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									          Theme II

Client-Centered Communication:
 The Client, the Provider, and the


                                    Session Objectives
         Participants will explore:
         u   The perspective of the client and factors influencing
             the client’s decision-making
         u   Basic concepts and principles of informed choice
         u   Basic concepts and principles of client-provider
             interaction (CPI)
         u   The importance of informed communities
         u   Findings of recent research on client-centered

    Client-Centered Communication                                    7-2

“Client-centered communication” embodies the belief that, in order to
achieve the highest quality of reproductive health (RH) services and to
best meet clients’ needs, all communication between the healthcare
system and clients should be centered on the knowledge, needs, and
concerns of the client, or the person who is considering becoming a
client, and the key family and/or community members who influence RH

Therefore, this session will address the perspectives of the individual
client (considering the context of the family and community in which
decisions are made), the provider of RH services, and the community
factors that support (or hinder) communication between clients and


         u   Interpersonal communication (IPC)
         u   Client-provider interaction (CPI)
         u   Counseling

     Client-Centered Communication                                        7-3

Interpersonal Communication” (IPC) refers to person-to-person, verbal and
non-verbal communication between two or more people. As such, it permits or
encourages the development of a relationship among the communicators. IPC
can be one-to-one or group communication.
 “Client-Provider Interaction” is interpersonal communication between clients
and healthcare workers. CPI is a subset of IPC. It refers to all encounters,
both verbal and nonverbal, that clients have with healthcare workers. The
client considers virtually everyone who works in the healthcare setting to be a
“provider.” Therefore, receptionists, cleaners, supply clerks, and other non-
medical staff can have just as much influence on a client’s thinking as nurses
and doctors.
“Counseling” is two-way communication between a healthcare worker and a
client to facilitate or confirm the client’s decision. Counseling is a subset of
CPI. Counseling differs from other IPC in terms of people’s roles and the
interaction’s goals.

When the interaction is “personalized” or tailored to the client’s needs and
concerns, it becomes client-centered communication (see next overhead).

N.B. Definitions for “informed choice” and “informed consent” are given later in
the presentation.

                   What is the health system’s role
                                 in client-centered
         u To  provide information to clients (or potential
           clients) based on client’s expressed needs
           and concerns

         u To help clients make reproductive health
           decisions based on client’s needs and

    Client-Centered Communication                                7-4

 “Client-centered communication” is the broadest category of interaction
between individuals and the healthcare system. It includes not only
communication within the clinic setting, but also the transmission of
messages to the community outside the clinic, through mass media,
group education programs, and outreach efforts.

             Client-Centered Communication
                          Role Play Scenario
           Miriam has come to the clinic for the first time.
           She has her two-month-old baby who is crying.
           She is sitting on her own in the corner, far from
           the other clients and she looks unhappy. You
           noticed Miriam sitting in the corner by herself.
           After some time, Miriam comes into your room,
           saying she wants to wait before she has her
           next child.

    Client-Centered Communication                                  7-5

§Performing the role play is optional for this session. If you choose not
to perform the role play, you may wish to show the video clips instead.
§Begin by having two participants come to the front of the room. One
participant takes the part of Miriam, a distraught mother who wants to
delay her next child. The second participant takes the part of the
§Have the participants role play for about 2 to 3 minutes. They may
want to play out some of the good characteristics of client-centered
communication and care (e.g., treating the client well), and some of the
characteristics that do not reflect client-centered care (e.g., provider
talking too much).
§After the role play, ask the group: 1) To point out good and bad client-
centered communication characteristics 2) To discuss how a provider
can explore the gender/family-related issues that might keep Miriam
from being able to delay the birth of her next child (e.g., Does her
husband disapprove of FP, will she be abused for not wanting another
child right away, or will clandestine use of FP be an appropriate option
for her?)

                               Communication Video
        Video Clip:

        Is this an effective or ineffective
        client-centered interaction?

    Client-Centered Communication                                  7-6

§Showing the video clips is optional for this session if you choose not to
conduct the role play scenario on the previous slide.
§Be sure to preview the tape before the session to select the most
appropriate clips (for the country, facilities, etc.)
§You may choose to show 1 to 2 clips for the provided video on sample
client-provider interactions.

Discussion Questions

Following the role play or video clips, ask the attendees to discuss what
they saw, using the questions below to prompt the discussion. Record
responses on flipchart paper.

§What in the example illustrated client-centered communication and
§What in the example did not illustrate client-centered communication
and care?
§Are effective client-centered communication and care easy to
§How do gender roles and status affect client-centered communication
and care?
                   Provider client-centered
            communication style results in. . .

        u   Three-fold likelihood of client satisfaction
        u   Double the continuation rate at 7 months–
            controlling for type of method used

                                              N=112 client/provider interactions

Source: Abdel-Tawab, N. and Roter, D. 1996.

  Client-Centered Communication                                                7-7

• Research consistently shows that Client-Centered Communication
has impact on behavior change.

•This finding is based on utilization of an index of client-
centeredness in counseling that is made up of total number of:
solidarity; information giving and facilitative statements made by the
provider, divided by the total number of: questions; instructions;
direction and disagreement statements made by the physician in
the same consultation.

•Note that the ultimate outcome that we hope to achieve
through client-centered communication is to improve our
ability to meet clients’ needs.

                               The Client

    Client-Centered Communication                                7-8

Take a few moments to ask participants:
      • Who is “the client”?

[In order to answer this question, you may need to clarify what services
you want to consider in this discussion: Are we talking about family
planning? Family planning plus sexually transmitted infection
(STI)/HIV? Comprehensive RH services? As we discuss broader RH
services, the following question may arise: Are “users” referred to as
“clients” or as “patients”? This terminology should be clarified during
preparations before the workshop, but, if the terminology is still not
clear, it should be discussed here (or at least referenced) in order to
clear up any confusion in participants’ minds.]

Possible responses to “who is the client?”:
      •Individual men and women
      •In-laws, or extended family
      •Influential community members
      •People who have not yet decided to use FP/RH services,
      but have the need

                        What factors influence an
                     individual’s decisions about
                             reproductive health?

     u   Individual experiences and preferences
     u   Community beliefs and norms
     u   Technology considerations, including access
     u   Service delivery factors, including quality

   Client-Centered Communication                                              7-9

The process of clients’ FP/RH decision-making is very individualized and does not follow
a standard, linear path with a clear beginning and end. It is a complex interplay of factors
at four levels:
Individual factors
• Economic and social status
• Age and parity
• Autonomy (social, economic, decision-making)
• Status and nature of relationship
• Health status; prior method experience; RH intentions
• Personal attitudes, religion and other beliefs, perceptions, preferences
Community and cultural factors
• Social, cultural, and gender norms
• Rights context (human rights, reproductive rights, consumer rights)
• Beliefs of family, friends, field workers and influential community members
• Reputation of the RH program in the community
• Access to (correct) information; rumors and myths; media
Technology considerations
• Method or treatment options available (access)
• Method or treatment attributes (perceived advantages and disadvantages)
Service delivery factors
• Access to services and method options; eligibility criteria; fees
• Provider communication skills; provider attitudes
• Targets, quotas, incentives
• Delivery of services during stressful times (e.g., labor, postabortion)
• Quality of service environment and staff

                          IPPF Rights of the Client

      Every FP client has the right to:
      u   1) Information: To learn about the benefits and
          availability of FP
      u   2) Access: To obtain services regardless of sex, creed,
          color, marital status or location
      u   3) Choice: To decide freely whether to practice FP and
          which method to use
      u   4) Safety: To be able to practice safe and effective FP
      u   5) Privacy: To have a private environment during
          counseling or services

  Client-Centered Communication                                       7-10

• The significance of describing communication as being “client-
centered” is that it reflects a shift in thinking about clients. In the past, it
has been common to think in terms of programmatic targets, with
clients representing the numbers needed to reach demographic targets
or public health goals. Now, clients are recognized as individuals with
individualized healthcare needs, which providers can help to meet, and
rights, which providers can help to facilitate.

