Provider and Client Both Play Roles in Client-Centered Counseling

The Provider’s Role

Client-centered counseling requires providers, building on their personal communication skills, to achieve interactions with clients that:

1. Establish rapport:

• Assure privacy and confidentiality,
• Be positive and encouraging,
• Encourage clients to ask questions and share information,
• Listen and observe what clients say and do,
• Use a friendly tone of voice and attentive body language to convey warmth, interest, and respect.

2. Focus on the individual:

• Respond first to the client’s stated need, interest, or question,
• Explore the client’s lifestyle, life stage, life goals, and preferences,
• Help the client understand how these might influence family planning and other reproductive choices,
• Respond to the client’s concerns, including rumors, respectfully and constructively,
• Review a returning client’s experience and satisfaction with the method, including any side effects and changes in goals, lifestyle, and preferences.

3. Communicate medical information clearly:

• Focus on making or confirming the choice or decision,
• Be brief,
• Use simple, nontechnical language,
• Do not give irrelevant information or too much information at once,
• Let clients see and touch samples and models,
• Encourage questions and make time for them,
• Check that the client understands,
• Know their own biases about methods and treatments and compensate for them,
• Use memory and job aids to guide and inform the interaction.

4. Give clients their choice:

• Let clients know they have options and that the choice belongs to them,
• Offer to help clients think through the options,
• Ask clients to confirm their decisions,
• Help the returning client weigh the pros and cons of continuing versus switching methods.

5. Plan next steps:

• Help clients plan how to carry out their decisions,
• Discuss dealing with side effects, checking carefully for a client’s personal concerns,
• Anticipate problems and discuss how to overcome them, including what the client can do if she makes a mistake, such as forgetting a pill,
• If possible, give clients pre-tested informational materials that they can consult at home,
• Invite clients to call or return if they have questions, doubts, concerns, or want another method,
• Schedule the next visit, if appropriate.

TheClient’s Role

Clients can improve the quality of their interactions with health care providers and their ability to make wise decisions if they:

1. Expect good care:

• Request privacy,
• Ask whether the provider will keep information confidential,
• Be aware of and, if necessary, draw attention to clients’ rights and providers’ responsibilities regarding CPI,
• Repeat their request for information or a method if the provider does not respond.

2. Elicit information:

• Request information about their options,
• Ask questions,
• Ask the provider to repeat or clarify information that they do not understand,
• Check their own understanding of information and instructions.

3. Disclose information:

• Respond fully to providers’ questions,
• Volunteer information about their preferences, needs, and problems,
• Express concerns, worries, and fears,
• Openly discuss their personal situation.

4. Make thoughtful decisions:

• Accept that it is their right and responsibility to choose a method,
• Understand how their personal circumstances and needs affect the decision,
• Discuss the advantages and disadvantages of options with the provider to help choose the best one,
• Ask for instructions and any other help they may need to carry out the decision.

Sources: Kim, 2001 (107); Kim, 2003 (78); Murphy, 2000 (107); Rinehart, 1998 (124)

How Supervisors Can Improve and Maintain Good CPI

1. Strengthen their own knowledge and skills:

• Understand the need for effective CPI, and support improvement,
• Model good communication skills with staff and clients.

2. Contribute to effective training:

• Work with providers to identify their training needs, and participate in performance needs assessments,
• Discuss training needs and curriculum content with the trainer,
• Meet with providers before training and debrief them afterwards to help them make the most of the experience.

3. Encourage and support providers’ good performance:

• Become comfortable observing how clients and providers interact,
• Use checklists and other tools to evaluate providers’ performance,
• Give providers constructive feedback on their interaction with clients,
• Help providers address barriers to good CPI,
• Emphasize confidentiality, and ensure that the physical setting allows for private consultations,
• Reward good CPI with praise,
• Ensure the availability of communication aids, contraceptive samples, and informational materials.

4. Develop other sources of reinforcement:

• Develop peer groups, inside the facility and among facilities, that support good CPI,
• Create rewards that motivate providers to excel at CPI.

Evaluating CPI Training Programs

A complete evaluation of CPI training assesses both the quality of the training event and its impact on providers’ behavior on the job. This requires evaluation before, during, and after training (42, 161):

• Before the design of a training event, a needs assessment can determine who should be trained, what they need to learn, and whether the health care system is ready and able to make the changes necessary for providers to apply new CPI skills.
• At both the beginning and the end of the training event, trainers should assess participants’ CPI knowledge, attitudes, and skills through questionnaires, interviews, and observations. The baseline data can help direct the training, while before-and-after comparisons can determine whether training objectives are met.
• During the training event, trainers should monitor participants’ progress so they can make adjustments in the course (34).
• After the training event, the actual implementation process should be compared with the original plans to see what succeeded and why, and to identify which materials and activities were most helpful.
• After participants return to work, observations can assess whether training has changed their everyday CPI practices. Further evaluation can determine if the changes had an impact on client satisfaction, return visits, or contraceptive continuation.
• Several months to one year after training, further rounds of observation can determine whether improved CPI practices persisted.

Curriculum for Integrated Reproductive Health Counseling

A new curriculum developed by EngenderHealth has adapted counseling frameworks from family planning to address a range of integrated sexual and reproductive health services. Applying evidence-based best practices in CPI, Comprehensive Counseling for Reproductive Health: An Integrated Curriculum promotes effective communication and counseling in all areas of reproductive health. The training package includes materials for a six-day workshop to teach providers the knowledge, attitudes, and skills they need to assess and address a client’s overall sexual and reproductive health needs, regardless of the health care setting or the service requested by the client. Also included are agendas for shorter workshops and for other frontline staff, administrators, and supervisors. For copies of the curriculum, send an e-mail message to info@engenderhealth.org or write to EngenderHealth Material Resources, 440 Ninth Avenue, New York, NY 10001, USA.

Tools for Improving CPI: CD-ROM Available

The Johns Hopkins University Center for Communication Programs has produced a CD-ROM, Client-Provider Communication: Successful Approaches and Tools, that highlights evidence-based best practices and recent innovations for improving client-provider interaction. It covers four areas: provider performance, client behaviors and community norms, management of service delivery, and research and evaluation. Program descriptions and evaluation findings demonstrate how the approaches can be implemented. The CD-ROM includes a variety of sample tools, including counseling guides, client education materials, and supervision and assessment forms, along with advice on how to adapt them for different settings. For copies of the CPI CD-ROM, send an e-mail message to orders@jhuccp.org, fill out the order form at http://www.jhuccp.org/cgi-bin/orders/orderform.cgi, or write to: Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202, USA.