• Editors' Summary
• Credits

1. Why Informed Choice Matters
2. Making Family Planing Decisions
3. Policies for Informed Choice
4. Communication for Choice
5. Improving Access
6. Managing for Informed Choice
• Program Leadership
• Improving Performance
• Monitoring and Evaluation
• Permanent and Provider-Dependent Methods
• Choice in Low-Resource Settings
7. Client-Provider Communication

• Figures
• Table
• Side-bars
• Bibliography

• What can be done?
• Women know what they want
• Why communities matter
• Eliminating targets
• More methods, more choices
• "Your health is in your hands"
• Do clients have choices?
• Please Ask!
• How much guidance?
• Active clients, better choices
• Counseling continuing clients

• POPLINE
• Media/Materials Clearinghouse
• Other Reports
• To Order
• CCP Home Page

Published by the Population Information Porgram, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Management approaches that identify the source of problems with quality of care and develop appropriate solutions can improve clients' ability to make informed choices. One such approach is Performance Improvement (PI)—a process for identifying the most important root cause of gaps between desired performance and actual performance (274). Another is the systems approach, in which family planning managers examine the role of each part of service delivery and how it influences clients' ability to make informed choices (256, 278).

In addition, training providers in interpersonal communication skills is important to informed choice because these trained providers are better able to involve clients in health decision-making (358). In Egypt women who received counseling from providers trained in interpersonal communication knew more about how to use their methods and expressed more satisfaction with services than those seen by other providers (2).

Also, in Ghana a study found that specially trained providers offered a wider choice of contraceptive methods, gave clients more information about side effects, and were more likely to leave the final choice to the client than providers who were not similarly trained (195). In Indonesia providers trained to foster rapport and encourage client participation doubled their facilitative communication in counseling, and clients asked twice as many questions (249).

Continuing support and reinforcement. Trained providers need continuing support and reinforcement from managers and supervisors to keep their skills fresh (222, 249, 250). Recognizing providers who help ensure informed choice—for example, by giving promotions, new titles, and more authority—complements training (220, 386). In addition, programs can maintain provider performance through on-site training, distance education, and self-assessment (58, 343, 412, 462). Management also can make communication job aids such as wall charts, cue cards, flip charts, and checklists accessible for providers to improve their performance and help clients make informed choices (234).

In an Indonesian study self-assessment and peer review helped to maintain providers' performance. Four months after the training, the percentage of providers' remarks that fostered rapport and client participation declined from 29% to 27% among those who did not have any reinforcement. By comparison, among providers who assessed one of their own counseling sessions each week, the percentage of such utterances increased from 28% to 33%. In the group that also participated in weekly peer review meetings to discuss their own performance, such utterances increased from 28% to 37% (249).

This wall chart is available in English, French, and Spanish. Health care providers can request copies at www.jhuccp.org/wallchart/

Monitoring and Evaluation

How well programs help people to make informed choices provides a key measure of program success (286). Managers can gauge a program's ability to ensure informed choice by monitoring a variety of indicators (see Evaluating Informed Choice).

Among the techniques that can apply to evaluating informed choice are using “mystery clients” or other observers in clinics, conducting exit interviews with providers and clients, and analyzing transcripts or videotapes of counseling sessions (256). Evaluation also can examine the number of methods available, the policies governing eligibility for receiving methods, fee structures, use of communication aids such as wall charts, and such service statistics as contraceptive method mix and referrals (286, 319, 407).

Using the HARI Index, developed by the Population Council, also can help programs determine how well they help clients choose a method appropriate to their needs and situation, use it effectively, manage side effects, and switch to another method when desired. HARI, which stands for “Helping Individuals Achieve their Reproductive Intentions,” measures how well a person is able to achieve fertility goals without suffering reproductive health morbidities in the process (211, 214, 239).

Another new evaluation approach for use in service delivery provides a checklist for informed choice and informed choice training modules that were developed by EngenderHealth (259). Also, the MEASURE Evaluation project has developed a tool called the Quick Investigation of Quality, which includes some components for monitoring and evaluation of informed choice (407).