Towards client-centered counseling: Development and testing of the WHO Decision-Making Tool
Introduction
Nowhere is client-centered counseling more appropriate and valuable than in choosing a contraceptive method. For many women and couples, decisions about contraception and reproductive choices are life-determining decisions. Women and men can benefit from their health care provider's help to make well-informed, well-considered choices that suit their needs, preferences, and concerns.
Informed choice has long been a fundamental tenet of family planning and a defining element of quality of care [1]. The principle encompasses not only an initial choice of whether and when to use contraception and if so, which method, but also a continuing option to stop or to switch methods as one's needs and preferences change [2]. Informed choice has roots in human rights but also has a pragmatic aspect: When women use the method that they want, they are more likely to continue using it [3].
Contraceptive choice is appropriately the user's decision. There are a number of contraceptive methods to choose among, and their effectiveness and safety do not vary so much as to override the user's preferences in most circumstances. Medical conditions that rule out certain methods are uncommon, particularly among young women. Furthermore, because contraception is linked to sex and reproduction, choice and use of a method can be highly sensitive to a user's important personal and social concerns.
In conventional provider-centered family planning care, based on a medical model of treatment decisions, the provider makes the decision on what is best for the client without eliciting her or his preferences. With the programmatic emphasis in the past several decades on informed choice in family planning, some providers have shifted to the other end of the spectrum, giving clients standard or routinized information on all available methods and leaving the client to make decisions unaided [4]. In between these two extremes lies a model of client-centered care where the decision-making process is shared by the client and provider: the provider facilitates the process and the client actively participates. The provider offers technical expertise while the client is the expert on her or his own needs, situation and preferences. This view brings into focus both the client's role in decision-making and the goal of the decision-making process: to match care with clients’ preferences.
Client-centered counseling can improve satisfaction with and continued use of a contraceptive method [5]. To this end, the World Health Organization (WHO) began in 2001 to develop a job aid to support contraceptive counseling, the Decision-Making Tool for Family Planning Clients and Providers. This article will describe how the tool applies counseling principles; review field-test findings; and discuss challenges and requisites for moving to shared decision-making.
Why can a job aid be particularly helpful to counseling on family planning decisions?
First, as noted, there are many contraceptive methods to choose from. While this can facilitate finding a method that suits one's circumstances and preferences, it also complicates decision-making. Methods have a range of attributes that can be important to potential users, such as how the method is used, effectiveness, side effects, and whether it protects against sexually transmitted infections. For a client, a decision-making aid can help to clarify what he or she wants in a method, to weigh the pros and cons of different options, and to understanding how the options would affect her or him personally [6]. With the use of a decision-making aid, clients can feel confident that they have the information necessary to make a decision. For providers, who may lack the training and experience to offer good-quality counseling, job aids can help them provide more accurate, structured and complete information; can reduce the need to memorize information; and can help assure compliance with standards [7], [8], [9], [10].
Second, job aids, if so designed, can provide a process that simultaneously guides decision-making for the client and structures counseling for the provider. In much of the world, family planning clients are not accustomed to playing an active and assertive role in health care decision-making. A decision-making aid can embody an interaction that gives the client opportunities to participate or even gently necessitates it. For providers, job aids can be normative. They can guide the provider to better counseling, away from practices that dominate or distort decision-making, and shift the locus of decision-making towards the client.
The Decision-Making Tool incorporates WHO's evidence-based recommendations regarding who can use and how to use contraceptive methods, and it aims to facilitate application of these recommendations during the client–provider interaction [11], [12]. At the same time, it reflects evidence on best practices in family planning counseling (see Table 1).
The tool is a flipchart designed for use in the counseling session. For each page addressed to the client, there is a corresponding page for the provider on the other side of the flipchart. For the client, the tool serves as a decision-making aid, while for the provider it serves as a job aid. The client's pages raise key questions and provide brief information. The provider's pages offer prompts, suggested wording of responses, and information for answering questions and concerns.
