• 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
7. Client-Provider Communication
• Improving Counseling
• Active Clients
• Helping Clients Make Informed Choices

• 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.

Better Client-Provider Communication

Good communication between clients and family planning providers during counseling is key to informed choice. When counseling is a partnership, in which clients and providers communicate openly, share information, express emotion, and ask and answer questions freely, clients are more satisfied, understand and recall information better, use contraception more effectively, and live healthier lives (104, 109, 173).

The process of making informed family planning choices begins long before people visit a provider, of course, and many people make informed choices without face-to-face communication with a provider. When clients do seek services, however, there is substantial evidence on what clients and providers can do together to ensure that family planning decisions are based on the principle of informed choice.

Counseling for informed choice, like good counseling in general, should be thought of as a partnership of two experts—the provider as the medical expert and the client as the expert on her or his own situation and needs (391, 432). Clients can play an active role in the counseling session (248), while providers can understand and address clients' concerns, desires, and needs—engaging in a genuine dialog (299, 436).

JHU/CCP Health workers in Nepal participate in an interactive radio education training program about family planning counseling. Training providers, along with offering continued support, increases their technical knowledge about family planning and improves client-provider communication.

Improving Counseling

Family planning clients and providers both have responsibilities to ensure that the counseling process reflects the principle of informed choice and leads to family planning decisions that clients make for themselves. A number of obstacles often stand in the way of good client-provider communication. These include unnecessary medical barriers and other restrictions that providers place on services, providers' own preferences about contraception and biases toward or against certain methods, both providers' and clients' discomfort with discussing sexuality, the differences in status and knowledge between providers and clients, and gender bias. Finding ways to surmount these obstacles helps foster informed choice.

Avoiding unnecessary medical barriers. Sometimes programs and providers inappropriately prevent clients from receiving the contraceptive method of their choice by adhering to scientifically unjustifiable policies or practices, based at least in part on a medical rationale (39, 382). Outdated contraindications sometimes remain in a program's official guidelines or providers' informal screening routine (39).

These unnecessary medical barriers can inhibit informed choice even where official policies try to ensure that medically eligible clients get the methods they want (383, 467). In a study in five African countries, for example, providers imposed twice as many eligibility criteria as the current national family planning guidelines required (288).

Also, in Kenya a study in 1999 estimated that 78% of nonmenstruating women were sent away without services to wait for their next menses to confirm they were not pregnant—an unnecessary restriction for most hormonal methods (399). Many clients who are turned away never get their contraceptive method of choice or any other method, as they are unable to return to the clinic (396).

Avoiding provider bias. The principle of informed choice means that providers avoid bias and, instead, respect client's preferences over their own—even if a client chooses a less effective method, uses a method only sporadically, switches frequently from one method to another, or refuses any or all services (139). Nevertheless, many providers think that they should make family planning decisions for their clients because they know what is best (102, 119, 244).

Providers sometimes erect barriers based on people's age, marital status, or other inappropriate criteria (178, 289). In particular, many providers deny family planning services to unmarried young people (195, 247). In a 1994 survey in Ghana, for example, 26% of providers said that marriage was a prerequisite to obtain family planning services. Some 76% of providers enforced minimum age requirements for contraception because they thought that access to contraception leads young adults to behave promiscuously (423).

Providers often have their own preferences and preconceived ideas about what contraceptive method is best for clients (102, 193, 378, 410). In a 1993 study in Jamaica, 90% of physicians said they preferred the pill for women who want to delay their first pregnancy, and 40% said they opposed at least one family planning method, usually injectables or fertility awareness-based methods (176).

In India a 1994 study found that most providers were influenced by the program's method-specific targets of that time and thus chose sterilization, the IUD, and to a lesser extent the pill for their female clients (255, 446). Also, in Kenya a reason that IUD use declined dramatically over a 10-year period was that many service providers were biased against the method (400).

