The Relevance of Client-Centered Communication to Family Planning Settings in Developing Countries: Lessons from the Egyptian Experience

From the Abstract: "Concern for client’s rights in the provision of reproductive health services in the developing world has prompted intense efforts by international experts to promote client-centered models of communication as a replacement for more provider-centered approaches. Nonetheless, the usefulness or feasibility of cross-cultural transplantation of client centered models of communication has not been examined.

The present study examines the feasibility, acceptability, and effectiveness of client-centered models of communication in 31 family planning clinics in Egypt. Consultations between 34 physicians and 112 clients requesting family planning methods were audio-taped and analyzed for physician communication style. Client satisfaction was measured through exit interviews. Method continuation was determined through home interviews at 3 and 7 months from the index visit.

Based on audio-tape analysis, two-thirds of physician consultations were characterized as physician-centered and one-third as client-centered. Client-centered consultations were only one minute longer than physician-centered consultations. A client-centered consultation was associated with a three-fold increase in the likelihood of client satisfaction and method continuation at 7 months. A high proportion of solidarity statements (positive talk) by the physician was predictive of client satisfaction whereas a high proportion of disagreement statements and directive instructions by the physician were predictive of method discontinuation.

The study findings suggest that in Egypt, as in more developed countries, client-centered models of communication are likely to produce better client outcomes than provider-centered models, with no substantial changes in the structure of services."

Based on an audio-tape analysis described in the study, an index of “client-centeredness” was developed. The “client centeredness” index is the ratio of client-centred to physician-centred talk.  "The client-centeredness index was computed as follows: total number of solidarity, information-giving and facilitation statements that were made by the physician in that consultation divided by the total number of questions, instructions, direction and disagreement statements made by the physician in the same consultation."

The data includes the following:
"On average physicians talked twice as much as clients, an indication of verbal dominance.... Physician talk was composed mainly of question asking (20%), facilitation (18%) and instruction statements (18%). Solidarity statements accounted for about one-tenth (12%) of physician talk. Client talk, on the other hand, was comprised mainly of bio-medical history-giving (44%)... Only one-tenth of client talk (11%) involved asking questions or making requests."

From the conclusions:
"The present study showed that family planning consultations in Egypt are predominantly physician centered and that client participation was to a large extent passive, mostly serving the doctor’s agenda, which is gathering information about the client. The above results are in agreement with those from other developing countries.....

Findings related to association between client-centered counseling and client outcomes were somewhat unexpected, given the hierarchical nature of the Egyptian society. But it appears from this study that in Egypt, as in more developed countries, the patient-centered model of care delivery is associated with better client outcomes than provider-centered care. Clients were more likely to be satisfied and to continue using a family planning method if the doctor consultation was client-centered; she was less likely to continue using the provided method if the provider was directive or negative....

The findings of the present study have significant implications for program managers in Egypt as well as other developing countries. Managers of family planning programs should proceed with more confidence to establish client centered models of communication in family planning clinics. Training of health care providers should emphasize the importance of treating clients nicely, involving clients in decision-making and treating clients as a complete human being who has physical, emotional and social needs. In addition, coordination should be established between the content of technical training courses for physicians and those on counselling and interpersonal communication to avoid any inconsistencies that could lead to more physician-centered rather than client-centered behaviors by physicians...."