The Decision-Making Tool was developed with the input of international experts, family planning providers, program managers, and clients. It has been translated into nearly 20 languages and has been introduced in nearly 50 countries. It was developed as a generic or prototype tool; WHO provides materials on how to adapt it to a specific local context and how to introduce it, including a training guide and training materials.1
The Decision-Making Tool supports the client and the provider in complementary roles. It guides the client to better practices – more participation in discussion and decision-making, greater self—awareness, and, underlying that, implicit recognition that she has a right to put her own needs and preferences first. At the same time, the provider is channeled into and supported in the roles of informant and guide to the decision-making process. Thus, the provider is given an important role that is an alternative to the role of decision-maker. The Tool helps the provider guide the client through a process of consideration and decision-making without imposing the provider's own judgments or opinions on the client's decision itself. In other words, the Tool specifies a process without determining its outcome.
The Decision-Making Tool is different from most other family planning counseling aids. The Tool was developed deductively from an explicit set of principles that define client-centered counseling (see Table 2). These principles focus on communication skills, effective interaction, and empowerment of the client—both to participate in the counseling and to make personally appropriate decisions.
Thus, a basic principle behind the tool is that the client's needs and interests guide the course of counseling. The structure of the flipchart enables this. It contains multiple, branching pathways available in the form of tabbed sections of the tool. While multiple pathways are common in computer-based decision aids, the Decision-Making Tool applies this approach in a printed tool, suited to health care facilities that do not have computers available. The process begins with the provider asking the client why she or he has come, thus getting immediately to the client's purpose. This approach replaces the usual list of standard questions, which may seem—and be—irrelevant to the client.
Continuing in this fashion, the tool poses questions for the client throughout the course of counseling. The provider, rather than flipping through all the flipchart pages one after another, uses the client's responses to determine the path of the discussion by using the tabs. For example, because research finds that women who receive the contraceptive they want will use it longer [13], the provider first asks if the new client has a method in mind, rather than presenting her with an array of options. If she does have a method in mind, counseling focuses on that method and whether it truly suits her.
For clients who do not have a method in mind, the tool provides the information needed to make a choice. It is designed to help providers tailor the information for the particular client rather than describing each method without regard to the client's interests. Further, the counseling process aims to help the client become more aware of what is important to her in a method and to formulate a sense of her own needs and preferences.
Clients are more satisfied with their choice of a method when they are told what to expect when using it. In particular, women who have been counseled on side effects are more likely to continue using the method when they experience them [20], [21]. The tool emphasizes discussing with clients what to expect, countering the common provider practice of not mentioning side effects for fear of frightening the potential user [22].
In a mature family planning program, the majority of clients are returning clients. Few counseling aids, however, address the return visit. Discussion at a return visit could seem more open-ended than discussing initial method choice. In just two pages for each method, however, the Decision-Making Tool offers a process for addressing returning clients’ varying needs, including addressing side effects and problems using the method, if they have occurred. Thus, the tool responds to a client's changing needs over time, including switching methods.
Section snippets
Quantitative evaluation and field testing of the WHO Decision-Making Tool
In Nicaragua [23], Mexico [24] and Indonesia (unpublished) we studied whether and how the Decision-Making Tool can improve family planning counseling. These studies had both qualitative and quantitative components. The qualitative component, discussed in the section on practice implications, sought to understand the strengths and weaknesses of the Tool and how it could be improved. The quantitative component sought to find out whether use of the Decision-Making Tool improved the quality of
Evidence of improvements in providers’ counseling
The findings from all three countries indicate that, in general, the introduction of the Decision-Making Tool, after brief training for providers and a period of practice on the job, improved providers’ counseling performance during family planning consultations. For providers the Tool proved an effective job aid. Providers’ overall decision-making scores rose significantly from the baseline rating to the post-intervention rating in Nicaragua (28.6–36.8, p < 0.001), in Mexico (20.0–33.8, p <
Discussion
Experience suggests that a systematic process for introducing guidelines is more likely to lead to changes in policies and practices than only introducing a tool or retraining providers [29]. A well-planned and participatory adaptation process helps to ensure that new guidance is accepted, promoted and utilized by providers. WHO has developed a guide to support national introduction of reproductive health guidelines and tools. It recommends a process to adapt and introduce generic guides such
Conflict of interest
None declared.
Funding
None declared.
Acknowledgements
None declared.
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