• One framework that helps to keep the client central to “client-centered
communication” is the Rights of the Client, developed by the
International Planned Parenthood Federation (IPPF). This articulates
the importance of respecting the expertise of the client in the healthcare
decision-making and service delivery interactions.

• Briefly state the 10 Rights (on this and the next slide).

                         IPPF Rights of the Client
    Every FP client has the right to:
    u   6) Confidentiality: To be assured that any personal
        information will remain confidential
    u   7) Dignity: To be treated with courtesy, consideration
        and attentiveness
    u   8) Comfort: To feel comfortable when receiving
    u   9) Continuity: To receive contraceptive services and
        supplies for as long as needed
    u   10) Opinion: To express views on the services offered

                                  Source: International Planned Parenthood
                                  Federation, adapted from IPPF Medical and
  Client-Centered Communication   Service Delivery Guidelines, 1992.       7-11

Having reviewed the 10 Rights of the Client, return to the previous slide
and ask participants:

        •Which of these rights is directly affected by client-centered

The answer should be “all of them”! This answer shows the importance
of client-centered communication to some very fundamental aspects of
quality of care.

Optional follow-up question (if time permits):
        •To what extent are these rights practiced/upheld in your

                                               Informed Choice

            u   Personal experience whereby a client makes a
                      voluntary decision after considering the
                            information and options available.
                                                         S.M. Palmore, 1999.

         Client-Centered Communication                                     7-12

Informed choice combines at least two of the IPPF client rights (information and
choice) and is considered to be a key element of quality of care from the client’s
perspective. Although informed choice can and does occur outside of client-
centered communication, it certainly can be enhanced or supported by structured
communications from the healthcare system, including communications with
healthcare providers.

Key points: Informed choice is something that is done by, or experienced by,
the client. Informed choice can happen anywhere, at any time, and does not require
the provider’s input. It is important to remember that:
       •a client’s information about family planning comes from many sources;
       •the reasons for choice are usually personal; and
       •key factors are usually the opinions of partners and the experience of
       friends and family.

You might expand on this idea by pointing out that clients’ choices are almost
always “informed.” However, the information on which the choice is based may be
inadequate or simply wrong. Therefore, one function of the provider is to provide
clients with accurate information that can help clients make choices that are well-

                                        Informed Consent

             A medical, legal, and rights-based construct
             whereby the client agrees to receive medical
             treatment, to use a family planning method, or
             to take part in a study, (ideally) as a result of the
             client’s informed choice

        Client-Centered Communication                                   7-13

You could begin this discussion by asking, “How is informed consent different
from informed choice?”

Note that “informed consent” is not only for family planning services, but is also
a standard procedure in most countries to authorize surgery, and should be
required for participation in any research that involves humans.

We usually associate informed consent in family planning with a written form
that is signed by the client. This is often limited to sterilization, because
sterilization is intended to be permanent and involves surgery. However,
informed consent can also be given verbally and should be part of the
interaction between the provider and client any time a contraceptive method is
given or a RH service is provided.

Ask participants: “What is the purpose of informed consent?” Someone
might say, to be sure the client understands the procedure, risks, etc. However,
the most common response (from both clients and providers) is to protect the
individual doctor or institution from litigation or accusations of wrong-doing. This
response puts the emphasis on the client’s signature and not on the client’s
level of understanding of the method or the decision. The client’s understanding
will be explored further in the next slide.

                   A Signed Informed Consent Form
                         Does Not Guarantee
                          Informed Choice.

                “It is important to keep in mind that informed consent
                is not a signature, but a process of communication
                and interaction.”                (FIGO, 1996)

          Client-Centered Communication                                         7-14

A common criticism of written informed consent is that clients do not understand the
language or intent of the document before signing. Clients’ lack of understanding is a
serious problem that needs constant attention from service providers.
However, even when the client is fully informed and in agreement with the procedure,
he or she may not feel that s/he has any choice in the matter. This can happen when:
       • someone is pressuring the client to choose a particular FP method (e.g., a
       provider, a referral agent, a relative), or
       • no other options are conveniently available (e.g., in an outreach service site
       where only one method is offered), or
       • financial or other incentives are offered that put pressure on the client to
       choose the method, although s/he might not actually want it.
[If the participants are working in programs funded by USAID, you can note that the
Tiahrt Amendment specifically prohibits these kinds of pressures on clients, and that this
will be discussed in more detail later in the workshop.]

For these reasons, we need the broader concept of “informed choice,” which puts
the focus squarely on the client’s perspective in this situation. Ideally, of course,
the client would have made an “informed choice” prior to giving “informed consent,” but
experience has shown that this is often not the case.

Recap: “Informed choice” is the decision a client makes to use a particular
contraceptive method or seek RH services (or not). “Informed consent” is the
communication from the client that authorizes the provider to go ahead with the
procedure, or to indicate understanding and acceptance of the conditions of the method.

                          Principles of Informed Choice

              u   Have the right and ability to make their own decisions
              u   Are individuals with different needs and circumstances
              u   Need reliable, timely, and understandable information

           Client-Centered Communication                                             7-15

Much of our thinking about informed choice assumes that, in principle, the client has both the right
and ability to make healthcare decisions. Unfortunately, this fundamental principle does not exist
in all situations in which we work, and that is why informed choice is not immediately grasped or
embraced by service providers, the community, or even the clients themselves. Thus, the very
first hurdle that informed choice has to overcome is the biggest one, that is, to help service
providers, the community, and the clients themselves to see that: 1) women do, in fact, have the
capacity to make such decisions (especially when given the necessary tools, i.e. information); and
2) when they are not allowed to make these decisions (i.e., they don’t have the right), clients are
less willing to accept contraceptive methods, or to continue with their use, and more likely to use
them improperly—which means more risk and lower effectiveness. [This can be reinforced when
you discuss the importance of community involvement in client-centered communication, later in
this module.]

The second bullet underscores the importance of utilizing “eligibility criteria” as guidelines for
decision-making with the client, not as absolute dictates. Decision-making also requires thoughtful
communication between client and provider in order to get an accurate assessment of the client’s
“needs and circumstances.”

“… timely, and understandable.” The “timely” issue points to a problem in postpartum and
postabortion FP service delivery. Although those are, in many cases, ideal times to provide a
contraceptive method, they are not ideal times for decision-making, or for receiving and
understanding new information. Efforts need to be made to provide FP information and facilitate
decision-making in the antenatal period (for postpartum FP), and to try to create a less stressful
environment for counseling postabortion care clients. “Understandable” means that providers
have to learn how to communicate in simple termsthe problem is not the client’s inability to
understand; it is the provider’s inability to communicate!

                        Principles of Informed Choice
           u   Have the right to a choice of methods, whether through
               clinics, pharmacies or community distributors
           u   Need to know about the risks and benefits of available
           u   Must decide freely—without stress, pressure, coercion,
               or incentives

         Client-Centered Communication                                               7-16

A right to method “choice” may seem obvious, but in fact policies, logistics, provider bias, and
economics often result in limited method choice for large segments of the client population.

