|
Careful communication between clients and providers is important for the provision of
all contraceptive methods, but it is especially relevant to oral con- traceptive (OC) use
because of the need for daily pill-taking and for following other instructions.
Research shows that the quality of interpersonal communication between clients and
health-care providers -- how the provider and client interact on a personal level --
influences both the attendance at family planning clinics and the initiation and
continuation of all reversible contraceptive methods.1
"Taking a pill every day can be difficult. That is why Norplant and Depo-Provera
were invented, because it is so hard for people to remember to take pills," says Dr.
Deborah Oakley, a professor at the University of Michigan School of Nursing who has
studied provider behavior as it relates to pill compliance.
"If providers think their job is only to give the method to women who are
medically eligible, we're not going to get anywhere," she says. "Providers need
to come to see it as their responsibility to ask about the environment for use, how women
will use the pill, and help women figure out strategies for correct use."
Based on a review of research on family planning counseling, Oakley has identified
several techniques for improving client-provider communication: She suggests providers
greet their clients by name; assure an atmosphere of privacy; and sit at the same eye
level as their client, instead of at a higher level. Counselors can improve communication
by asking clients about their family planning goals, listening carefully to answers, and
by being aware of such "nonverbal" cues as the client's attitude.2
Listening to a client's particular doubts and concerns, including her difficulties with
using contraception, is necessary to determine what each woman needs, and what type of
counseling will be most effective.
Good communication is important because each user enters a clinic with her own needs
and concerns, says Dr. Linda Potter, an FHI principal scientist who is currently a
visiting researcher at Princeton University. And each woman has a unique set of economic
or family constraints that may limit her ability to follow an oral contraceptive routine,
says Dr. Potter, whose research has focused on oral contraceptive compliance. For example,
some women may live in remote rural areas, making it difficult to travel to clinics or
pharmacies for refills and counseling; others may be too poor to spend scarce resources on
refills; and still others may come from families that do not allow women to travel outside
the village, and do not support the use of contraceptives.
A recent review of literature on oral contraceptives by Dr. Potter shows that nearly
one-third of all pill-users worldwide do not take OCs correctly and up to 60 percent take
pills irregularly.3 Pregnancy rates are substantially higher
for some types of pill users than others. For example, married women in the United States
who have moderate incomes and are over age 30 have low pregnancy rates -- only 3 percent a
year while taking OCs. However, about 27 percent of low-income U.S. adolescents get
pregnant each year while using the pill.4
A woman's situation
Sometimes, a woman arrives at a clinic with doubts about not having another child. She
may feel ambivalent about the goal of preventing pregnancy and may need guidance to
resolve her feelings. Other women will feel more certain that they want to use
contraceptives, but have trouble taking pills correctly and may need help figuring out
what they are doing wrong. Common pill-taking errors include missing pills and transition
errors between stopping one pill pack and beginning another.
"We probably need to do more questioning and listening about what a woman's
situation is," says Dr. Oakley. "Instead, we try to determine which
contraceptive method a woman is medically eligible for, without examining her personal
situation. Providers don't assess a woman's particular ability to take pills every
day."
Providers may need to make a distinction between telling a woman to take pills every
day, and motivating her or enabling her to do so, says Dr. Potter. Some women may
frequently miss pills but do not realize they are doing so. Others may lack the ability to
get home in time to take a pill on schedule, or to make up a missed pill.
In the clinic, women may talk about their pill-taking behaviors inaccurately. An
analysis compared a record kept by an electronic device inside the pill pack, which
registered each time a pill was dispensed, with women's self-reported diary cards. The
study showed that the women's own reports were only accurate 45 percent of the time.5 Diary data reported an average of one missed pill per cycle. By
contrast, electronic data showed that participants actually missed an average of two pills
per cycle, increasing to three missed pills by the third cycle. Providers can help women
develop good pill-taking strategies by asking questions about how a woman leads her life,
and how she deals with various situations that may interfere with her contraceptive
routine.
