. In Ghana, despite a supportive policy environment for adolescent SRH, major implementation gaps persist. Key policies, such as the Adolescent Reproductive Health Policy [ 13 ], National HIV and AIDS, STI Policy [ 14 ], and Adolescent Health Policy and Strategy [ 15 ], have emphasized multisectoral collaboration and the integration of SRH content into school curricula. The 2016 strategy aimed to provide Comprehensive Sexuality Education (CSE) and ensure equitable access to SRH information. However, public backlash rooted in tensions between abstinence-based social values and comprehensive SRH approaches disrupted classroom implementation [ 16 – 18 ]. A critical and often overlooked barrier to effective implementation is the literacy demand of SRH materials. Structured, age-appropriate SRH resources remain scarce, particularly in basic schools, where most adolescents are first exposed to health education. While SRH topics are embedded in integrated science and life skills curricula, existing materials frequently exceed the reading abilities of target learners. For example, the SRH section of an 8th-grade integrated science textbook, covering reproduction and abstinence, scored 54 on Flesch Reading Ease and 12.0 on Gunning Fog Index, well above the typical comprehension level of students with limited vocabulary and low independent reading habits (19–20). National data underscore this literacy gap: only 30% of Ghanaian adolescents aged 10–14 can read at a third-grade level [ 21 ]. This mismatch between policy intentions and the linguistic accessibility of materials constrains the ability to understand critical health information, make informed decisions, and utilize services. The rise in early adolescent pregnancies and ongoing challenges with SRH-related stigma and misconceptions underscore the need for literacy-sensitive, developmentally appropriate SRH education. Findings from a recent intervention study in Ghana highlight the scope of the problem and a potential solution. Most print and digital SRH materials were found to be inaccessible to basic school adolescents, while simplified and picture-enhanced texts significantly improved functional SRH literacy and decision-making skills [ 22 – 23 ]. These results illustrate a clear mismatch between standard materials and adolescents’ literacy realities, and they raise concerns that health systems may disseminate SRH content that is too complex for adolescents to understand, undermining empowerment and policy objectives. Bridging this gap requires multi-level strategies that combine: 1) Routine readability and comprehensibility assessment of educational materials, 2) Integration of health literacy principles into program and curriculum design, 3) staff training and stakeholder engagement, and 4) development of structured, culturally appropriate SRH resources tailored to adolescents’ cognitive and literacy needs. In this article, I present the framework for developing an adolescent-friendly SRH educational resource. Theoretical and Contextual Background This framework draws on three complementary cognitive learning theories to inform the design of adolescent-friendly SRH materials: Cognitive Load Theory (CLT) [ 24 ], Cognitive Theory of Multimedia Learning (CTML) [ 25 ], and Pictorial Realism Theory (PRT) [ 26 – 27 ]. CLT and CTML emphasize the role of human cognitive architecture in learning, particularly how information is processed through sensory memory, working memory, and long-term memory. Both theories highlight that working memory has limited capacity, able to hold and process only 3–4 short elements at a time [ 28 – 29 ]. To enhance learning, they recommend reducing cognitive load so that essential content can be more effectively processed and stored. CLT identifies three types of cognitive load: 1) intrinsic load (essential processing), linked to the complexity of the material. 2) extraneous load, caused by poor instructional design. 3) Germane or generative processing, the learner’s effort to integrate new information. CTML builds on this by proposing dual-channel processing (visual and auditory) and active learning principles, advocating for the use of multimedia to reduce extraneous load and support deeper understanding. It emphasizes that pictorial information closely aligns with how learners naturally process information and is especially effective when guided by principles such as redundancy, coherence, modality, segmenting, and personalization [ 30 ]. However, critics argue that CLT overemphasizes load reduction without accounting for diverse learning objectives and differences in cognitive ability [ 31 ]. CTML may not address subject-specific complexities or learner motivation [ 32 – 33 ]. These limitations prompted the inclusion of PRT as a complementary lens. PRT is grounded in visual realism and posits that more life-like images enhance learning by providing clearer, more relatable cues [ 34 – 35 ]. It highlights the importance of realistic visual representation, especially in sensitive and concrete topics like SRH, where abstract visuals might impede understanding. PRT supports the notion that the degree of visual realism should align with learners’ needs, subject matter, and instructional objectives [ 36 – 37 ]. Together, these theories support the design of SRH resources that are not only cognitively accessible but also visually intuitive, realistic, and contextually appropriate for adolescents in low-literacy settings. Methods/Development of the Conceptual Framework This paper presents a practical approach to closing the gap between standard materials and adolescents’ literacy realities, offering a conceptual framework derived from intervention research in Ghana. The framework provides a stepwise, theory-driven process for transforming complex SRH content into simplified, adolescent-friendly educational materials. Grounded in Cognitive Load Theory (CLT), Cognitive Theory of Multimedia Learning (CTML), and Pictorial Realism Theory (PRT), it supports educators, curriculum developers, and public health practitioners in creating SRH resources that are accurate, readable, engaging, and culturally sensitive, thus advancing health equity and adolescent empowerment. The framework was developed through a participatory and iterative design process aimed at guiding the creation of adolescent-friendly educational resources to improve SRH literacy and support informed decision-making. Figure 1.0 presents the process flow chart for the materials development Baseline Assessment and Initial Design The initial design phase began with a review of existing SRH educational materials. However, the search yielded no context-specific, adolescent-friendly SRH resources suitable for use in Ghanaian basic schools. Consultations with public health practitioners at the local level confirmed the absence of appropriate materials within the School Health Education Program. Similarly, outreach to relevant organizations failed to produce feedback. In response, a literacy needs assessment was conducted to explore how adolescents in basic schools construct meaning around SRH, identify existing knowledge gaps, and assess barriers to information access. The methods and findings of this assessment are reported elsewhere [ 19 ]. Based on the assessment findings, relevant SRH texts were gathered from digital and print sources. A sample of these texts was randomly selected for evaluation of readability, comprehensibility, and vocabulary demands. The methods and results are published elsewhere [ 22 ]. Insights from both assessments informed the synthesis of SRH content into six thematic domains: 1) pubertal changes. 2) abstinence. 3) friendship. 4) sexual activities and risky behaviors. 5) contraception. 