Table of Contents
Chapters
- Promoting Dialogue
- Supporting the Client’s Role
- Clients' Perspectives Crucial to Family Planning Decisions
- Client and Provider Roles Need Clarity, Balance
- Counseling Models Help Guide Decision-Making
- Clients' Participation Encouraged
- Improving Providers’ Performance
- Table: Activities to Improve CPI
- Box: Supervisors Can Improve CPI
- Best Practices in Training
- Evaluating the Quality of CPI
- Moving Beyond Family Planning
- Bibliography
This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.
Published by the Information & Knowledge for Optimal Health (INFO) Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.
Volume XXXI, Number 4,
Fall 2003
Series Q, Number 1
Maximizing Access to Quality
Supporting the Client’s Role
There are two “experts” present in any health care consultation: the provider and the client (85, 142). The client’s understanding of her or his personal preferences and situation is as essential to good reproductive health decisions as the provider’s technical knowledge.
Only recently, however, have family planning programs learned to appreciate and support the client’s role in decision-making. This requires both providers and clients to change their attitudes and behavior. To be effective, providers must understand and respect clients’ perspectives and expectations, and they must tailor the information and guidance they offer to meet each client’s unique needs. Likewise, clients benefit more from a consultation when they take responsibility for making decisions, actively communicate with providers, and insist on good care.
Clients’ Perspectives Crucial to
Family Planning Decisions
Informed choice is one of the fundamental rights of family planning clients (7, 58, 157). It takes place when a client voluntarily makes a well-considered decision based on full knowledge and understanding of the alternatives (41). But the right also carries responsibilities: clients are expected to make their own decisions regarding reproductive health after thoroughly considering the options. This is no easy task since decision-making about reproductive health is often complex and ongoing. For example, clients must decide whether and when to seek services, which family planning methods to try, and whether to continue with, change, or discontinue those methods (41). In order to facilitate thoughtful decisions by clients, providers need to understand how clients approach reproductive decisions and the challenges they face in making them.
Social context dominates decision-making. For clients, reproductive health decision-making is often an intuitive process of balancing individual needs, family responsibilities, and social expectations. Usually, the most important influences on decision-making come from outside the service delivery setting. People consider personal, social, and economic issues along with fertility and health concerns when they make contraceptive decisions (52, 147); these include relationships with partners, anticipated effects on social status, and sometimes even concerns that contraceptive side effects will limit their ability to work (22).
Before coming to a decision, people often engage in a lengthy information-gathering and decision-making process, during which they seek out contraceptive users among their friends and family and discuss their experiences (134). This process does not end when a woman adopts a method. She continues to talk with others and to monitor her own experience with the method so that she can decide whether or not to continue using it. Viewed from this perspective, clinic visits and other contacts with health care providers are brief moments in a largely social decision-making process.
Local beliefs about reproduction, health, and the meaning of physical symptoms—which may conflict with medical models—also influence people’s decisions (134). In Togo, for example, menstrual changes prompted many women to discontinue hormonal methods—not because the changes were uncomfortable or inconvenient, but rather because women believed the changes were signs of sterility or serious illness (52). Dismissing such beliefs as myths and rumors only contributes to distrust between clients and providers. Rather, providers must learn to recognize their own medical assumptions and to treat clients’ concerns seriously and respectfully.
Family planning programs need to consider clients in a broader context, as members of couples, extended families, informal social networks, and the larger community, and to appreciate the economic pressures, social issues, and local beliefs that shape their decisions. Providers can accomplish this by asking clients about their needs and situation and about the consequences of their decisions in terms of work, friends, and family relations.
Program managers can explore the larger context of decision-making during monitoring and evaluation activities (see chapter 5, Evaluating the Quality of CPI). For example, extended monitoring of a mobile outreach female sterilization service in Nepal included client interviews. More than half of the clients interviewed said that they were afraid of dying from the procedure but felt the risk was worth taking to avoid another pregnancy (66).
Side effects need discussion. Contraceptive side effects are one of the most important factors in clients’ decisions about family planning. Fear of side effects is pervasive. It is often grounded in real experiences (147). Misinformation and unfounded beliefs also are widespread. Anticipation of side effects may discourage people from adopting certain family planning methods, while experiencing side effects may lead women to discontinue a method (33, 53).
Training in contraceptive counseling usually covers how to discuss side effects with clients, but providers often avoid the subject because they think that negative information will scare clients away (26, 71). This strategy is self-defeating, however, since women learn about side effects from family and friends. Clients also may fear the worst if they experience side effects without warning and without understanding. Their fears may be exacerbated by local beliefs that interpret side effects as more dangerous than they are (52).
Providers can dispel many of these fears by helping women understand which side effects commonly occur, how long they usually persist, that they usually are not dangerous or signs of danger, and that they often disappear as the body adjusts. Providers must present this information accurately and in a way that is not alarming (123).
Research has found that clients counseled on side effects before starting a method are more likely to keep using it when side effects occur than clients who are not counseled about side effects (25, 91). In Mexico, for example, discontinuation rates among women using injectables were far lower when they were thoroughly counseled ahead of time about possible side effects—17% versus 43% among those not counseled, after one year (25).
Equally important is how providers respond when returning clients complain about side effects. Rather than taking these concerns seriously, providers sometimes dismiss them as unimportant or even scold women for bringing up a subject that they have discussed before (52, 73). Providers need to understand that, even though side effects may not be harmful, they may still be inconvenient, uncomfortable, and upsetting for the client.
Reassurance about side effects, while important, is not always enough (52). Clients should be offered a choice among various courses of action—for example, waiting to see if bothersome side effects resolve over time, making behavioral changes (such as eating foods that contain iron or taking iron supplements to prevent anemia if an IUD causes heavy menstrual bleeding), taking medications (such as short-term combined oral contraceptives or a nonsteroidal anti-inflammatory for spotting when using implants), or switching methods (164).
