• Summary
• Credits

1. Promoting Dialogue
2. 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


• Box: Client-Centered Counseling
3. Improving Providers’ Performance
• Table: Activities to Improve CPI
• Box: Supervisors Can Improve CPI
4. Best Practices in Training
5. Evaluating the Quality of CPI
• Box: Evaluating Training Programs
6. Moving Beyond Family Planning
7. Bibliography

• INFO Project
• Order
• Online Reports
• Upcoming Reports
• POPLINE

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.

Finding a balance between client and provider input into health decision-making is a continual challenge (135). Medical thinking has rejected paternalistic models that put decisions entirely in the hands of the provider. Yet concepts of “shared” and “informed” decision-making, which give clients a pivotal role, are new to many providers and even more foreign to clients, especially in developing countries (28).

According to the informed choice model adopted by family planning programs around the world, clients are responsible for choosing a contraceptive method and should have a deciding voice in most other reproductive health decisions as well. For their part providers play the important role of confirming or facilitating the client’s decision, first by helping the client explore and assess her or his own needs, preferences, and knowledge, and then by using professional expertise, experience, and communication skills to help the client make a medically and personally appropriate decision (159).

Assuring informed decision-making can be difficult. Studies in both developed (17) and developing (71, 72) countries have found that most consultations do not fully achieve the goal of informed decision-making. One common reason for this may be lack of discussion of the client’s role in decision-making. Family planning clients may not understand that, given the safe and effective contraceptive methods available, it is their right and responsibility to choose a method that fits their own personal needs and preferences. As a result, they may revert to the passive role that medical patients usually play, deferring to providers’ expertise and expecting them to make the decisions (57, 71).

Providers who misunderstand the client’s role in decision-making may act inappropriately as well. In the mistaken belief that decisions should be left entirely to clients, providers sometimes abdicate their role altogether (71). After providing the information that they think a family planning client needs, providers may passively wait for the client to figure out what it all means and reach a decision, without providing any further help. While an understandable reaction against older authoritarian approaches, this approach is equally flawed.

Activities designed to improve counseling and informed choice can convince providers that clients have the right and the capability to make their own decisions about contraceptive use. They also can convince providers that encouraging clients to make their own decisions will improve outcomes for the client and the program. After training in family planning counseling, for example, doctors in four Central Asian countries had more respect for the client’s role in decision-making (8), while in Ghana providers were more likely to leave the final choice of contraceptive method to the client (55).

Training, along with good supervision and coaching, can make providers aware of biases—for example, in favor of a particular method or against switching methods—that threaten the client’s right to make her or his own decisions. Providers also can learn how to engage clients in decision-making while retaining their own role in the process (124). Complementary activities directed to clients can teach clients how to play an active role in decision-making (see Clients' Participation Encouraged).

Given the challenges in balancing the client’s and provider’s roles in decision-making, providers need—and clients want help with—a systematic process, or series of steps, that will lead to a sound decision. At the same time, each client is an individual and so both the process and the content of counseling must respond to her or his unique situation.

Ideally, the counseling process itself should help providers individualize the consultation. To this end, most counseling approaches rely on short series of easily remembered steps that allow the provider to focus on the client’s unique situation and needs. Approaches, such as the six-step GATHER model (Greet, Ask, Tell, Help, Explain, Return) (124) or the four-step REDI model (Rapport-building, Exploration, Decision-making, Implementing the decision) (42, 132), strike a balance between provider and client input into the decision-making process.

J. Fortin

At this health clinic in the Philippines the receptionist and cashier treat clients with warmth and respect. Every health care worker should understand the importance of good CPI.

While counseling models generally focus on the provider’s tasks, Young Mi Kim and colleagues, based on research in Kenya, describe the client’s tasks in contraceptive decision-making in a four-step model: understand personal circumstances, consider alternatives, choose the best option, and implement the decision (71).

Counseling models can recognize and respond to fundamental differences among clients, such as a new client versus a continuing client, returning clients with or without problems, and clients with or without concerns about sexually transmitted infections (STIs) (124). Of course, providers must go beyond these broad categories in order to tailor a counseling session to the individual client. Within the framework supplied by any counseling model, providers must use interpersonal skills to elicit and address specific details of the client’s situation and preferences, including the client’s medical history, sexual practices, relationship with her or his partner, vulnerability to violence, need to conceal use of family planning, ability to pay for a method, even perhaps a woman’s feelings about getting injections versus taking pills. (See box, Provider and Client Both Play Roles in Client-Centered Counseling.)

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