The next bullet raises the question of how much information is “enough”? Early approaches to
FP counseling resulted in all clients being told everything about every method before making a
choice. These approaches have been found to be too much—for clients, providers, and the
system itself. Still we find that, in general, clients are not told enough about the possible risks
and side effects of their chosen method, which often results in discontinuation if/when side
effects occur.

“… stress, pressure, coercion, or incentives.” “Stress” is usually considered to be internal
pressure on the client; stress can be caused by a pregnancy-related event (as noted
previously), or it can be the result of any physical or emotional situation that would cause
someone to make a decision they might regret later, such as loss of income, divorce or marital
problems. “Pressure” usually refers to the efforts of others (e.g., spouse, in-laws, or service
providers) to make someone decide a particular way. “Coercion” usually refers to negative
consequences (e.g., withholding social benefits if one does not accept family planning); and
“incentives” are the rewards (getting money, better housing, or educational benefits for your
children if you do accept family planning). [Some of these concepts are addressed further in the
slides on the Tiahrt Amendment.]

Of these six principles of informed choice, do any affect your program? How?

                        Consequences of Not Ensuring
                                    Informed Choice
         u   Unwanted pregnancy from improper method use
         u   Fear and dissatisfaction with side effects, leading to
         u   Potential health risks caused by failure to recognize
             serious warning signs, or by insufficient focus on
             prevention of STIs in method selection
         u   Dissatisfaction with quality of services or with method
             given, leading to drop out, poor word-of-mouth, low
             service utilization

       Client-Centered Communication                                   7-17

The importance of informed choice to client satisfaction is hard to prove
because most researchers generally expect bias in favor of the clinic during the
usual “satisfaction” surveys. Thus, we often end up measuring the impact of
informed choice by looking at tangible behavioral indicators, such as
continuation rates. Two such studies (cited in the following slides) have found:
• Increased continuation rates when clients are informed about side effects
• Increased continuation rates when clients are able to get their chosen method

However, we know that some decision-makers still tend to see informed choice
as a luxury of time and resources. For these folks, the negative outcomes of
not ensuring informed choice may have more impact.

The consequences of method failure or discontinuation often lead to unwanted
pregnancy, and to client dissatisfaction with the program—which can result in
low utilization of services and low contraceptive prevalence.

Extreme cases in which providers make decisions for clients and don’t even tell
them that a procedure has been performed (e.g., postpartum IUD insertion or
sterilization without informed choice and consent) can destroy entire programs.

                   Counseling About Side Effects
                 Decreases Discontinuation Rates
             Percentage Discontinuation
           50                                             Clients not
           40          37                                 counseled about
                                                          side effects
                              19                          Clients counseled
           20                                       14    about side effects
                         Niger               The Gambia

    Source: Family Health International, Network,
    September 1991.

     Client-Centered Communication                                             7-18

Another important area in improving quality of services is the content of
client-provider interaction. These data show us that failure to counsel
clients on potential side effects of their chosen method can result in 2 to
31/2 times higher discontinuation rates.

We see here that among clients not counseled about side effects in
Niger, 37% discontinued use of a method whereas only 19% of those
who had been counseled discontinued.

The difference is even greater in the data from The Gambia where
discontinuation was only 14 percent among those who had been
counseled about side effects.

                      Clients Who Receive Their
             Method of Choice Are More Likely to
                     Continue Using the Method


                   40                                                     Denied
          % of
       Continuous 20
           Use      0
                         Injection       Condom             Pill

   Source: Pariani, Studies in Family Planning, Nov/Dec 1991.

     Client-Centered Communication                                              7-19

The 1991 Pariani study shows that clients who receive their method of
choice are much more likely to continue using the method.

• Approximately 90% or more of the women who received their method
of choice were continuing with a FP method one year later.

• On the other hand, only 20% of the women who had not received their
method of choice were still using a method.

                      Threats to Informed Choice

                   What have you experienced?

     Client-Centered Communication                              7-20

§Based on these principles, what threats to informed choice have you
experienced in your program/clinic? A “threat” can be thought of as any
aspect of the community, institution, or service site that limits the
client’s ability to make an informed choice.

§Note: Next slide give illustrative examples.

                            Threats to Informed Choice
           u   Limited methods available
           u   Inadequate information and counseling
           u   Economic and/or population pressures
           u   Medical model of provider-based decision-
           u   Social inequities (e.g., those based on gender,
               age, socioeconomic status, or caste)

      Client-Centered Communication                                                        7-21

Although informed choice has been officially accepted as a guiding principle of RH services by
most countries of the world (per the International Conference on Population and Development
(ICPD), significant challenges remain in efforts to ensure informed choice at the service delivery
§The reality is that the choice of contraceptive methods in many settings is still very limited
because of resource constraints and sometimes provider or institutional bias.
§Counseling is widely regarded as the most effective means of ensuring informed choice, yet it
requires a commitment and investment of time and resources that are still beyond the scope of
many healthcare systems. Even when offered, the quality of counseling is poor in most settings,
and information provided to clients is less than adequate.
§Economic and/or population pressures still motivate governments to set performance
targets for family planning programs, based on demographics. Such targets put pressure on
service providers to recruit clients, rather than to help them to make decisions that are right for
their families.
§The medical training of most providers emphasizes using their knowledge and expertise to
make decisions in the best interest of the patient. This kind of training conflicts with the widely
accepted concept that family planning clients have the right to make their own decisions. The
conflict between client and provider decision-making can be especially evident when public
health problems such as maternal mortality and morbidity are weighed against the rights of
the individual. Programs that aggressively promote postpartum contraception to reduce
maternal mortality and morbidity, although well intended, often have resulted in pressuring
women to make major decisions at a stressful time, without the benefit of careful thought and
consideration of options.
§Social and gender inequities—like the lack of power and rights of women in society as a
whole—often combine with inadequate access to a range of family planning methods and
biases of health institutions, which makes true informed choice elusive.
Again, remember that client-centered communication is not the only factor that impacts on
informed choice. But it is the factor most directly under the control of the service
provider/healthcare system. So, client-centered communication is a critical element in ensuring
that quality of care efforts consider the client’s situation and needs.

                               USAID Requirements:
                              The Tiahrt Amendment
        USAID-supported FP projects must ensure that:
        u   Service providers and referral agents are not subject to
            targets or quotas
        u   No incentives are offered to individuals in exchange for
            becoming “acceptors”
        u   No incentives are offered to program personnel
            for achieving targets or quotas

    Client-Centered Communication                                  7-22

Informed choice, as an element of quality of care and supporting clients’
rights, is considered to be important by donors, politicians, and
policymakers, as well as clients. The importance of informed choice
was demonstrated by passage of the Tiahrt Amendment by the US
Congress in 1998. The Tiahrt Amendment applies to all family planning
programs supported by USAID. (“Support” includes training, technical
assistance, research, and provision of commodities.)

Let’s look briefly at how the Tiahrt Amendment affects client-centered
communication and supports the client’s right to make informed

Please note: The word “acceptors” is from the language of the
amendment [quotation marks are added here]. In order to make
communication and services more oriented to the client’s needs and the
client’s primary role in decision-making, the RH community in general
prefers to use the words “clients” or “users.”

                             USAID Requirements:
                            The Tiahrt Amendment
    u Do   not withhold rights or benefits from persons who
        decide not to become “acceptors.”
    uProvide comprehensible information to “acceptors”
      on health benefits and risks, adverse side effects, and
    conditions that would make use of their chosen
    method inadvisable.
    uProvide experimental family planning methods only
      in the context of scientific studies, and advise
    participants of potential health risks and benefits.

