For example, in Bukidnon Province, the Philippines, women who were counseled about potential OC side effects and who rated their provider as friendly were less likely to stop using the pill than women who did not receive such counseling. Based on these findings, provider training in the Philippines now emphasizes friendly interaction and explaining common side effects (191, 196).

Despite such findings, other studies show that many OC clients know little about the possibility of side effects and how to manage them. Studies in 10 sub-Saharan African countries, for example, found that only 25% to 54% of family planning users were informed about side effects during counseling. Even fewer received information on managing common side effects—from just 1% in Côte d'Ivoire to 42% in Burkina Faso, among the five countries with data (138).

Explanations that women can understand help them continue to use the pill until the side effects subside. A Nepal program puts side effects in a familiar context by comparing them to changes that occur during pregnancy: “Just as a woman's body changes when she is pregnant, so changes can occur when she prevents pregnancy. But these changes are not dangerous” (105).

Training can help a wide range of pill providers, including clinic staff, pharmacists, social marketing agents, and community-based health workers. In Gujarat, India, for example, gynecologists, general practitioners, and pediatricians who had special training about the pill improved their counseling skills. Trained providers, when compared with others who had not received the special training, were more likely to show clients how to use the pill and to provide a pill packet at the counseling session. In turn, clients' perception of the quality of care improved. In a study using “mystery clients”—local women who visited clinics posing as clients—satisfaction with counseling averaged 83% for the specially trained doctors compared with 56% for doctors without the training (204).

On-the-job training during working hours often can help providers apply their new skills more effectively than formal off-site training because trainees develop skills within the work environment (215). In Kenya trainers noted that providers with on-the-job training were better counselors than those who had been trained otherwise. This was because the providers encountered a variety of clients on the job, thus honing their counseling skills (68).

Performance improvement goes beyond training to address the institutional, organizational, and managerial factors that affect health care delivery. The performance improvement approach recognizes that achieving better quality of care, including better counseling, is the responsibility of the entire health care system, not just of providers and trainers themselves. Each part of a health care delivery system has a role to play in improving quality (107, 116).

In particular, assuring providers enough time to counsel their clients would improve the quality of care they can offer. Most providers have so many duties and so many clients that time for counseling is limited. In Bangladesh, for example, rising demand for the pill reduced the amount of time that field workers had to counsel each woman on proper pill use. The result was that, as more women used the pill, fewer women knew correctly when to begin their next pill pack (123). Removing administrative burdens on providers, such as excessive paperwork, can free up time for counseling.

Enabling staff to make improvements in their working environment can increase the quality of care they provide and boost job satisfaction (116). When staff members feel empowered, they often find ways to solve institutional problems rather than to keep working in an unsatisfactory setting (56).