6) Sexually transmitted infections (STIs). The synthesis was organized using Microsoft Word, formatted in Times New Roman (Font size 18). Simplifying Existing SRH Texts To ensure readability and relevance, the synthesized SRH content was simplified using a combination of structured methods, guided by comprehension and readability assessment, and intuitive strategies informed by writing experience. Techniques such as text simplification and elaboration were employed to align content with the literacy skills of adolescents. A draft of the simplified text-only format was created using Microsoft Word (2013) in Times New Roman, size 20. This simplified draft served as the foundation for the development of a picture-enhanced version. A graphic artist used the text to generate a pool of static images aimed at reinforcing and complementing the written content. These visuals enhanced comprehension and engagement among low-literate adolescents. Type of Static Pictures The illustrations varied in fidelity, ranging from cartoon-like and semi-realistic drawings to realistic images and silhouettes. Sensitive topics like sexuality and risky behaviors were illustrated with silhouettes and semi-realistic drawings to soften their impact. Detailed, realistic visuals were used for tangible items like contraceptives. Cartoon-style drawings represented general behaviors and human figures in a familiar, culturally appropriate manner. Visual placement followed instructional design principles drawn from the CTML and CLT, especially the principles of split attention, contiguity, and coherence [ 25 , 38 ]. Each image was positioned adjacent to the corresponding text to minimize cognitive burden and enhance understanding. The final output consisted of two formats: 1) a simplified text-only version, and 2) a picture-enhanced version (text with visuals). Validation of Static Pictures and Text Since the picture-enhanced version maintained the same text as the simplified format, both were validated together. The first draft was reviewed by the Municipal Education Service (MES), the Municipal Health Directorate (MHD), and a Medical Officer from the University of Education, Winneba. The MES team, including education officials and a gender coordinator, evaluated the clarity of the text and suggested visual revisions. They recommended modifying five sensitive illustrations and suggested images for abstract concepts like “ovulation” and “withdrawal method.” They also proposed a red ink cross-out for risky behaviors. The MHD team reviewed content accuracy, suggested reordering topics, and emphasized alignment with health messaging. All recommended changes were incorporated, including the revision and addition of new illustrations. A new draft was finalized accordingly. Validation by Adolescents The third draft of the picture-enhanced SRH was validated by adolescents who participated in the earlier literacy needs assessment. These participants were intentionally selected for their prior inputs, particularly their recommendations to combine visuals with text. In a focus group, the materials were projected and reviewed in both English and Fante. Participants assessed the clarity, cultural sensitivity, and relevance of the visuals. Feedback was audio-recorded, translated, and transcribed to guide a further round of revisions that incorporated adolescents’ preferences and addressed content gaps. Review by Academic and Thematic experts The revised draft was then reviewed by academic researchers supervising the dissertation. Their key recommendations included: 1) adding an introductory section explaining the SRH concept. 2) expanding lessons on sexual activity and abstinence with culturally grounded examples and risks, 3) including critical topics like rape and defilement, and 4) reorganizing lesson sequencing to support abstinence and align with local moral values. These revisions were implemented, and the revised draft was resubmitted for confirmation. The improved material was subsequently reviewed by subject-matter experts, an educational psychologist, language and assessment specialists, and an implementation researcher. Their feedback focused on improving cognitive load and recall by segmenting texts, converting bullet points into numbered lists, and condensing content. As a result, the simplified text decreased from 43 to 32 pages, and the picture-enhanced version from 84 to 60. A final round of review with stakeholders, including MES, MHD, and adolescents, was advised to confirm content clarity and institutional endorsement. Final Stakeholder Validation The revised picture-enhanced materials were sent to both the MES and MHD for final comments. Simultaneously, adolescents from four of the original schools were invited to participate in a proofreading exercise. Sixty in-school adolescents (aged 12–15) assented to take part. In small group sessions, participants read the assigned lessons aloud, underlining words they found difficult to pronounce or understand. Post-reading discussions were held to capture their feedback on text comprehensibility and image appropriateness. Participants identified several challenging terms, including: “Family Unit Nurse,” “infection,” “defilement,” “masturbation,” “abstinence,” “pornographic,” “contraception,” and “cuddling.” Suggested revision included: replacing “Family Unit Nurse” with “Family Planning Nurse.” Substituting “infection” with “illness” or “sickness.” Clarifying complex terms with simplified definitions: “pornographic” explained as “Porno” (a local term). “Abstinence” as “no sexual activity,” and “contraception” is “ways to avoid pregnancy.” While the MES approved the revised materials, the MHD requested greater clarity on specific sections and recommended that all images depicting risky sexual behaviors be marked with scarlet red instead of ruby red to more strongly signal risk. Final revisions were made to both the text-only and picture-enhanced formats to incorporate all relevant feedback. The resulting materials reflect multi-stakeholder consensus and target audience validation, ensuring both cultural relevance and user accessibility. Supplementary file 1 presents samples of static pictures created and validated by adolescents and stakeholders. Sequencing of Lessons The SRH educational material was structured to promote abstinence while delivering age-appropriate and culturally sensitive content aligned with Ghanaian values. Lessons were organized to build progressively from foundational biological knowledge to interpersonal relationships, risk awareness, and preventive strategies, fostering informed and responsible decision-making. The resource begins with an introduction to SRH and its relevance to young adolescents. Six core lessons follow: 1) Pubertal Changes: covers physical and emotional developments, with a focus on ovulation and the menstrual cycle to establish reproductive health foundations. 2) Sexual Activity and Health Risks: explores sexual behavior and associated risks, including rape, defilement, and cultural views on same-sex practices, handled with sensitivity. 3) Friendship and Etiquette: addresses peer influences, healthy relationships, and respectful social interactions. 4) Abstinence and Sexual Self-Regulations: defines abstinence and its benefits while providing strategies to manage sexual urges and peer pressure. 5) STIs: introduces common STIs, their causes, symptoms, and treatments, emphasizing prevention and timely care. 6) Contraception: positioned last, this lesson introduces contraceptive options as a backup strategy when abstinence is not practiced. This sequencing reflects a culturally grounded, rights-based approach that respects moral values while equipping adolescents with comprehensive knowledge. By carefully sequencing topics, the framework supports a balanced view of SRH, beginning with self-awareness and abstinence, and then gradually introducing risk management tools, such as contraception. This approach ensures content is both educational and contextually appropriate, addressing key gaps in existing SRH instruction in Ghana. Minor revisions were made to the simplified materials after their experimentation to address the reactions of educators and parents and to get them ready for publication [ 39 ]. Ethics Consideration and Ethics Approval The study was conducted in accordance with the Declaration of Helsinki. The author obtained ethics approval from the Ghana Health Service Ethics Review Committee, ethics approval number GHS-ERC006/10/21. A written approval from the Municipal Education Service was obtained to conduct the study. I also obtained written permission and informed consent from the school heads and parents of participating adolescents. Furthermore, inclusion in the intervention was based on adolescents’ written assent. Results The conceptual framework, as presented in Fig. 1.1, outlines a cyclical, theory-informed process for developing adolescent-friendly sexual and reproductive health (SRH) resources. It is grounded in CLT, which informs the simplification of complex texts to reduce extraneous cognitive burden; the CTML, which guides the integration and sequencing of text and visuals; and the PRT, which shapes the level of visual detail and realism in illustrations and animations. The framework begins with an SRH literacy needs assessment to identify adolescents’ knowledge