  Client-Centered Communication                                 7-23

Today’s presentation provides only a brief introduction to the Tiahrt
Amendment. A full presentation by USAID of the Tiahrt
Amendment will come at another time. Today’s presentation is
intended to discuss Tiahrt in light of informed choice and client-
centered communication.

                The Client and the Provider

    Client-Centered Communication                                7-24

Consider optional video or role play.

Remind participants where we are in the process. (“We’ve talked about
the client. Now, let’s explore the client in the CPI context.”)

Facilitated discussion: “I noticed when we were making our
introductions that there are a few medical clinicians here—doctors,
nurses, midwives. But despite the number of providers present, there
are even more clients in the room. More patients. Consider an
experience you have had as a patient, as a client. Something that
happened in the area of CPI. Think of both positive and negative
experiences. Please share your thoughts with a neighbor.

Any volunteers? (Ask for volunteers to share their experiences with the
group. Several participants will share their stories. Record responses on
flip chart.)

POINT: Let’s keep in mind both those perspectives—the client and the
provider perspective, as we examine what is important about effective
CPI and what makes providers effective.

                      Client-Provider Communication
                      is Key to High Quality Services
                              Supply         Client               Client


        Job               Provider                                Proper
    Satisfaction                                                   Use

                               Informed Choice
     Client-Centered Communication                                        7-25

Ask the group: “Do you think CPI matters? Why is CPI important?” (Write
answers on flip chart). Reveal and discuss slide.
Studies tell us that clients who have received adequate, accurate information,
based on their needs, and who believe that the provider is concerned about
their well-being, show greater satisfaction. They are also more likely to utilize
and continue the services. Several studies show strong positive health
outcomes and improved quality of care associated with effective provider
Compare the list with the participants’ comments. Ask participants if they have
observed this positive impact of CPI in their programs/countries.
Indicate that now you want to share some of the studies that helped us
understand the importance of effective CPI.
Interaction between clients and providers is a key component of service
quality. From Source: Abdel-Tawab, N. and Roter, D. 1996, Source: Kols, A.J.
and Sherman, J.E., 1998. And Rinehart, W., Rudy, S., et al, 1999, we know
that effective CPI increases:
• Providers’ effectiveness and job satisfaction
•The likelihood of informed choice
•The likelihood of client satisfaction
•Use of services
•Treatment adherence; client compliance with recommended health behaviors
•Continuation ( three-fold)
•Positive health outcomes

                    What Is Effective
               Client-Provider Interaction?
           u Principles:         Partnership and Process
           u Behaviors:          What effective providers
                                 and clients do

     Client-Centered Communication                             7-26

Introduce the subject by returning to the flip charted responses that
people gave when they talked about what effective CPI was in their own
experiences as clients or patients.

                                  Principles of Effective
                                              FP/RH CPI

         The Partnership Principle ÷

         u Each person is an expert.
         u   Each person has rights
             and needs.
         u   Each person has a role.

     Client-Centered Communication                                        7-27

Present the principles section by introducing the idea that you are going to talk
about two principles of effective CPI and then specific best practices. The
principles relate to partnership and process. We want to highlight them
because of the complexity of the issues they represent. In the partnership
principle, both the client and the provider bring expertise to the interaction.
The provider is the expert in medical information and services; the client
knows his/her personal history, situation and needs best. Sometimes clients
need advice about how medical information and services can best match their
needs, history and situation. Both the provider and the client need to care
about the outcome of the interaction.
Another aspect of partnership is the rights and needs that each person has.
(Link to previous client section if this was presented.) Show copy of
“Counseling,” Population Reports and last page of listed rights, IPPF example
or a local example.
A third aspect of the partnership idea is that each person has a job—each
person has a role in this interaction. We will talk more about the provider’s job
in a moment but now let’s look at what research tells us about the client. The
client’s job is to (from Pop Reports): state wishes, ask questions, describe
medical history as accurately as possible, and follow instructions. The final
aspect of this partnership is that both the client and the provider have
expectations of the interaction, based on gender norms and their past

Optional slides: Role of Clients, Role of Providers, Encouraging Clients,
Encouraging Providers

                                    Principles of Effective
                                                FP/RH CPI
                                      The Process Principle ÷
                                      u   CPI, especially counseling,
                                          is a dynamic yet organized

                                      u   The decision-making process
                                          is important.

      Client-Centered Communication                                           7-28

The Process Principle reflects the idea that a common CPI (particularly when
counseling) can have four major stages or activities: (1) establishing and maintaining
rapport, (2) exchanging information, (3) decision-making and (4) planning next steps.
An example of this principle in family planning is GATHER. GATHER is an important
effort to organize the process and help providers remember the important moments in
the interaction. The dynamic tension—between the habits of helping (certain phrases a
provider says or actions a provider takes that over time become work habits) and the
need to react to and respond to each individual as a person whose medical and
personal situation is unique—poses a challenge to the provider with each interaction.
Providers need both habits and responsiveness. They need communication habits that
make the work go easier (such as always asking, “Do you have a method in mind?”).
And, they need to be “present” with the client and responsive to the information they

Optional slide: The GATHER Method

The decision-making process is another aspect that we need to pay attention to.
(Link to previous information presented on the factors that influence individual
decisions, slide 7-9.) The decision-making process needs to be organized. Within the
client-provider interaction, a mini-process occurs. This process includes weighing
options and considering multiple factors in an organized way. Organization is important
because decisions cannot be based exclusively on medical information. The client’s
hopes, dreams, and history contribute significantly to whether or not the decision
translates into right action.

Decision-making poses some challenges (see next slide).

                                       Challenges to Making
                                        Informed Decisions
                                         u   Providers’ perceived
                                             lack of time
                                         u   Providers’ predisposition
                                             and skill
                                         u   Client’s inexperience
                                             with making medical-
                                             related decisions

   Source: Towle and Godolphin, 1999

    Client-Centered Communication                                        7-29

As Towle and Godolphin said in “a Framework for Teaching and
Learning Informed, Shared Decision-making” ( BMJ, Vol. 319, Sept. 18,

Challenges to putting informed, shared decision-making into practice
are providers’ perceived lack of time, providers’ predisposition and skill
and the client’s inexperience with making decisions about medical
things. The fact that it’s easier to accomplish informed, shared decision-
making if the client knows the method s/he wants makes a strong case
for putting the decision-making processes into action before the client-
provider interview.

                                Effective Clients…
u   Participate in
    personal/social exchanges
u   Ask questions
u   Clarify points/issues
u   State opinions
u   Express concerns
u   Provide essential

Client-Centered Communication                   7-30

                                     Effective Providers…
               u   Are responsive
               u   Manage the medical information
               u   Help the client plan next steps

           Client-Centered Communication                                   7-31

Brainstorm, if time permits, what participants think makes a provider effective in
  client-provider interaction. Write responses on flip chart or overhead and link
  them to the following three key points:

•    Effective providers are responsive to the needs of the client. They
    communicate respect and inspire trust.

(2) Effective providers communicate medical information so that the client
   understands and remembers it.

(3) Effective providers help the client plan next steps. The client leaves the
   interaction knowing what happens next, where and when to return, what to do
   about side effects, surprises and mistakes.

                                       Effective Providers...

