• 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.

Clients who participate actively in the counseling process—that is, who ask questions, state opinions, express concerns, and freely offer relevant personal information—make better health decisions (105, 230, 346). When clients play an active role in their family planning decisions, they have more confidence in the outcome and are more likely to follow through (201, 244).

Clients need encouragement to be active in counseling (373). Most clients feel more comfortable speaking out when prompted by the provider. Clients who have had little contact with family planning providers often do not know what is expected from them in a health care setting. Many think that providers do not want them to ask questions or are afraid of wasting providers' time. Some are passive because they worry about appearing ignorant, while others do not want to challenge the provider's authority (14, 353). Clients are particularly reluctant to ask questions when they think “the provider knows best,” and they accept a method urged by the provider even if it is not their own choice.

Providers sometimes believe incorrectly that, when clients are quiet, they have no questions or concerns. Usually, however, their silence indicates lack of confidence to ask questions and the practice of waiting for the provider's cues before speaking (37, 68). Providers often do not give clients enough information to play an active role (14, 137). Although asking clients a lot of questions does not always increase active client communication (173, 243), providers who are supportive—offering reassurance, approval, and constructive suggestions—usually help clients participate more (248).

Providers can assure clients that they can speak frankly even about sensitive matters and that nothing said will be discussed with anyone else (299). They can ask clients to express their feelings and to feel free to talk about their personal situation (38). Providers can encourage clients to tell their own story, talking about what they want to talk about, without guiding clients in any particular direction (391). This approach can efficiently bring out what is most important to the client.

JHU/CCP A health care worker meets with a group of people in a Peruvian community. As people learn more about reproductive health, they are better able to participate actively in family planning decisions.

Increasing client participation. Family planning programs can increase client participation by making more productive use of the time that clients spend at clinics and by training clients in active participation. The time that clients spend waiting can be an opportunity for learning (14, 353, 416). If clients learn more about the range of available contraceptive methods before seeing a provider, the provider can better focus on methods that interest the client (245).

Before counseling, clients can prepare by completing a checklist that covers questions they may have for the provider (447) (see The Choice Is Yours.). Showing a video that models active clients, offering reading materials, or holding an active waiting room discussion also can help (13, 230, 408).

Programs also can train clients to be more active participants in decision-making. Research, mostly in developed countries in health fields other than family planning, has found that training helps clients seek information more effectively, tell providers more about their health condition, and verify the information they receive from providers (68, 353, 394). Training clients in active behavior also increases the amount of information that they obtain and remember from counseling sessions (394). Client training can cover the right to make informed choices about family planning; the skills to obtain information; the skills to make family planning decisions; and assertiveness in communicating with providers (230, 250, 394).

Clients are more likely to ask questions when they can think about them ahead of time (416). In 2000 an Indonesian pilot project, “Smart Patient,” worked with 525 clients individually to write their questions, prioritize them, and then rehearse asking them. The training gave clients confidence that they could ask questions during counseling. Evaluation found that clients who received coaching spoke significantly more often than other clients, asking on average 5.5 questions compared with 3.5. Also, coached clients voiced an average of 5.6 concerns compared with 4.5 concerns among clients without coaching. Although the project would be difficult to implement in all clinics nationwide, it demonstrates that preparing clients in advance leads to more active client behavior (250).