gaps and evaluate the readability, comprehensibility, and vocabulary of existing texts. Findings inform the resource development stage, where simplified text and static or animated visuals are co-created and validated with adolescents and stakeholders, producing formats such as simplified text, picture-enhanced resources, and animations. The resources are then implemented and evaluated in an experimentation phase to measure their impact on SRH literacy, with results feeding back into earlier stages. The supporting factors, including individual-level factors, sociocultural context, design factors, and stakeholder and expert inputs, shape the resource design, while an enabling environment (policy, funding, technical expertise, and ICT infrastructure) provides the systemic support required for sustainability and scalability. Evaluation of the Educational Resource The framework was operationalized through a quasi-experimental study involving 317 adolescents aged 11–15 years, enrolled in Grades 7 and 8 across 16 basic schools. The intervention aimed to assess the impact of literacy-sensitive SRH materials, developed through the framework, on adolescents’ functional SRH literacy and decision-making. Two versions of the SRH resource (a simplified text-only version and a picture-enhanced version) were compared with a synthesized standard SRH text derived from existing materials. The intervention was implemented over six weeks using four groups: one control and three intervention arms. Assignment to control and intervention groups was based on cluster randomization. Of the 317 participants enrolled, 249 completed the study, yielding a 21% dropout rate. Attrition was largely attributed to prevailing misconceptions about adolescent SRH education, as well as stigma and sociocultural resistance, particularly from some school teachers and parents. These findings reinforce the need to integrate supportive components such as community engagement and parental involvement in the resource development process. However, due to time and funding constraints, these elements were not fully embedded during the initial implementation phase. Difference-in-Difference analysis of the intervention data demonstrated significant improvements in both SRH decision-making and print literacy scores among participants exposed to the literacy-sensitive resources. Specifically, SRH decision-making skills increased by 11 points among participants who used the simplified text (95% CI: 4.68–18.52; p = 0.001). Decision-making skills also improved by 11 points among those who used the picture-enhanced text (95% CI: 3.96–18.32; p = 0.002), compared with the control group. While the comparison group also showed some improvement (10 units; 95% CI: 1.25–20.36; p = 0.027), the gains were statistically less robust [ 23 ]. For print literacy outcomes, participants using the picture-enhanced text improved by 13 points (95% CI: 7.39–19.59; p = 0.001), and those using the simplified text improved by 14 points (95% CI: 7.40–20.80; p = 0.001). In contrast, the comparison group showed a non-significant increase of only 4 units (95% CI: -3.97–13.34; p = 0.288) [ 20 ]. These results affirm the framework’s emphasis on reducing cognitive load through simplified language and enhancing comprehension with visual aids. Moreover, they highlight the framework’s potential to inform scalable, culturally sensitive, and literacy-aligned interventions in adolescent SRH education. Discussion This framework provides a novel contribution to adolescent-focused SRH literacy by addressing both individual and organizational dimensions of health communication. While much of the existing research in Sub-Saharan Africa (SSA), including Ghana, has focused on individual-level knowledge and access to SRH services [ 40 – 42 ], this framework recognizes the critical role of health and education systems in fostering accessible, age-appropriate materials [ 5 , 31 ]. It operationalizes key principles from organizational health literacy, which emphasize institutional responsibility in ensuring that all individuals, regardless of literacy level, can access, understand, and use health information effectively [ 4 , 12 ]. Unlike conventional SRH programs, this framework integrates literacy-sensitive strategies grounded in CLT, CTML, and PRT. The participatory and iterative design, incorporating feedback from adolescents, health authorities, educators, and subject-matter experts, ensures cultural relevance, acceptability, and usability across literacy levels. Its dual-format outputs (simplified and picture-enhanced) offer adaptable pathways for diverse resource settings. Three major strengths underpin the framework's design: 1) Theory-informed structure: Drawing from CTML and CLT, visuals were used to reduce cognitive overload and support information integration [ 38 , 43 ]. PRT guided illustration styles, allowing the materials to balance clarity and sensitivity on topics such as STIs and contraception. 1) Stakeholder validation, which included engagement of the Municipal Education Service, Municipal Health Directorate, and adolescents, ensured relevance, accuracy, and cultural appropriateness [ 44 ]. Adolescents helped refine terminology and visuals, reflecting real-life barriers to SRH understanding [ 8 , 21 ]. 3) The third strength is in the framework’s scalability and flexibility. Though designed in Ghana, the stepwise approach, content synthesis, simplification, visual enhancement, and validation can be replicated in other SSA contexts facing similar challenges [ 3 , 7 ]. Limitations and Contextual Considerations Despite these strengths, several limitations warrant consideration: 1) Geographic and contextual limitations. The framework was developed in one Ghanaian municipality, which may limit generalizability. Broader validation is needed across regions with linguistic, cultural, and educational diversity. 2) The next limitation is related to resource constraints. Picture-enhanced versions require design expertise and printing resources that may be unavailable in some schools, affecting scalability. Another noteworthy constraint is the partial stakeholder involvement. Community leaders and parents were not engaged in early design phases due to time and financial constraints, which may have contributed to stigma and dropout. Short-term testing: The framework’s impact was evaluated over six weeks. While improvements in text comprehension and decision-making were significant, long-term retention was insignificant, and behavioral outcomes were not assessed [ 19 ]. Policy and Practice Implications Ghana has a relatively strong policy environment promoting adolescent SRH, with key frameworks such as the Adolescent Reproductive Health Policy, the National HIV/AIDS and STI Policy, and the Adolescent Health Policy and Strategy. However, implementation has suffered due to the absence of literacy-sensitive and structured educational materials [ 44 – 45 ]. The framework presented here offers a practical tool to fill that gap. It can guide the development of national SRH materials that reflect adolescents’ cognitive and literacy needs. Ministries of Education and Health can adapt the framework to enhance clarity and inclusivity, as advocated by organizational health literacy principles [ 5 , 6 ]. Moreover, teacher training programs and community outreach strategies should incorporate literacy-sensitive communication as a standard practice. Future Research To build on this work, future research should assess the framework’s long-term effectiveness, particularly in relation to retention, behavior change, and service uptake. Evaluating its adaptability in multilingual and rural settings would also be valuable. Further exploration into integration with digital platforms could enhance accessibility for low-literate learners. Additionally, involving parents and community leaders early in the development process may improve uptake and help address potential misconceptions. Conclusion The discussion underscores the need for integrated approaches to adolescent SRH education that consider both individual literacy levels and institutional communication responsibilities. The proposed framework advances this agenda by offering a replicable, theory-informed, and context-sensitive model for designing SRH educational resources. With further testing and institutional support, it holds promise for promoting equitable access to SRH information among adolescents in Ghana and similar low-resource settings. The framework can inform national curriculum reform