                                            Are responsive
                                            u   Communicate respect
                                            u   Focus on the person
                                            u   Ensure client gets her/his

      Client-Centered Communication                                             7-32

Effective CPI is both an art and, to some extent, a science. We’ve learned about some
better practices that define a provider’s role when interacting with a client. Providers
who are effective when interacting with clients are responsive. They communicate
respect both verbally and nonverbally. They inspire trust, and they ensure privacy and
confidentiality. Let’s experience a bit of what we mean when we talk about the
importance of building a trusting relationship with a client.
EXERCISE: Ask participants to think of a secret–something they are or they’ve done;
something they hold close to themselves. Reassure them that you will not be asking
them to share the secret. So, they should not hesitate to think of a good one. Then ask
them to look at another person and answer to themselves, “What would it take for me
to tell that person my secret?” Ask for volunteers to share what they think the pre-
conditions would be for sharing their secret. THAT is what it takes for a client to talk
easily about her/his sexual behavior (the behavioral heart of reproductive health).
 Focus on the person. Effective providers don’t assume they know best or talk down to
the client. They understand that each encounter brings with it a combination of medical
and personal issues that are not only unique to that person but unique to that
interaction. People often complain that this level of quality interaction takes too long;
however, a study of physicians in Egypt, performed by Abdel-Tawab and Debra Roter,
which compared client-centered communication with provider-centered
communication, showed that “client-centered consultations were only one minute
longer than physician-centered consultations.” JHU/PCS research in CPI has shown a
40% increase in time—then a decrease—because good counseling is ultimately
efficient. Good counseling takes less time because ineffective behaviors are replaced
with effective behaviors. Use pre-consultation time (e.g., time in the waiting room)
more effectively; don’t ask questions that don’t relate to the client’s medical and
personal situation; ensure that the client gets her/his choice [informed and voluntary

                        What provider behaviors
                     contribute the most to client
       u   Key elements in client satisfaction (ranked
           highest by clients on different aspects of
       u   Perceived respect for the client by the provider
       u   Humaneness and technical quality of medical

       Source: Hall, J.A. and Dornan, M.C. 1988

     Client-Centered Communication                                7-33

Next two slides:

Think of yourself and your own experiences as a client, as a patient in a
medical environment. What did providers do that you liked? What didn’t
you like?
(Option: flip chart responses)

Research indicates that the key elements in client satisfaction (as
ranked highest by clients on different aspects of satisfaction) are
perceived respect for the client by the provider, humaneness and
technical quality of medical care. Data and quotes on provider skills and
effectiveness in client behavior change support this finding.

                        Contraceptive Continuation
                     Increases with Respectful and
                             Responsive Providers

           Relative risk of
            subsequent 1                                            continuation
           contraceptive                                            All-method
            continuation                                            continuation

                              Low          Medium           High
                                        Quality of Care
    Source: Koenig, Studies in Family Planning, December 1997.

     Client-Centered Communication                                                 7-34

• Both first-method and all-method continuation increases when
fieldworkers have better interpersonal skills.

                                     Effective Providers...

         Manage the medical information
         u   Avoid giving too much information.
         u   Don’t give inaccurate information or spread rumors.
         u   Consider information within the community context.
         u   Don’t use words that are too technical.
         u   Check for comprehension.

     Client-Centered Communication                                  7-35

An effective provider manages the medical information. Avoid too much
information. Also avoid information that is inaccurate or too technical.
We know that the way in which medical information is communicated
influences what the client understands and remembers. We know that
providers can be a source of inaccuracies and rumors–especially
concerning FP methods. And, we know that technical jargon does not
connect (i.e., the message is sent but not received). But also be careful
about using slang (especially when referring to body parts). Some
clients perceive slang as disrespectful and inappropriate. Check for
comprehension, using IEC materials and samples (if FP) to help the
client see what you are talking about. Even providing medical
information is a two-way street.

Recent studies (Intrah, Togo, 1999; FHI, El Salvador 1998; Population
Council, Kenya, 1997) all emphasize the crucial role of informal social
interaction in influencing the meaning clients attach to side effects, the
use of modern methods, and ultimately, the use of contraception. A
provider’s ability to understand the important influence of respected
sources of misinformation and provide corrections respectfully will
impact clients’ ability to change their minds and their RH behavior.

                                     Effective Providers...
         Help the client plan next steps.
         u   Talk about what happens next.
         u   Talk about where and when to return.
         u   Help the client plan what to do about side effects,
             surprises and mistakes.

     Client-Centered Communication                                  7-36

Bridge from visit to real life by planning Clients need to know what
happens next, where and when to return, what do to about side effects,
surprises and mistakes. Just as a strong link is needed between training
and on-the-job performance, a strong link is also needed between the
client-provider interaction and what that client then does in her/his real
life. (Refer to “Side Effects” slide 7-37. You may also refer to optional
slide 7-65.) Also, note previous comments about the community context.

Recent research (Intrah, 1999) on discontinuers (who discontinued
into in-need status).
An interaction among four factors caused these clients to stop using the
method: (1) husband opposition; (2) fertility and health concerns; (3)
side effects and (4) provider issues. In this research, women stopped
using the method—not because of the discomfort associated with
menstrual changes (hormonal methods)—but because of the way they
explained these changes to themselves. In this case, women who
stopped using hormonal contraceptives because of menstrual changes
interpreted these changes as signs of sterility or serious illness. It’s not
enough to explain side effects to clients, we need to understand how
women explain their bodies’ changes to themselves and how they might
interpret such changes.

                        Clients Need to Know About
                                        Side Effects

                      Country 1, 1996
                      Country 2, 1992
                      Country 3, 1992             Percentage of New
                      Country 4, 1993             FP Users
                      Country 5, 1989
                      Country 6, 1991
                                                  Informed About Side
                      Country 7, 1992             Effects
                      Country 8, 1994
                                                  in 11 Country Studies
                      Country 9, 1992
                   Country 10, 1991-92
                     Country 11, 1995

                                         0   50              100
 Source: Miller, Population Council, 1995.

  Client-Centered Communication                                       7-37

• On average, new clients are told about side effects one-half of the time
or less.

         “Nobody ever went to work to do a bad job”
                       ……. Edward Deming

    Client-Centered Communication                                 7-38

(Turn off slides/overheads) Talk with the group and discuss the
following three points:
(1) What are some of the investments and efforts that have been made
to improve CPI? Training? Mass or local community activities modeling
good CPI? IEC materials? Supervision support?
You’ve paid an enormous amount of attention to this issue. You have
invested in interventions to improve CPI. Would you like better results?
Are you seeing the kind of change you want?
(2) The providers we’re talking about come from cultures with deep
values about hospitality and kindness to strangers. These are people
who have loving relationships with their families, are members of the
community and—in these contexts—probably have a rich depth of
interpersonal skills.
(3) Do you agree with what Edward Deming said? (He was an
organizational consultant who strongly influenced post World War II
Japan and US business. Deming said, (turn slide/overhead on and
show his quote).

So, what are some strategies we can use to make a difference?

