Simply telling a woman to take pills daily may not motivate correct or continued use. Careful communication between a woman and her health provider improves correct use and continuation.
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.
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