and catalyze scalable interventions that bridge the SRH literacy gap among adolescents in low-resource contexts. Declarations Acknowledgment The author would like to thank the parents of the adolescents who agreed to participate in the needs assessment and resource development process. Acknowledge the valuable inputs of members of the Effutu Municipal Education Service and the Public Health Unit of the Health Directorate. The management of the participating schools and my Ph.D. dissertation supervisors are also duly acknowledged. Author’s contribution JN is the sole author who conceptualized and designed the framework. She is responsible for data collection, analysis, and drafting of the initial and final manuscript. Data Availability Statement The data supporting the findings of the conceptual framework are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions Ethics Approval and Consent for Participation The study involves basic school adolescents, and the protocol was reviewed and approved by the Ghana Health Service Ethics Review Committee in October 2021, with ethics approval number GHS-ERC006/10/21. Participating school heads provided written consent, and all participating adolescents provided written parental consents and gave personal assents to participate in the study. Clinical Trial Number Not applicable Competing Interests The author declares that there are no competing interests. 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Australasian J Philos. 2007;85(1):1–7. Therriault DJ, Yaxley RH, Zwaan RA. The role of color diagnosticity in object recognition and representation. Cogn Process. 2009;10(4):335–42. Skulmowski A. Realistic visualizations can aid transfer performance: Do distinctive shapes and descriptive labels contribute towards learning? J Comput Assist Learn. 2022;38(3):681–91. Sweller J. Cognitive load theory. In: Mestre J, Ross B, editors. The psychology of learning and motivation: Cognition in education. Oxford: Academic; 2011. pp. 37–76. Nkrumah J. Sexual and Reproductive Health Is Made Simple: Educational Resource for Young Adolescents . 2024. https://shorturl.at/uDr2M Ahinkorah BO, Hagan JE Jr, Seidu AA, Budu E, Hormenu T, Mintah JK, et al. Access to adolescent pregnancy prevention information and services in Ghana: a community-based case-control study. Front Public Health. 2019;7:382. https://doi.org/10.3389/fpubh.2019.00382 . Manortey S, Geh EK. Access to Sexual and Reproductive Health Information among Female Adolescents in Selected Senior High Schools in the Lower Manya Krobo Municipality, Ghana. Appl Sci Innov Res. 2018;2(4). Klu D, Gyapong M, Agordoh PD, Azagba C, Acquah E, Doegah P, et al. Adolescent perception of sexual and reproductive health rights and access to reproductive health information and services in Adaklu district of the Volta Region, Ghana. BMC Health Serv Res. 2023;23(1):1456. https://doi.org/10.1186/s12913-023-10447-1 . Mayer RE. Introduction to multimedia learning. Multimedia learning. 2nd ed. Cambridge: Cambridge University Press; 2009. pp. 1–27. Awusabo-Asare K, Stillman M, Keogh S, Doku DT, Kumi-Kyereme A, Esia-Donkoh K, et al. From paper to practice: Sexuality education policies and their implementation in Ghana. New York: Guttmacher Institute; 2017. National Population Council. Adolescent Reproductive Health Policy. Accra, Ghana: National Population Council; 2016. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":132816,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipatory and Iteration Design Process of SRH Materials Development\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7879931/v1/9e9446e00b78e483ff7ff397.jpg"},{"id":95663373,"identity":"2ac40f23-e03c-404d-80a1-6ea7fbe81523","added_by":"auto","created_at":"2025-11-11 16:38:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":274707,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1.1: Conceptual Framework of Adolescent-Friendly SRH Resource Development\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7879931/v1/0824f0b30acebbdd3358911f.jpg"},{"id":105755820,"identity":"0ac90dbb-1267-4caf-8efa-1dc9fd99dd30","added_by":"auto","created_at":"2026-03-30 16:31:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1157020,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7879931/v1/51fb73fa-08e0-45a3-8d47-f7b6e9ee4c99.pdf"},{"id":95798776,"identity":"6fd891f9-6de2-46af-b769-5550ac41341e","added_by":"auto","created_at":"2025-11-13 08:17:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":534640,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYFILE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7879931/v1/442785e2653e62c64247c78a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFrom Standard Text to Simplified Learning: A Conceptual Framework for Developing Adolescent-Friendly Sexual and Reproductive Health Resources in Ghana\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth literacy (HL) encompasses the cognitive and social skills needed to access, understand, appraise, and apply health information for informed decision-making [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While individual capacity has traditionally been emphasized, contemporary definitions highlight a shared responsibility between individuals and the health system. Organizations are expected to create enabling environments through policies, services, and communication practices that support people of all literacy levels in making informed health decisions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This principle of organizational health literacy aligns with the Sustainable Development Goal (SDG) 3.7, which calls for universal access to sexual and reproductive health (SRH) information. Prior literature demonstrates that institutional support for health literacy fosters comprehension, engagement, equity, and informed decision-making, particularly among low-literate populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Africa, health communication is challenged by limited language accessibility, low functional literacy, and weak information navigation skills, which hinder the understanding of both print and digital materials [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A growing body of research in Sub-Saharan Africa (SSA) consistently reports low health literacy levels among adolescents and the general population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Ghana reflects these patterns, with studies showing limited awareness of health literacy and poor literacy outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Most research in the region has focused on individual-level health literacy, while the role of institutions in reducing literacy barriers and fostering accessible communication environments remains underexplored [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn adolescent SRH, the literature in SSA has primarily emphasized knowledge, awareness, and information sources, with limited assessment of adolescents’ ability to comprehend, evaluate, and apply SRH information meaningfully [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Ghana, despite a supportive policy environment for adolescent SRH, major implementation gaps persist. Key policies, such as the Adolescent Reproductive Health Policy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], National HIV and AIDS, STI Policy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and Adolescent Health Policy and Strategy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], have emphasized multisectoral collaboration and the integration of SRH content into school curricula. The 2016 strategy aimed to provide Comprehensive Sexuality Education (CSE) and ensure equitable access to SRH information. However, public backlash rooted in tensions between abstinence-based social values and comprehensive SRH approaches disrupted classroom implementation [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA critical and often overlooked barrier to effective implementation is the literacy demand of SRH materials. Structured, age-appropriate SRH resources remain scarce, particularly in basic schools, where most adolescents are first exposed to health education. While SRH topics are embedded in integrated science and life skills curricula, existing materials frequently exceed the reading abilities of target learners. For example, the SRH section of an 8th-grade integrated science textbook, covering reproduction and abstinence, scored 54 on Flesch Reading Ease and 12.0 on Gunning Fog Index, well above the typical