A review of contraceptive provision in the United Kingdom shows providers rarely
attempted to discover the cause of noncompliance and frequently became angry with clients
for missing pills. Such anger threatens to break clients' trust or confidence in the
provider and may discourage clients from returning. Anger also fails to get at the root
causes for contraceptive errors and misses an opportunity for improving a woman's
pill-taking habits.6
A recent study by McFarlane Consultants, a Jamaican-based research firm, and Dr. Karen
Hardee, FHI senior research scientist, examined the quality of care at 346 health
facilities in Jamaica through interviews and surveys of 1,074 health workers and 135
supervisors. Researchers also used 20 women posing as clients to visit clinics and report
how they were treated by providers.
According to these "simulated clients," no providers explained all of the
advantages, disadvantages, and side effects of the combined pill. Only half of the
providers explained that the pill must be taken every day, and that pills must be taken in
a sequence indicated by arrows on some pill packages. Providers rarely gave information on
what to do about missed pills.
Although experience shows it is important to let clients voluntarily choose their
family planning method, the simulated clients said they felt pressured to accept a method,
especially the pill, during nine of their 50 clinic visits. One nurse offered a client a
choice between the pill and the injectable, but refused to give information about either
method until the client had made a decision.
Frequently, providers' own perceptions of their services do not match clients' reports.
One objective of the Jamaican study was to find out how providers rated their own
services. While providers reported spending an average of 20 minutes with each female
client, more than half of the counseling sessions at simulated client visits, 29 out of
50, took 10 minutes or less.7
Difficult work
Unfortunately, funding and time constraints frequently lower the quality of counseling
that providers can offer. Family planning providers are often overworked and balance
multiple jobs, and some are dissatisfied with their careers.
A 1995 assessment of the quality of family planning in Malawi, by the Centre for Social
Research at the University of Malawi, surveyed 160 family planning providers at 42
health-care facilities throughout the country. Results showed that many providers are not
in their chosen line of work, and most perform family planning services in addition to
other health-care duties. Providers reported feeling divided between making services more
accessible to clients and not wanting to further increase their own workload. Although
most providers said they did not want to turn clients away, they often refused to meet
with clients who had missed group counseling sessions to avoid having to repeat basic
information. While providers recognized that long waits are frustrating to clients, they
generally gave priority to other types of patients, creating an average wait of three
hours for family planning clients.
The Malawi assessment team trained six women to pose as clients desiring family
planning services. They made a total of 85 health-care visits. In one-tenth of the
client-provider interactions, the simulated clients either were turned away by providers
or reported they would be too embarrassed to return because of how they were treated.
Nearly 60 percent of providers used language that simulated clients found difficult to
understand, and most providers placed a higher value on giving medical information about
contraceptive methods than attending to individual clients' knowledge, abilities,
motivation and intentions for use.8
In Nepal, research shows communication suffered when providers were disrespectful of
clients from a lower economic caste. To investigate the quality of client-provider
interactions at clinics in Kathmandu, the Nepal Family Planning/Maternal-Child Health
Project of the Ministry of Health sent simulated clients to 16 clinics. The study showed
that traditional class hierarchies and social discrimination interfered with communication
between clients and providers. Lower-class clients were less likely to receive good
information and courteous treatment than their middle-class counterparts.9
In other research, clients report a lack of trust when they go to a clinic.10 These feelings can discourage clients from returning for
follow-up visits or initiating and continuing contraception. Clients are more likely to
use OCs correctly and return for refills if health workers take the time to understand
clients' personal needs and circumstances, and treat them with respect.
Strengths and weaknesses
To improve client-provider interaction, programs must first identify their strengths
and weaknesses. In the Philippines, researchers conducted in-depth interviews and clinic
observations to help improve quality of care in the Philippine Family Planning Program
(PFPP).
The study examined 107 family planning workers and 1,440 clients. Overall, Filipino
providers received high marks from their clients. The area in need of improvement,
according to 52.5 percent of the clients, was providers' tendency to be too authoritative
and tell clients what to do. One-third of clients felt providers always advocated a
particular contraceptive method, rather than giving them a choice.