A balanced presentation is best—a discussion of both positive and negative aspects of methods (2, 413, 421). When providers become more aware of their own biases and perceptions, they are better able to avoid making choices for their clients and instead help clients make informed decisions for themselves. One indication of an individual provider's bias toward certain methods is a contraceptive method mix among one provider's clients that differs drastically from that of other providers' clients. Similarly, if the contraceptive method mix among clients of a certain clinic is skewed toward a particular method, provider bias may be the reason (41, 382).

To help overcome bias, role-playing exercises and discussion groups with clients can help providers understand how their behavior affects clients' choices (69, 128, 358). Behavior modeling—that is, presenting examples of positive counseling behavior—can help providers improve their interaction with clients (325, 374).

Rick Maiman, Courtesy of the David and Lucile Packard Foundation Men need to know about family planning, too. Providers sometimes assume that men do not want to make family planning decisions or to use contraception. Counseling men, as in this clinic in Mexico, can encourage their participation.

Becoming comfortable with sexuality. Family planning providers can be uncomfortable or uncertain about sexual issues themselves and avoid discussing them, and many assume that clients do not want to talk about them either (34, 294, 300). Without discussion of sexuality, however, many clients are likely to make poorly informed family planning choices (100, 294).

For many clients the counseling session is the only opportunity to talk about sexual matters, which makes them eager to discuss such issues. In Egypt 71% of clients who received counseling about sexuality said they were not embarrassed. As one client said, “If the doctor asks us,...we would tell her about our problems, but otherwise I would be embarrassed to tell her” (3). Training that invites staff members to reflect on their own feelings and experiences about sexuality can help make them more comfortable discussing the topic with clients (34, 294).

Narrowing social distance. Differences between providers and clients in social class, education levels, scientific knowledge, and other types of status often interfere with good client-provider communication. Sometimes, providers treat clients of high socioeconomic status differently from those of low socioeconomic status (139, 429). Providers are particularly likely to believe they know what is best for poor clients. High-status service providers often underestimate their lower-status clients and thus make decisions for them (429). For example, in a 1993 Bolivian study many Aymara clients said providers often were rude or patronizing and offered the IUD as the only contraceptive option, without explaining side effects (370).

Providers and clients often have different health beliefs and different ways of understanding how the body works and what causes illness. Typically, the provider's understanding is based on science, while the client's is based on tradition, popular accounts, and informal discussions (166, 188).

Clients rarely mention their own health beliefs unless providers ask about them, but they often reject information that does not fit their own beliefs (110, 150, 157, 254). Providers can narrow such distances in understanding by expressing respect for the client's beliefs and drawing connections between these beliefs and the medical model of health (188).

Addressing gender. Gender roles—roles that a culture considers appropriate for a man or a woman—are little discussed but often affect the way providers and clients interact and the decisions that clients make. When clients are women, providers are less likely to answer questions, provide tech-nical information, offer alternatives for treatment, and diagnose and treat certain diseases, and they are more likely to attribute clients' complaints to psychosomatic factors (242, 321).

Providers sometimes assume that men do not want to make family planning decisions or use contraception. In effect, such providers make men's choices for them, providing one explanation for the fact that male-oriented contraceptive methods are used much less widely than female-oriented methods (111, 429).

To help address gender issues related to family planning decisions, providers can ask each client how much he or she wants other people to be involved in his or her family planning decision. If other family members oppose a client's own family planning wishes, and if the client is comfortable talking about the issue, the provider can invite the client's spouse or other family member to discuss the different family planning options and explain why family planning decisions are best made by clients themselves (77, 298).

When being counseled together with their partners, however, women participate less than when counseled alone and may have less influence over family planning decisions. In Kenya, for example, male clients communicated more actively than female clients during counseling as couples. Men volunteered extra information or asked questions during 66% of their turns to speak compared with 27% for women. Providers offered more detailed information to the men than to the women, and men had more influence over the session's content, direction, and duration (242). Training can help providers, both male and female, better understand gender roles. When providers understand how gender influences such life issues as spousal communication, childbearing intentions, and domestic violence, they are better able to help clients make informed family planning choices (106, 186, 326).