comprehension level of students with limited vocabulary and low independent reading habits (19–20). National data underscore this literacy gap: only 30% of Ghanaian adolescents aged 10–14 can read at a third-grade level [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis mismatch between policy intentions and the linguistic accessibility of materials constrains the ability to understand critical health information, make informed decisions, and utilize services. The rise in early adolescent pregnancies and ongoing challenges with SRH-related stigma and misconceptions underscore the need for literacy-sensitive, developmentally appropriate SRH education. Findings from a recent intervention study in Ghana highlight the scope of the problem and a potential solution. Most print and digital SRH materials were found to be inaccessible to basic school adolescents, while simplified and picture-enhanced texts significantly improved functional SRH literacy and decision-making skills [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These results illustrate a clear mismatch between standard materials and adolescents’ literacy realities, and they raise concerns that health systems may disseminate SRH content that is too complex for adolescents to understand, undermining empowerment and policy objectives.\u003c/p\u003e\u003cp\u003eBridging this gap requires multi-level strategies that combine: 1) Routine readability and comprehensibility assessment of educational materials, 2) Integration of health literacy principles into program and curriculum design, 3) staff training and stakeholder engagement, and 4) development of structured, culturally appropriate SRH resources tailored to adolescents’ cognitive and literacy needs. In this article, I present the framework for developing an adolescent-friendly SRH educational resource.\u003c/p\u003e"},{"header":"Theoretical and Contextual Background","content":"\u003cp\u003eThis framework draws on three complementary cognitive learning theories to inform the design of adolescent-friendly SRH materials: Cognitive Load Theory (CLT) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Cognitive Theory of Multimedia Learning (CTML) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and Pictorial Realism Theory (PRT) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e–\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. CLT and CTML emphasize the role of human cognitive architecture in learning, particularly how information is processed through sensory memory, working memory, and long-term memory. Both theories highlight that working memory has limited capacity, able to hold and process only 3–4 short elements at a time [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e–\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. To enhance learning, they recommend reducing cognitive load so that essential content can be more effectively processed and stored.\u003c/p\u003e\u003cp\u003eCLT identifies three types of cognitive load: 1) intrinsic load (essential processing), linked to the complexity of the material. 2) extraneous load, caused by poor instructional design. 3) Germane or generative processing, the learner’s effort to integrate new information. CTML builds on this by proposing dual-channel processing (visual and auditory) and active learning principles, advocating for the use of multimedia to reduce extraneous load and support deeper understanding. It emphasizes that pictorial information closely aligns with how learners naturally process information and is especially effective when guided by principles such as redundancy, coherence, modality, segmenting, and personalization [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, critics argue that CLT overemphasizes load reduction without accounting for diverse learning objectives and differences in cognitive ability [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. CTML may not address subject-specific complexities or learner motivation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e–\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These limitations prompted the inclusion of PRT as a complementary lens. PRT is grounded in visual realism and posits that more life-like images enhance learning by providing clearer, more relatable cues [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e–\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It highlights the importance of realistic visual representation, especially in sensitive and concrete topics like SRH, where abstract visuals might impede understanding. PRT supports the notion that the degree of visual realism should align with learners’ needs, subject matter, and instructional objectives [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e–\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Together, these theories support the design of SRH resources that are not only cognitively accessible but also visually intuitive, realistic, and contextually appropriate for adolescents in low-literacy settings.\u003c/p\u003e"},{"header":"Methods/Development of the Conceptual Framework","content":"\u003cp\u003eThis paper presents a practical approach to closing the gap between standard materials and adolescents’ literacy realities, offering a conceptual framework derived from intervention research in Ghana. The framework provides a stepwise, theory-driven process for transforming complex SRH content into simplified, adolescent-friendly educational materials. Grounded in Cognitive Load Theory (CLT), Cognitive Theory of Multimedia Learning (CTML), and Pictorial Realism Theory (PRT), it supports educators, curriculum developers, and public health practitioners in creating SRH resources that are accurate, readable, engaging, and culturally sensitive, thus advancing health equity and adolescent empowerment. The framework was developed through a participatory and iterative design process aimed at guiding the creation of adolescent-friendly educational resources to improve SRH literacy and support informed decision-making. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1.0\u003c/span\u003e presents the process flow chart for the materials development\u003c/p\u003e\u003ch3\u003eBaseline Assessment and Initial Design\u003c/h3\u003e\u003cp\u003eThe initial design phase began with a review of existing SRH educational materials. However, the search yielded no context-specific, adolescent-friendly SRH resources suitable for use in Ghanaian basic schools. Consultations with public health practitioners at the local level confirmed the absence of appropriate materials within the School Health Education Program. Similarly, outreach to relevant organizations failed to produce feedback.\u003c/p\u003e\u003cp\u003eIn response, a literacy needs assessment was conducted to explore how adolescents in basic schools construct meaning around SRH, identify existing knowledge gaps, and assess barriers to information access. The methods and findings of this assessment are reported elsewhere [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Based on the assessment findings, relevant SRH texts were gathered from digital and print sources. A sample of these texts was randomly selected for evaluation of readability, comprehensibility, and vocabulary demands. The methods and results are published elsewhere [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Insights from both assessments informed the synthesis of SRH content into six thematic domains: 1) pubertal changes. 2) abstinence. 3) friendship. 4) sexual activities and risky behaviors. 5) contraception. 6) Sexually transmitted infections (STIs). The synthesis was organized using Microsoft Word, formatted in Times New Roman (Font size 18).\u003c/p\u003e\u003ch3\u003eSimplifying Existing SRH Texts\u003c/h3\u003e\u003cp\u003eTo ensure readability and relevance, the synthesized SRH content was simplified using a combination of structured methods, guided by comprehension and readability assessment, and intuitive strategies informed by writing experience. Techniques such as text simplification and elaboration were employed to align content with the literacy skills of adolescents. A draft of the simplified text-only format was created using Microsoft Word (2013) in Times New Roman, size 20. This simplified draft served as the foundation for the development of a picture-enhanced version. A graphic artist used the text to generate a pool of static images aimed at reinforcing and complementing the written content. These visuals enhanced comprehension and engagement among low-literate adolescents.