The study compared clients in two parts of the country that were similar in size and
demographics, but one area had significantly higher contraceptive prevalence than the
other. Filipino clients who lived in the higher-use area generally rated their providers
more favorably and had more contact with family planning providers. Clients who lived in
the lower-prevalence area liked their providers less and received fewer family planning
visits. About 77 percent of the client-provider interactions in the high-use area were
person-to-person or individualized, compared to 54.2 percent in the low-use area.11
In Peru, higher quality service also appeared to be correlated with greater
contraceptive use. A recent Population Council analysis of the 1992 Demographic and Health
Survey in Peru, combined with an assessment of the national service delivery system,
showed that contraceptive prevalence among 7,841 women was 16 to 23 percentage points
higher in areas with better quality services, compared with areas with services the
researchers rated as lower quality. Quality was measured by six categories, including
method choice, provider bias, privacy, and keeping clients adequately informed.12
A comparison of 78 U.S. adolescents aged 13 to 18, who were randomly assigned two kinds
of counseling methods, showed clients had a significantly greater contraceptive
continuation rate when they were encouraged to talk with counselors about sexual feelings.
After one year, only 47 percent of the young women who received conventional counseling
were still contra-cepting, compared to 98 percent of the teenagers who received counseling
that encouraged personal discussion of sexuality.13
Supervisors play an important role in creating a good climate for counseling, according
to the Pathfinder Fund, a U.S.-based reproductive health organization that has prepared a
handbook for improving provider skills. The handbook describes how supervisors can promote
better client- provider communication by creating an atmosphere of trust among clinic
staff, and improving communication among staff members and management. Role-playing and
group discussions among staff are some of the suggestions.14
-- Sarah Keller
Footnotes
- Bairagi R, Barua MK. Contraceptive use dynamics in
Matlab, Bangladesh: Does the quality of worker make a difference? Unpublished paper.
International Centre for Diarrheal Disease Research, Bangladesh, 1994. Vera H. The
client's view of high-quality care in Santiago, Chile. Stud Fam Plann 1993;24(1):40-49.
Koenig MA, Hossain MB, Whittaker M. The Influence of Fieldworker Quality of Care upon
Contraceptive Adoption in Rural Bangladesh. Paper presented at Population Association
of America annual meeting, Denver, CO, April 30-May 2, 1992.
- Oakley D. Rethinking patient counseling techniques for
changing contraceptive use behavior. Am J Obstet Gynecol 1994;170(5):1585-89.
- Potter L, Oakley D, de Leon-Wong E, et al. Measuring
oral contraceptive pill-taking. Unpublished paper. Family Health International, 1996.
- Oakley D, Potter L, de Leon-Wong E, et al. Toward
Understanding OC Pill-use Behaviors that Protect against Unintended Pregnancy. Paper
presented at Population Association of America Conference, New Orleans, LA, May 7-8, 1996.
- Potter, 13.
- Kite S. Family planning provisions: Whose needs are
being met? Brit J Fam Plann 1990;16:109-13.
- McFarlane C, Hardee K, DuCasse M, et al. The quality of
Jamaica public sector and NGO family planning services: Perspectives of providers and
clients. Unpublished paper. McFarlane Consultants, Family Health International, 1996.
- Tavrow P, Namate D, Mpemba N. Quality of care: An
assessment of family planning providers' attitudes and client-provider interactions in
Malawi. Unpublished paper. Centre for Social Research, University of Malawi, 1995.
- Schuler RS, McIntosh EN, Goldstein MC, et al. Barriers
to effective family planning in Nepal. Stud Fam Plann 1985;16(5):260-70.
- Gay J. A literature review of the client-provider
interface in maternal and child health and family planning clinics in Latin America.
Unpublished paper. Pan American Health Organization, 1980: 13-14; Roberto E. Perceived
factors of family planning clinic performance and service quality. Philip Pop J
1993;9(1-4):74-84; Cotten N, Stanback J, Maidouka H, et al. Early discontinuation of
contraceptive use in Niger and The Gambia. Int Fam Plann Perspect
1992;18(4):145-49.
- Raymundo CT, Cruz GT. Family planning client-worker
interaction as an ingredient of quality of care. Philip Pop J 1993;9(4):56-72.
- Mensch B, Arends-Kuenning MA, Jain A. The impact of
quality of family planning services on contraceptive use in Peru. Stud Fam Plann
1996;27(2):59-75.
- Marcy SA, Brown JS, Danielson R. Contraceptive use by
adolescent females in relation to knowledge, and to time and method of contraceptive
counseling. Res Nurs Health 1983;6:175-82.
- Edmunds M, Strachan D, Vriesendorp S. Client-responsive
Family Planning: A Handbook for Providers. Watertown, MA: The Pathfinder Fund, 1987.
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network |
Copyright