• 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.

When clients take the initiative during reproductive health consultations—for example, by requesting privacy, asking questions, or clarifying instructions—they improve the quality of CPI and the decision-making process. They help to keep the focus of the session where it should be: on their own needs, concerns, and priorities. They also request enough information to make a sound decision and make certain that they understand that information.

Clients may even compensate for weaknesses in the provider’s counseling skills. A close analysis of transcripts in Indonesia revealed that some family planning clients took responsibility for key steps in the decision-making process often overlooked by providers, such as identifying the problem needing resolution (72).

Usually, however, clients are passive and hesitant to ask questions or state their needs. Clients, like providers, have expectations about their role in reproductive health consultations—expectations that are shaped by family, friends, and community as well as by health care providers. Many clients consider passively listening to providers and deferring to their expertise to be appropriate behavior.

What providers say (or fail to say) and how they act may either reinforce clients’ negative expectations or else encourage them to speak. In Colombia and Indonesia, for example, postabortion care clients reported not asking questions because providers seemed too busy and never told them that it was acceptable to ask questions (155). Such research can shed light on local barriers to client participation (70, 76, 165).

Clients’ limited communication and decision-making skills also contribute to their passivity. Most clients have little practice in formulating questions and seeking clarification from professionals or in weighing the pros and cons of various health care options. Depending on their culture, they may not even be familiar with the concept of conscious decision-making.

Gender and age differences between clients and providers, as well as educational and socioeconomic disparities, may further inhibit clients (134). Even the physical layout of a clinic and its work patterns can be a barrier to clients’ participation if they deny clients uninterrupted privacy to discuss sensitive issues.

Various strategies increase clients’ participation. Programs and research studies in developed and developing countries have devised a wide variety of materials and activities to encourage clients’ participation in health care consultations (3, 43, 143). Most focus on two areas:

• Legitimating the client’s right to speak out, so that clients will feel that it is appropriate—even expected—for them to play an active role in health care consultations; and
• Strengthening basic communication skills, so that clients feel confident in their ability to ask questions, disclose information, and check their own understanding.

Print materials have been used to accomplish both goals. For example, the International Planned Parenthood Federation (IPPF) poster on the “Rights of the Client” encourages clients to claim their rights to information, confidentiality, and privacy during consultations (58). It has been translated into more than 20 languages and displayed in thousands of clinics worldwide. Information sheets or brochures listing sample questions are another approach. They can encourage clients to formulate their own questions for providers and remember to ask them during the consultation (79).

Mass media campaigns can portray clients playing an active role in interactions, giving clients a model for their own behavior. Because the mass media reach a wide audience, these portrayals also may change community norms about clients’ behavior. For example, communication campaigns in Egypt and Nepal developed television spots and radio soap operas depicting client-centered counseling (39, 153). While their main objective was to raise clients’ expectations of providers’ behavior, the broadcasts also modeled positive client behavior, such as requesting information. Observations of counseling sessions in Nepal found that clients became more active participants after the radio soap opera aired, regardless of whether their providers had received CPI training and so might be expected to encourage such behavior (152).

Coaching clients individually on their role in CPI has been tested in Indonesia. Educators from the State Ministry of Population/National Family Planning Coordinating Board (BKKBN) spent about 20 minutes with each family planning client. They explained that clients had both the right and the responsibility to speak out. They helped clients to formulate and write down questions and concerns and to practice raising them with the provider. A comparison of experimental and control groups found that coaching persuaded clients that they had the right to speak, enhanced their participation, and improved providers’ information giving, but it had only a marginally significant impact on the contraceptive continuation rate at an eight-month follow-up (79).

Group education, whether in the waiting room or in the community, can reach far larger audiences than individual coaching. In a pilot test of this approach in Indonesia, specially trained community workers led group meetings in villages, factories, mosques, and clinics. They discussed clients’ rights and responsibilities, instructed women to complete a picture checklist of common questions before seeing a family planning provider, and encouraged them to ask questions and express concerns during consultations. According to household interviews, women were more likely to prepare questions ahead of time for providers and asked more questions during consultations if they lived in communities where these group meetings were held (69).

Reproductive health programs using a broader women’s empowerment approach also have stimulated client participation, as two projects conducted by feminist organizations in Peru have demonstrated. Workshops for women conducted by Consorcio Mujer (139) and the ReproSalud project (29) discussed reproductive rights and gender issues as well as health care. This approach raised women’s self-esteem, appreciation of their rights, and reproductive health knowledge, which, in turn, led women to openly discuss problems with providers, ask them questions, and request services. Community and provider groups sponsored by Consorcio Mujer also negotiated initiatives to improve CPI, including procedures to reward or discipline clinic staff members based on how well they interact with clients (139).

Many family planning programs try to influence clients’ behavior indirectly, via training and other activities designed for providers. Training in client-centered counseling, for example, instructs providers to give clients more opportunities to talk, to prompt clients to ask questions and express concerns, and to facilitate clients’ decision-making (159). In Indonesia this kind of interpersonal communication and counseling training for providers increased the average number of questions that family planning clients asked, even without activities directly encouraging clients to participate (77).

Disclaimer: The information provided on this web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.