\u003c/p\u003e\u003ch3\u003eType of Static Pictures\u003c/h3\u003e\u003cp\u003eThe illustrations varied in fidelity, ranging from cartoon-like and semi-realistic drawings to realistic images and silhouettes. Sensitive topics like sexuality and risky behaviors were illustrated with silhouettes and semi-realistic drawings to soften their impact. Detailed, realistic visuals were used for tangible items like contraceptives. Cartoon-style drawings represented general behaviors and human figures in a familiar, culturally appropriate manner. Visual placement followed instructional design principles drawn from the CTML and CLT, especially the principles of split attention, contiguity, and coherence [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Each image was positioned adjacent to the corresponding text to minimize cognitive burden and enhance understanding. The final output consisted of two formats: 1) a simplified text-only version, and 2) a picture-enhanced version (text with visuals).\u003c/p\u003e\u003ch3\u003eValidation of Static Pictures and Text\u003c/h3\u003e\u003cp\u003eSince the picture-enhanced version maintained the same text as the simplified format, both were validated together. The first draft was reviewed by the Municipal Education Service (MES), the Municipal Health Directorate (MHD), and a Medical Officer from the University of Education, Winneba. The MES team, including education officials and a gender coordinator, evaluated the clarity of the text and suggested visual revisions. They recommended modifying five sensitive illustrations and suggested images for abstract concepts like “ovulation” and “withdrawal method.” They also proposed a red ink cross-out for risky behaviors. The MHD team reviewed content accuracy, suggested reordering topics, and emphasized alignment with health messaging. All recommended changes were incorporated, including the revision and addition of new illustrations. A new draft was finalized accordingly.\u003c/p\u003e\u003ch2\u003eValidation by Adolescents\u003c/h2\u003e\u003cp\u003eThe third draft of the picture-enhanced SRH was validated by adolescents who participated in the earlier literacy needs assessment. These participants were intentionally selected for their prior inputs, particularly their recommendations to combine visuals with text. In a focus group, the materials were projected and reviewed in both English and Fante. Participants assessed the clarity, cultural sensitivity, and relevance of the visuals. Feedback was audio-recorded, translated, and transcribed to guide a further round of revisions that incorporated adolescents’ preferences and addressed content gaps.\u003c/p\u003e\u003ch3\u003eReview by Academic and Thematic experts\u003c/h3\u003e\u003cp\u003eThe revised draft was then reviewed by academic researchers supervising the dissertation. Their key recommendations included: 1) adding an introductory section explaining the SRH concept. 2) expanding lessons on sexual activity and abstinence with culturally grounded examples and risks, 3) including critical topics like rape and defilement, and 4) reorganizing lesson sequencing to support abstinence and align with local moral values. These revisions were implemented, and the revised draft was resubmitted for confirmation. The improved material was subsequently reviewed by subject-matter experts, an educational psychologist, language and assessment specialists, and an implementation researcher. Their feedback focused on improving cognitive load and recall by segmenting texts, converting bullet points into numbered lists, and condensing content. As a result, the simplified text decreased from 43 to 32 pages, and the picture-enhanced version from 84 to 60. A final round of review with stakeholders, including MES, MHD, and adolescents, was advised to confirm content clarity and institutional endorsement.\u003c/p\u003e\u003ch3\u003eFinal Stakeholder Validation\u003c/h3\u003e\u003cp\u003eThe revised picture-enhanced materials were sent to both the MES and MHD for final comments. Simultaneously, adolescents from four of the original schools were invited to participate in a proofreading exercise. Sixty in-school adolescents (aged 12–15) assented to take part. In small group sessions, participants read the assigned lessons aloud, underlining words they found difficult to pronounce or understand. Post-reading discussions were held to capture their feedback on text comprehensibility and image appropriateness. Participants identified several challenging terms, including: “Family Unit Nurse,” “infection,” “defilement,” “masturbation,” “abstinence,” “pornographic,” “contraception,” and “cuddling.” Suggested revision included: replacing \u003cem\u003e“Family Unit Nurse” with “Family Planning Nurse.” Substituting “infection” with “illness” or “sickness.” Clarifying complex terms with simplified definitions: “pornographic” explained as “Porno” (a local term). “Abstinence” as “no sexual activity,” and “contraception” is “ways to avoid pregnancy.”\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the MES approved the revised materials, the MHD requested greater clarity on specific sections and recommended that all images depicting risky sexual behaviors be marked with scarlet red instead of ruby red to more strongly signal risk. Final revisions were made to both the text-only and picture-enhanced formats to incorporate all relevant feedback. The resulting materials reflect multi-stakeholder consensus and target audience validation, ensuring both cultural relevance and user accessibility. Supplementary file 1 presents samples of static pictures created and validated by adolescents and stakeholders.\u003c/p\u003e\u003ch2\u003eSequencing of Lessons\u003c/h2\u003e\u003cp\u003eThe SRH educational material was structured to promote abstinence while delivering age-appropriate and culturally sensitive content aligned with Ghanaian values. Lessons were organized to build progressively from foundational biological knowledge to interpersonal relationships, risk awareness, and preventive strategies, fostering informed and responsible decision-making. The resource begins with an introduction to SRH and its relevance to young adolescents. Six core lessons follow: 1) Pubertal Changes: covers physical and emotional developments, with a focus on ovulation and the menstrual cycle to establish reproductive health foundations. 2) Sexual Activity and Health Risks: explores sexual behavior and associated risks, including rape, defilement, and cultural views on same-sex practices, handled with sensitivity. 3) Friendship and Etiquette: addresses peer influences, healthy relationships, and respectful social interactions. 4) Abstinence and Sexual Self-Regulations: defines abstinence and its benefits while providing strategies to manage sexual urges and peer pressure. 5) STIs: introduces common STIs, their causes, symptoms, and treatments, emphasizing prevention and timely care. 6) Contraception: positioned last, this lesson introduces contraceptive options as a backup strategy when abstinence is not practiced. This sequencing reflects a culturally grounded, rights-based approach that respects moral values while equipping adolescents with comprehensive knowledge. By carefully sequencing topics, the framework supports a balanced view of SRH, beginning with self-awareness and abstinence, and then gradually introducing risk management tools, such as contraception. This approach ensures content is both educational and contextually appropriate, addressing key gaps in existing SRH instruction in Ghana. Minor revisions were made to the simplified materials after their experimentation to address the reactions of educators and parents and to get them ready for publication [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eEthics Consideration and Ethics Approval\u003c/h2\u003e\u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki. The author obtained ethics approval from the Ghana Health Service Ethics Review Committee, ethics approval number GHS-ERC006/10/21. A written approval from the Municipal Education Service was obtained to conduct the study. I also obtained written permission and informed consent from the school heads and parents of participating adolescents. Furthermore, inclusion in the intervention was based on adolescents’ written assent.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe conceptual framework, as presented in Fig.