                 Client-Provider Interactions

               Strategies for Effective
           Client-Centered Communication

Client-Centered Communication              7-39

                                  Strategies for Effective
                         Client-Centered Communication
                 u   Organizational systems including health priorities for
                     service delivery, mission, values (especially gender
                     equity), political environments and resource bases
                 u   Policies →guidelines → job expectations
                 u   Performance feedback compared to standard
                 u   Physical work environment and tools
                 u   Knowledge and skills
                 u   Motivational systems

            Client-Centered Communication                                                               7-40

So, given all of that, why have we not made a bigger difference in developing the norm of effective client-
provider interaction? Let’s look at provider performance issues from a performance improvement perspective
and the factors that primarily influence performance. What are some activities that could occur to increase
effective CPI in each of these areas:
Developing (1) organizational support - Organizational support focuses on examining whether the organization
upholds or obstructs the desired performance (or best practice). Organizations have unique cultures, and
elements of organizational culture have profound effects on how work gets done. Organizational culture includes
elements such as strategic direction, leadership and management systems, communication and organizational
structure. At the provider level, one would consider the best practice in relation to recruitment and deployment
practices, supportive supervision systems, and the organization of work processes.
Defining (2) performance expectations and (3) integrating feedback - Information, in the form of clear
performance expectations and clear and immediate performance feedback, is crucial to the successful
integration of best practices. Information focuses on whether or not the organization (or the individual provider)
has clear information about what is expected, how effectively systems are operating, and how the organizational
performance relates to the desired FP/RH results. When relating effective CPI behavior to individual provider
performance, this factor addresses questions such as: How clearly do providers understand the organizational
goals and desired results? How well are they able to link their performance to these goals and desired
performance? How clear are providers about their job descriptions and performance expectations? When and
how do they receive feedback about how well their performance is matching expectations (effective CPI)?
Ensuring availability of (4) physical environment and tools - It is crucial to determine whether or not the
physical work environment, tools and supplies that are needed to implement and sustain effective CPI are
available. How does the physical environment affect and influence CPI? What kind of physical environment
supports and sustains effective CPI?
Assuring (5) knowledge, skills - Effective CPI often involves new information or new behaviors—whether or not
managers will implement new organizational systems or providers will need new technical competence.
Sometimes a best practice is to stop doing something. Training is the most common intervention to increase
knowledge and skills. Linking training to performance via learner support systems is the most powerful
intervention to ensure performance on-the-job. Knowledge and skills includes technical and clinical competence.
(6) Motivation - Motivation focuses on determining whether the organization is doing all it can to encourage and
support good performance. Do people have a reason to perform effective CPI? Does anyone notice? What are
the consequences of good performance? Does someone’s work become more difficult if s/he implements the
best practice? Is motivation sufficient to balance the scale in favor of desired performance? In short, good
performance should be met with positive consequences.

                         Strategies and Interventions
                               that Make a Difference

            Problem Solving & Tools                     Client Engagement

         Evaluation/Certification                           Community Engagement

         Supportive Supervision

                                          Q A           Provider Rewards/Engagement


                       Job Aids                         Organization of Work


     Client-Centered Communication                                                    7-41

The MAQ Initiative provides comprehensive illustrations of intervention
areas that are important to consider.

The following slides give a variety of examples of strategies that have
successfully improved provider CPI skills: distance learning, self-
assessment, peer review, peer support, supervision—all have made a

                     A Synergy of Distance Learning
                       Approaches Can Improve CPI
                        Peer review             Scheduling

                                              The GRMA / PRIME

                                       Self-Directed Learning /

          Learners evaluate           Client-Provider Interaction
                                      Adolescent Reproductive
                                           Health Initiative

           accomplishments                  a programme in six modules

               and module                                                        reading, exercises
                                                                                      and activities
                                                Module 1:
                                         Introduction to the SDL

                       visits                                             Paired learner

    Client-Centered Communication                                                                          7-42
                                                                         GRMA/PRIME SDL/CPI, Ghana, 1999

The Ghana Registered Midwives Association (GRMA) is a professional
association of private-sector midwives in Ghana. A needs assessment
done jointly by PRIME, GRMA and FOCUS in 1997 found that (1)
GRMA midwives needed to update knowledge of FP/RH and of national
service policies; (2) Counseling/CPI skills were weak. (We hoped to
prove that counseling and CPI (“soft” skills) could be improved through
a distance learning (DL) approach. And (3), adolescents remain an
underserved population in Ghana. MOH and GRMA recognized a need
to increase adolescent access to services.

Five distance learning modules were developed. Then multiple distance
learning methods were used to disseminate and support the learning.
This visual shows the implementation cycle for the modules in which
self-assessment, self-directed learning, paired learning, and coaching
are used to improve provider CPI skills with youth.

SDL=self-directed learning

                                                Distance Learning Improves
                                                          CPI Skills−Ghana
                                                (Mean score by competency area)
                                                                                   Learners (n=30)
                                                                                   Non-learners (n=30)
                       .79                                                           .76
                                  .60                                     .57

               Establishing   Gathering info/   Providing info/ Decision-making/    Planning
                 rapport         listening        explaining    problem-solving     next steps
                 p <0.01            n/s            p <0.01           p <0.05         p <0.01
          Client-Centered Communication                             GRMA/PRIME SDL/CPI, Ghana, 1999   7-43

(Roman numerals denote the section of the CPI observation instrument, described
below. Because of small sample sizes, evaluators used a non-parametric measure,
the Kruskal-Wallis H, although the results were identical when using the ANOVA
test, which assumes normal distributions.)
I. Establishing rapport and maintaining a good connection: Greeting,
confidentiality and privacy, caring manner, attentiveness (9)*
II. Gathering information and listening: Using open-ended questions, listening to
answers, asking about feelings, asking about sexually transmitted disease
(STD)/HIV risks (7)
III. Providing information and explaining: Encouraging client to talk; using visual
images, models, or samples; linking technical information to client’s situation; giving
accurate information concisely; explaining issues related to adolescents (14)
IV. Decision-making and problem-solving: Helping client identify decision areas,
helping client examine consequences, summarizing discussion, allowing client to
make decision without offering solutions prematurely (9)
V. Planning next steps: Confirming decision and checking understanding, referring
to other resources/support; thanking client for coming (6)

* number in ( ) = highest possible score

                                    Distance Learning Improves
       # of                            Critical CPI Skills−Ghana
                                                                           29               p <0.01
       30        28

       15              13          13
       10                                                                                      Non-learners
                                         5                                                 (n=30)
        5                                                   3

              Ensures          Asks about STD    Invites client to Thanks client/
            confidentiality   and HIV/AIDS risk bring/send others Invites return
                                                  GRMA/PRIME SDL/CPI Follow up and Evaluation, Ghana, 1999
     Client-Centered Communication                                                                       7-44

The bars represent 4 (of 12) counseling skills deemed critical. Self-directed learners
were more likely to perform as desired than the non-learners. (On the remaining 8
critical skills, no significant difference was found between the two groups, although
learner scores were higher in all categories.)

Ensures privacy: Privacy (confidentiality) is a big issue, especially for adolescent
clients. Privacy means that no one can hear or see the client during the counseling
session. Many of the midwives in the learner group rearranged their maternities to
provide a private space, sometimes incurring additional costs as a result.

Asks about risk for STD/HIV/AIDS: An entire module was devoted to this skill.
Learners showed improvement over the control and since the 1997 assessment.

Invites clients to bring/send others: This skill improves the chances that new
adolescent clients will come to the maternity and therefore promotes wider access to
services for adolescents. Encouraging clients to make recommendations and holding an
information, education and communication (IEC) session on adolescent RH (another
emphasis of the course) sends the message to young clients that services are available
for them in the community.

Thanks the client and invites her to return: Good business practice for these private
sector, entrepreneurial midwives.

                                  Radio Distance Education Program
                                      Improves Provider Counseling
                                                       Skills −Nepal
       Average Exam Score



                                 Before Distance   After Distance Education
                                                      MOH/JHUPCS/Varg/RCPMonitoring Data, 98-99
    Client-Centered Communication                                                                 7-45

An enter-educate serial radio soap opera entitled ‘Service Brings
Rewards,’ was designed as a distance education series to improve the
technical knowledge and counseling skills of rural health workers with
regard to family planning services.

