Increasing Client Participation in Family Planning Consultations: "Smart Patient" Coaching in Indonesia

This 39-page report explores one type of strategy for increasing interpersonal communication between family planning (hereafter, FP) providers and their clients. The intervention described here was carried out by Indonesia's National Family Planning Coordinating Board (BKKBN) and Johns Hopkins University Center for Communication Programs (CCP), with support from FRONTIERS, in an effort to test a "Smart Patient" intervention in which clients were trained to communicate more openly with FP providers. This project was motivated by research showing that patients who actively communicate with doctors, nurses, and other providers experience better quality of care and possibly, better reproductive health outcomes. Yet studies have found that health care and FP clients in both developed and developing countries generally participate little in consultations. For instance, they ask few questions, keep their responses brief, seldom request information or seek to clarify instructions, and rarely disclose - fully - their concerns, expectations and preferences.

To address this situation, project collaborators identified one provider who is predominantly providing FP service at each of 64 clinics in East Java to participate in the study. All the providers in the study had had interpersonal communication and counseling training on FP in the past 3 years. A total of 768 new or continuing FP clients (about 12 per provider) were assigned to either the "Smart Patient" group or a control group. Clients in the control group were given a leaflet on HIV/AIDS to read. The educator remained with the client for about 15 minutes while she read the leaflet and answered any questions the client had, but did not actively educate the client on HIV/AIDS. Intervention clients met individually with a client educator who provided individual instruction on 3 basic skills: asking questions, expressing concerns, and seeking clarification. Educators also helped clients formulate specific questions for the provider, rehearsed the questioning using role-playing, and encouraged use of these new skills during counseling. The intervention added about 20 minutes to the visit.

The study assessed both information-seeking and longer-term continuation of contraceptive use by participants. (To assess the latter, researchers conducted follow-up visits and used life tables to analyse contraceptive continuation 8 months post-intervention.) In short, evaluators found that, after individual coaching, FP clients asked providers more questions about their treatment or chosen method, but long-term contraceptive continuation rates did not change. Selected results include:

• Clients found the "Smart Patient" coaching valuable, particularly the interactive role-playing. In exit interviews and focus groups, nearly all women agreed that the coaching increased their confidence about speaking to providers, asking questions, and requesting clarification.
• Compared with clients in the control group, those who received "Smart Patient" coaching raised significantly more questions (6.3 vs 4.9) and concerns (6.7 vs 5.4) during the consultations, but they did not seek clarification or volunteer information more often. The coaching narrowed differentials in active communication by client type, age, and assertiveness, but it widened differentials by client education and socioeconomic class.
• Coaching was associated with more tailored information-giving by providers (24.9 vs. 21.1). This suggests that empowering clients to participate in counseling sessions can in turn enhance providers' counseling skills. However, the 2 groups provided about the same amount of technical and medical information.
• 8 months after the intervention, 6% of all new family planning clients had stopped using contraception, mainly due to health concerns and side effects (53%). The proportion of clients still using a method was slightly higher in the intervention group (89%) than in the control group (85%). This difference was marginally significant (p=.08).
• Women age 35 or older benefited more from coaching than younger women. Coaching also had a significant impact on the 2 types of patients one might expect to have fewer questions for providers: new patients with prior experience of FP and continuing patients without any problems to report.
• Providers supported the principles of client-centred counseling, but often lacked the ability to implement such counseling. Observations by researchers showed that providers sometimes gave incomplete or inaccurate responses to clients' questions.

Based on the promise of the study's findings, BKKBN expanded the "Smart Patient" intervention by means of a mass media campaign and community mobilisation by local workers. The "Smart Patient" model has been revised to furnish self-learning materials that do not require literacy or the presence of an educator. BKKBN will also provide job aids and training to enable providers to respond accurately to clients' questions. In light of the above findings, and these efforts to refine the programme, the authors conclude that "Educational interventions directed to family planning clients can complement and reinforce provider Interpersonal Communication and Counseling (IPC/C) training by giving clients the confidence and the communication skills to take advantage of increased opportunities for participation."