\u0026nbsp;1.1, outlines a cyclical, theory-informed process for developing adolescent-friendly sexual and reproductive health (SRH) resources. It is grounded in CLT, which informs the simplification of complex texts to reduce extraneous cognitive burden; the CTML, which guides the integration and sequencing of text and visuals; and the PRT, which shapes the level of visual detail and realism in illustrations and animations. The framework begins with an SRH literacy needs assessment to identify adolescents\u0026rsquo; knowledge gaps and evaluate the readability, comprehensibility, and vocabulary of existing texts. Findings inform the resource development stage, where simplified text and static or animated visuals are co-created and validated with adolescents and stakeholders, producing formats such as simplified text, picture-enhanced resources, and animations. The resources are then implemented and evaluated in an experimentation phase to measure their impact on SRH literacy, with results feeding back into earlier stages. The supporting factors, including individual-level factors, sociocultural context, design factors, and stakeholder and expert inputs, shape the resource design, while an enabling environment (policy, funding, technical expertise, and ICT infrastructure) provides the systemic support required for sustainability and scalability.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eEvaluation of the Educational Resource\u003c/h2\u003e\u003cp\u003eThe framework was operationalized through a quasi-experimental study involving 317 adolescents aged 11\u0026ndash;15 years, enrolled in Grades 7 and 8 across 16 basic schools. The intervention aimed to assess the impact of literacy-sensitive SRH materials, developed through the framework, on adolescents\u0026rsquo; functional SRH literacy and decision-making.\u003c/p\u003e\u003cp\u003eTwo versions of the SRH resource (a simplified text-only version and a picture-enhanced version) were compared with a synthesized standard SRH text derived from existing materials. The intervention was implemented over six weeks using four groups: one control and three intervention arms. Assignment to control and intervention groups was based on cluster randomization. Of the 317 participants enrolled, 249 completed the study, yielding a 21% dropout rate. Attrition was largely attributed to prevailing misconceptions about adolescent SRH education, as well as stigma and sociocultural resistance, particularly from some school teachers and parents. These findings reinforce the need to integrate supportive components such as community engagement and parental involvement in the resource development process. However, due to time and funding constraints, these elements were not fully embedded during the initial implementation phase.\u003c/p\u003e\u003cp\u003eDifference-in-Difference analysis of the intervention data demonstrated significant improvements in both SRH decision-making and print literacy scores among participants exposed to the literacy-sensitive resources. Specifically, SRH decision-making skills increased by 11 points among participants who used the simplified text (95% CI: 4.68\u0026ndash;18.52; p\u0026thinsp;=\u0026thinsp;0.001). Decision-making skills also improved by 11 points among those who used the picture-enhanced text (95% CI: 3.96\u0026ndash;18.32; p\u0026thinsp;=\u0026thinsp;0.002), compared with the control group. While the comparison group also showed some improvement (10 units; 95% CI: 1.25\u0026ndash;20.36; p\u0026thinsp;=\u0026thinsp;0.027), the gains were statistically less robust [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For print literacy outcomes, participants using the picture-enhanced text improved by 13 points (95% CI: 7.39\u0026ndash;19.59; p\u0026thinsp;=\u0026thinsp;0.001), and those using the simplified text improved by 14 points (95% CI: 7.40\u0026ndash;20.80; p\u0026thinsp;=\u0026thinsp;0.001). In contrast, the comparison group showed a non-significant increase of only 4 units (95% CI: -3.97\u0026ndash;13.34; p\u0026thinsp;=\u0026thinsp;0.288) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These results affirm the framework\u0026rsquo;s emphasis on reducing cognitive load through simplified language and enhancing comprehension with visual aids.\u003c/p\u003e\u003cp\u003eMoreover, they highlight the framework\u0026rsquo;s potential to inform scalable, culturally sensitive, and literacy-aligned interventions in adolescent SRH education.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis framework provides a novel contribution to adolescent-focused SRH literacy by addressing both individual and organizational dimensions of health communication. While much of the existing research in Sub-Saharan Africa (SSA), including Ghana, has focused on individual-level knowledge and access to SRH services [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], this framework recognizes the critical role of health and education systems in fostering accessible, age-appropriate materials [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt operationalizes key principles from organizational health literacy, which emphasize institutional responsibility in ensuring that all individuals, regardless of literacy level, can access, understand, and use health information effectively [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Unlike conventional SRH programs, this framework integrates literacy-sensitive strategies grounded in CLT, CTML, and PRT. The participatory and iterative design, incorporating feedback from adolescents, health authorities, educators, and subject-matter experts, ensures cultural relevance, acceptability, and usability across literacy levels. Its dual-format outputs (simplified and picture-enhanced) offer adaptable pathways for diverse resource settings.\u003c/p\u003e\u003cp\u003eThree major strengths underpin the framework's design: 1) Theory-informed structure: Drawing from CTML and CLT, visuals were used to reduce cognitive overload and support information integration [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. PRT guided illustration styles, allowing the materials to balance clarity and sensitivity on topics such as STIs and contraception. 1) Stakeholder validation, which included engagement of the Municipal Education Service, Municipal Health Directorate, and adolescents, ensured relevance, accuracy, and cultural appropriateness [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Adolescents helped refine terminology and visuals, reflecting real-life barriers to SRH understanding [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. 3) The third strength is in the framework\u0026rsquo;s scalability and flexibility. Though designed in Ghana, the stepwise approach, content synthesis, simplification, visual enhancement, and validation can be replicated in other SSA contexts facing similar challenges [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Contextual Considerations\u003c/h2\u003e\u003cp\u003eDespite these strengths, several limitations warrant consideration: 1) Geographic and contextual limitations. The framework was developed in one Ghanaian municipality, which may limit generalizability. Broader validation is needed across regions with linguistic, cultural, and educational diversity. 2) The next limitation is related to resource constraints. Picture-enhanced versions require design expertise and printing resources that may be unavailable in some schools, affecting scalability. Another noteworthy constraint is the partial stakeholder involvement. Community leaders and parents were not engaged in early design phases due to time and financial constraints, which may have contributed to stigma and dropout. Short-term testing: The framework\u0026rsquo;s impact was evaluated over six weeks. While improvements in text comprehension and decision-making were significant, long-term retention was insignificant, and behavioral outcomes were not assessed [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003ePolicy and Practice Implications\u003c/h2\u003e\u003cp\u003e Ghana has a relatively strong policy environment promoting adolescent SRH, with key frameworks such as the Adolescent Reproductive Health Policy, the National HIV/AIDS and STI Policy, and the Adolescent Health Policy and Strategy. However, implementation has suffered due to the absence of literacy-sensitive and structured educational materials [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The framework presented here offers a practical tool to fill that gap. It can guide the development of national SRH materials that reflect adolescents\u0026rsquo; cognitive and literacy needs. Ministries of Education and Health can adapt the framework to enhance clarity and inclusivity, as advocated by organizational health literacy principles [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, teacher training programs and community outreach strategies should incorporate literacy-sensitive communication as a standard practice.