This approach was used in response to two challenges:
1) lack of funds and difficult travel conditions meant that face-to-face
training was not a feasible program option, and
2) community members had expressed dissatisfaction with disrespectful
treatment and poor quality information received when they visited clinics
for family planning services.

Approximately, 75% of providers in the target area listened to the
series. The graph above shows the significant improvement in
counseling skills among those providers who listened.

                               CPI-focused Supervision Enhances
                            Doctors’ Communication Skills−Mexico
       communication behaviors
       per minute of interaction*   4
          Average # effective

                                                  With CPI Supervision

                                                              Without CPI Supervision
                                            Pre                                            Post
                                            Intervention                                   Intervention
                                                           Source:   IMSS/s, QAP, JHU/CCP, 1999
                                                           Note:     Control pre n=40; Control post n=61;
                                                                     Supervision pre n =56; Supervision post n=46
                                                                     *Facilitative communication is adjusted by length
     Client-Centered Communication                                    of consultation                                  7-46

In addition to some initial training, the improved supervision portion of
this work consisted of the following elements:
-1 hour of the existing, full day/monthly supervision visits, was
dedicated solely to client-provider interaction (CPI)
-Observed consultations
-Used a CPI checklist to assess doctors’ skills
-Provided feedback.

At the end of the supervision session, the doctor and supervisor
agreed on a couple of specific behaviors that the doctor would work on
over the following month and recorded the ‘assignment’ in a homework
log. Doctors’ improvement with these skills was assessed during the
next supervisory visit.

The impact depicted in this graph represents just 5 months of
intervention, or in other words, 5 hours of supervision per site total!
Qualitative data indicate that providers also noted the following
improvements in supervisor-provider communication:
                                    -Improved sense of ‘team’ working towards common goal
                                    -Joint problem solving
                                    -Effective feedback                                                                       7-46
                         Reinforcement is Critical to Sustain
                                  Provider Skills−Indonesia
                Percentage of provider
                facilitative communication
                                                                                                  Peer Support
           25                                                                                     Reinforcement

                Pre-training   Post-training                                                    Reinforcement
                                                                                                  (4 months)
                               Source:   Kim et al., International Family Planning Perspectives, 2000
                               Notes:    No reinforcement group: baseline n=123; post-training n=121; follow-up n=119
                                         Self-assessment baseline n=141; post-training n=142; follow-up n=142
                                         Peer support group baseline n=133; post=training n=143; follow-up n=142

    Client-Centered Communication                                                                                7-47

This study demonstrates:
-‘Synergy of interventions’ - increased and sustained impact of
strategically selected, multiple interventions
-Limitations of training in effective client-provider communications
without reinforcing interventions—note control group drops back to
baseline performance only four months after training

            The Client and the Community

    Client-Centered Communication                                7-48

Having considered the client and the provider, let’s look now at the
larger community issues that affect client-centered communication.

As we know, clients never make decisions in a vacuum. Providers are
also influenced by the community norms in which they live and work.
Communities contribute greatly in creating a positive social norm and
environment and influencing the extent to which effective CPI exists.
Therefore, informed communities are a critical part of client-centered

Two key roles communities can play are:
•to improve knowledge of RH and quality, and
•to support and encourage correct practices of RH and quality, through
many channels and means.

                            Informed Communities
        Informing communities in client-centered
    u   Changes social norms and expectations for client-
        centered communication and care
    u   Leverages sustainable resources that support informed
        choice, informed consent, and quality service
        environments and practices
    u   Encourages public endorsement of new practices

  Client-Centered Communication                                 7-49

The goal of client-centered communication for communities is to gain
sustainable resources and encourage public endorsements, which lead
to changes in social norms and expectations that support effective CPI,
informed choice and informed consent.

One key element in changing social norms and expectations is helping
community members to think of healthcare in the “rights” context. The
IPPF rights of the client can be a starting point for this new thinking,
with the addition of a gender equity perspective that includes the needs
of both men and women.

                       Community Advocacy for
               Client-Centered, Quality Services

      u   Credible advocates: satisfied clients,
          respected community leaders, women’s health
          and rights advocates, service providers,
          business/private sector
      u   Partnerships and coalitions: non-profits,
          commercial groups, employers, insurance
          agencies, schools, religious rights groups and
          advocacy groups

  Client-Centered Communication                             7-50

• Effective community advocacy must begin with credible advocates
who say the right message to the right decision-makers in the
community. Effective community advocacy involves demonstrating
community support through partnerships and coalitions. Media
advocates are key in disseminating messages quickly and repeatedly.

                                              Family Focus

     Client-Centered Communication                                7-51

This photo represents typical families in our programs.

§Nuclear rural family (top)
§Mother as head-of-household family (right)
§Nuclear urban family (bottom left)

The role of the “family” in client-centered communication includes:
§Decision-making between the couple and within the family
§Influence of the extended family
§Trusted neighbors as social supports
§Reinforcing (or challenging?) gender norms

                                    “The Buzz Outside the
          …the decision to…practice family planning is
           not made during a counseling session with a
           helpful [FP] nurse…[C]learly they also make
           their decisions based on the stories that
           circulate in their informal social networks,
           and they supplement the providers’
           instructions through conversations...with
           women whose bodies and circumstances
           they regard as being more like their own.
    Source: Rutenberg and Watkins, 1997

      Client-Centered Communication                                 7-52

This slide cites one study on the importance of the community in influencing
and reinforcing clients’ decision-making. Researchers in western Kenya in
1994-95 used household surveys, focus groups, and in-depth interviews with
women from four rural communities, plus providers, to examine the role of
informal social interaction in influencing the use of contraception. Instead of
finding a wild proliferation of “myths and rumors,” the researchers describe a
decision-making process that combines information provided by health
professionals with careful consideration of clients’ own and other women’s
experiences with contraceptives. Suggested applications of these findings
• Family planning programs should try to view women not only as individuals
but also as members of informal networks that are meaningful to them.
• Programs should address sincerely the concerns of both women and men
about side effects, rather than ignoring or dismissing them.
• Programs should recognize and address women’s concerns that methods
“rhyme” with their own bodies (by incorporating more “satisfied users” from
their own community into education and counseling).
• Programs should strive to reduce the social distance between the providers
and the community.
• More research on the status and motivation of providers should be
conducted in order to address, more constructively, the barriers between
providers and their clients.

                                  Community Groups
      Within the community-at-large and the
      community of providers, informing and working
      with community groups on the benefits of
      u   Effective CPI
      u   Informed choice and informed consent
      u   Quality of services

      actively supports changes in social behaviors and
      norms for acceptable client-centered care.

 Source: Piotrow, et al, 1997

  Client-Centered Communication                                 7-53

One way of addressing “the buzz outside the clinic” is to work with
community groups in developing and contributing to client-centered

• Community groups can be instrumental in organizing members and
the community at large in communicating new social norms and
creating a demand for effective CPI.

• Ask attendees if they have achieved this in their programs, and if so,

              Community Defined Quality
   In CDQ programs, community members and
     health service providers:
   ♦   Explore and share their perceptions of quality
   ♦   Establish partnerships to achieve jointly defined desired
       results related to quality care
   ♦   Emphasize mutual rights and responsibilities to improve
   ♦   Bridge the social, cultural, political, resource and other
       gaps between them
   ♦   Shift the concept of quality care beyond a health facility
       focus to include community and household levels

Client-Centered Communication                                   7-54

                                         CDQ Framework
      Building support involves               BUILDING SUPPORT
      obtaining commitment for
      participation and collaboration
                                         COMMUNITY             HEALTH
      from key members of the             DEFINED              WORKER
      community and the health system.    QUALITY              DEFINED

      Defining quality from different
      perspectives, while creating
      concepts for shared rights and           BRIDGING THE GAP
      Developing a shared vision for
      quality improvement between
      health workers and the community
                                                 WORKING IN
                                               PARTNERSHIP FOR
                                             QUALITY IMPROVEMENT
      Working QI Teams comprised of
      community members and health
      workers identifying, problem
      solving and implementing
      solutions                                Adapted for USAID/MAQ
                                               CDQ Subcommittee

Client-Centered Communication                                            7-55

                        CDQ                                   BUILDING SUPPORT

                   Framework                            COMMUNITY                HEALTH
                                                         QUALITY                 DEFINED

                                     Reduce unmet
              communities’                                      BRIDGING THE GAP
                                                                BRIDGING     GAP
                sense of
              ownership of
              health facility

                                                                 WORKING IN
                                                               PARTNERSHIP FOR
                                                             QUALITY IMPROVEMENT

                        Improve provider
                         job satifaction

Adapted for USAID/MAQ
CDQ Subcommittee         Shared rights and                      Improve client
                           responsibilities                      satisfaction
                          for better health
                              outcomes                                              Increase community
                                                                                     capacity for social
Client-Centered Communication                       Better health

                      Outcomes of Community and
                            Provider Action−Peru
   u   Posted services, prices and staff schedules
       to increase transparency
   u   Community emergency fund
   u   Jointly arranged community health education
   u   Improved transport arrangements
   u   Improved stock of medicines at lower prices
   u   Mechanisms to deal with complaints (for both
       providers and clients)
Client-Centered Communication                         7-57

                                        Positive Results
                                    Puentes Project−Peru

        u   Increased health service utilization
        u   Joint community/provider progress reviews
        u   Community members treated better
        u   Clients less afraid to go to health facility

    Client-Centered Communication                          7-58

This project has been labor intensive.

                           Community of Providers

    Client-Centered Communication                                     7-59

This photo represents a typical community of providers. Notice that all
members are represented—directors, physician, nurse, social worker,
outreach worker, pharmacist, laboratory technician, janitor/maid and

The healthcare community is responsible for:

§Changing provider practices and behaviors
§Changing organizational structures including health priorities for
service delivery
§Changing political environments and resource bases
§Rewarding positive changes

The question must always be asked: what can be done at the higher
levels of the healthcare community to encourage, support and promote
effective CPI, informed choice and informed consent?

                                    Where are you now?

         u   Where is your country/program now with
             client-centered communication?
         u   To what extent does effective client-centered
             communication extend to all clients (including
             groups such as adolescents, continuing
             clients, men and new acceptors)?

    Client-Centered Communication                                 7-60

Having considered the role of the client, the provider, and the
community in client-centered communication, take a few moments to
reflect and share with the group how these issues apply to the situation
in your country/program.

                                  Where are you now?

    u   What are the key constraints to effective CPI,
        informed choice and informed consent in your

    u   What opportunities exist for improvement?

  Client-Centered Communication                                   7-61

•Use the questions on this and the preceding slide to help attendees get
started in developing their action plans. Using the MAQ Lotus
Interventions (see slide 7-41):
1) Identify those interventions specific to the Client-Centered
Communication theme.
2) Select 4 to 5 interventions appropriate for your specific situation
(priority interventions).
3) Develop a prioritized action plan to improve/change/reprogram
approaches in this country program project.

• Break the group into smaller groups to work together if that would

      Based on your experience and this
      presentation, what are two things you plan
      to do to improve client-centered
      communication in your programs?

Client-Centered Communication                      7-62

                Optional Slides

Client-Centered Communication     7-63

                               Client-Provider Interaction:
                                   Providers Dominate the
                             Provider                                        Client

                                              Leads                                   Leads
                                               71%                                     8%

           Responses                                          Responses
              29%                                                92%

             Source:   Client-Provider Interaction Study, Indonesia, 1997.
                       JHU/PCS, BKKBN.
             Note:     Providers (n=23) Providers' Utterances (n=2,852)
                       Clients (n=36) Clients' Utterances (n=1,689)

    Client-Centered Communication                                                             7-64

This graphic gives an example of how managing medical information
doesn’t work. Why is this result (not such a great partnership) so
commonly seen? This study from Indonesia, conducted by JHU/PCS,
shows that the provider is in charge of the communication 71% of the
time, whereas the client is in charge of the interchange only 8% of the
time. Also, we have all heard stories about—or have witnessed scenes
of—incredible rudeness and insensitivity to clients.

                             Few Clients Receive Optimal
                       Information About Method Options
                                         and Side Effects

    Data from:   80
    Country 1
    Country 2    60
    Country 3
    Country 4
    Country 5

                       Offering at   At least 4   At least 3   Told how   Told side effects
                         least 4     in stock     mentioned     to use

Source: Population Council, 1998.
  Client-Centered Communication                                                               7-65

•Fewer than 40% of clients served in these countries are accurately told
how to use the chosen method or told of side effects.

                                          Role of Clients

           u To  prepare questions and concerns
             in advance
           u To state wishes and concerns clearly
           u To ask questions
           u To give medical history truthfully
           u To take brochures or other materials
           u To follow provider instructions
           u To return if they have any problems

    Client-Centered Communication                                7-66

§Given that every interaction includes two experts, each must have a
role in the dialogue. Listed here is the role of the client.
§Go through the bulleted items with attendees.
§Are clients assisted/taught to do the above in your country/program? If
so, how is this achieved? What empowerment approaches are used?
§Most importantly, how do clients do the above?

                                    Role of Providers

     u   To listen carefully to the client
     u   To explore topics and issues raised by the client
     u   To inquire in depth on the salient issues
     u   To be non-judgmental of the client
     u   To trust the client and s/he will trust you in
     u   To adjust to the client’s needs and situation

  Client-Centered Communication                                 7-67

• Providers are the other experts in the interaction. Go through the
bullets with attendees.

• Is this achieved in the attendees’ programs? If so, how?

                                  Encouraging Clients
     u   Clients should have the opportunity to choose
         freely whether or not to use family planning and
         what method to use from among those
     u   Services should be made available to those
         clients who want to use them.
     u   Information should be provided to clients to help
         inform their choice, including benefits to them
         and to their country of using family planning and
         the health benefits and risks of particular
  Client-Centered Communication                                7-68

• Clients must often be encouraged to exercise their rights.

                             Encouraging Providers

        u   Provider CPI training
        u   Supportive supervision system
        u   Performance evaluation
        u   Supportive personnel policies
        u   Quality services environment

    Client-Centered Communication                                7-69

§Providers need encouragement/motivation, which can come in various
forms (note five bullets on slide/overhead).
§Training of providers and the supervision/monitoring/positive coaching
of their performance is essential to performance improvement and the
empowerment of providers to respect and provide for clients’ informed
§Management and supervision roles are also key to assure providers of
needed and adequate supplies, equipment and supportive physical and
personal environments.

                                        The GATHER Method
            uG    - Greet Clients
            uA   - Ask clients about themselves
            uT   - Tell clients about choices
            uH   - Help clients make an informed choice
            uE   - Explain fully how to use the chosen
            uR   - Return visits should be welcomed
        Source: Rinehart, W. et al, Population Reports, 1998.
    Client-Centered Communication                                7-70

The GATHER method (as outlined above) is a well-established 6-step
process aimed at establishing a positive and comfortable client-provider
relationship, which produces satisfied clients who make informed
choices and who use their methods appropriately.


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