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eFuture Research\u003c/h2\u003e\u003cp\u003eTo build on this work, future research should assess the framework\u0026rsquo;s long-term effectiveness, particularly in relation to retention, behavior change, and service uptake. Evaluating its adaptability in multilingual and rural settings would also be valuable. Further exploration into integration with digital platforms could enhance accessibility for low-literate learners. Additionally, involving parents and community leaders early in the development process may improve uptake and help address potential misconceptions.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe discussion underscores the need for integrated approaches to adolescent SRH education that consider both individual literacy levels and institutional communication responsibilities. The proposed framework advances this agenda by offering a replicable, theory-informed, and context-sensitive model for designing SRH educational resources. With further testing and institutional support, it holds promise for promoting equitable access to SRH information among adolescents in Ghana and similar low-resource settings. The framework can inform national curriculum reform and catalyze scalable interventions that bridge the SRH literacy gap among adolescents in low-resource contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author would like to thank the parents of the adolescents who agreed to participate in the needs assessment and resource development process. Acknowledge the valuable inputs of members of the Effutu Municipal Education Service and the Public Health Unit of the Health Directorate. \u0026nbsp;The management of the participating schools and my Ph.D. dissertation supervisors are also duly acknowledged.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJN is the sole author who conceptualized and designed the framework. She is responsible for data collection, analysis, and drafting of the initial and final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of the conceptual framework are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent for Participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involves basic school adolescents, and the protocol was reviewed and approved by the Ghana Health Service Ethics Review Committee in October 2021, with ethics approval number GHS-ERC006/10/21. Participating school heads provided written consent, and all participating adolescents provided written parental consents and gave personal assents to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Funding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNote applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary File 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSamples of Pictures created and validated by Adolescents and Stakeholders.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNutbeam D. Defining and measuring health literacy: what can we learn from literacy studies? 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Cambridge: Cambridge University Press; 2009. pp. 1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAwusabo-Asare K, Stillman M, Keogh S, Doku DT, Kumi-Kyereme A, Esia-Donkoh K, et al. From paper to practice: Sexuality education policies and their implementation in Ghana. New York: Guttmacher Institute; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Population Council. Adolescent Reproductive Health Policy. Accra, Ghana: National Population Council; 2016.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adolescent SRH literacy, simplified text, instructional design, cognitive theory, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-7879931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7879931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAdolescents in low-resource settings often lack access to sexual and reproductive health (SRH) materials that match their literacy levels. In Ghana, despite policy support for adolescent SRH education, implementation gaps persist due to the complexity of available texts. This paper presents a conceptual framework for developing simplified, culturally appropriate SRH resources tailored to the cognitive and literacy needs of adolescents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis framework was developed through an iterative process, including a baseline needs assessment, resource design, stakeholder validation, and evaluation of quasi-experimental methods. A review of existing materials and a literacy assessment identified major gaps in comprehension and vocabulary demands. Content was synthesized from six SRH themes and simplified into formats: a text-only version and a picture-enhanced version with static illustrations. Validation was conducted with educators, health officials, adolescents, and academic experts.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe resources were piloted with 317 adolescents aged 11\u0026ndash;15 over six weeks. A total of 249 participants completed the study. Compared to the control group, users of the simplified and picture-enhanced texts showed significant improvements in SRH decision-making skills (+\u0026thinsp;11 points, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and print literacy scores (+\u0026thinsp;13\u0026ndash;14 points, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). A 21% dropout rate, linked to stigma and sociocultural resistance, highlighted the need for greater community and parental engagement.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe framework offers a stepwise, theory-informed approach to developing adolescent-friendly SRH materials. By reducing cognitive load and improving readability, it supports equitable access to SRH education.\u003c/p\u003e","manuscriptTitle":"From Standard Text to Simplified Learning: A Conceptual Framework for Developing Adolescent-Friendly Sexual and Reproductive Health Resources in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 16:29:24","doi":"10.21203/rs.3.rs-7879931/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T04:53:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-20T17:35:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T11:06:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100275591487621499909669958602542977951","date":"2025-12-01T16:35:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22303550452672379037021687673600611431","date":"2025-11-26T22:45:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T19:36:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293766017963073593163997474477599375376","date":"2025-11-06T11:43:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191225818226507770922343072595280077874","date":"2025-11-05T08:03:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296460471489546433602844390178649294530","date":"2025-11-04T15:10:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2157022331896863994100828146645079196","date":"2025-11-02T20:37:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255271477488212808888554601072859995029","date":"2025-10-30T14:48:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T14:42:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-20T09:08:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-20T02:42:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-20T02:42:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-16T16:58:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64d59796-5c08-4bdf-84f1-233dfab320df","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:24:23+00:00","versionOfRecord":{"articleIdentity":"rs-7879931","link":"https://doi.org/10.1186/s12889-026-27166-x","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-03-28 16:13:01","publishedOnDateReadable":"March 28th, 2026"},"versionCreatedAt":"2025-11-11 16:29:24","video":"","vorDoi":"10.1186/s12889-026-27166-x","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27166-x","workflowStages":[]},"version":"v1","identity":"rs-7879931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7879931","identity":"rs-7879931","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}