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Enhancing Quality for Clients: The Balanced Counseling Strategy
Program Brief No. 3, July 2003

Part 1: Improving Counseling in Peru

The balanced counseling strategy originated in research conducted in Peru to assess providers’ compliance with national norms for family planning care. Peru has promoted family planning for decades through its National Family Planning Program, a division of the Peruvian Ministry of Health (MOH). 

In the late 1990s the Ministry modified its policies to enhance the quality of family planning services. A major rationale for this policy shift was an increased emphasis on informed choice for each client.  New guidelines, issued in 1999, reflected the reforms and outlined a specific counseling process. The MOH directed providers to follow a five-step strategy consisting of: (1) a warm welcome; (2) diagnosis of the client’s needs; (3) assistance to help the client choose a method; (4) assurance that the client understood; and (5) a warm farewell (see Figure 1). Providers were instructed to complete a specific number of tasks, and to spend an average of 15 minutes with each client. Most providers had access to a flip chart depicting available methods for use during counseling sessions (MOH 1999).

Figure 1. Five-step counseling process outlined in the 1999 MOH guidelines Source: MOH 1999

The MOH and the Population Council conducted a study in 1999 with two goals: to assess Peruvian providers’ compliance with the new guidelines; and to develop methods for monitoring compliance with the guidelines. Three main findings emerged:

• Providers failed to discuss clients’ wishes. At the beginning of the counseling session, providers asked mainly medical questions (such as the date of the client’s last menstrual period) and failed to ask the client basic questions about her reproductive intentions—such as whether she wanted more children, or whether her partner cooperated in contraceptive use. Furthermore, the information obtained from the client (such as her weight) often had limited practical use in the selection process.
  
• Providers often gave excessive information. Providers furnished excessive detail on most of the 11 methods available in MOH clinics—whether or not they suited the client’s needs. This overloaded clients with more information than they could remember, and much that they could not use.
  
• Information provided on the chosen method was sparse. Most of the counseling time was spent describing numerous method options, while important information for both provider and client—such as contraindications, use instructions, side effects, and warning signs related to the chosen method—was neglected.

Because of these weaknesses in counseling, clients interviewed after the consultation knew little about the method they had chosen (León et al. 2001; León et al. 2003b). Take-home pamphlets, which might have provided further information for this mainly literate client population, were either unavailable or incomplete.

Two data collection methods—exit interviews with clients as they left the clinic, and the use of trained simulated clients presenting a designated profile and method request—proved reliable for monitoring the content and quality of the client-provider exchange during counseling (León 1999). These two methods were used in subsequent studies.

Improving Opportunities for Choice: The Balanced Counseling Strategy  

1. Greet the client warmly;
    
2. Assess her needs based on her stated reproductive intentions and, with the client, discard methods that are irrelevant to her needs;
    
3. From among the remaining methods, offer and discuss a set of methods suited to the client’s needs, and ask her to choose a method;
    
4. Focus on the method chosen, beginning with screening for contraindications (verifying comprehension and choosing an alternative method if necessary), and including detailed information on the use, side effects, and warning signs of the method; and
    
5. Provide oral and written follow-up instructions to ensure that the client can use the method safely and continuously at home, as long as her reproductive intentions remain stable. 

Figure 2. Balanced counseling model with specific tasks for providers in Peru Source: Leon et at. 2003.

Supporting the Strategy: Job Aids

To support provider compliance with the balanced counseling strategy, researchers also developed and pre-tested three job aids: 

1. A poster describing the new counseling model, with step-by-step guidance for the provider.
   
2. A set of 11 palm-sized cards, one per contraceptive method offered. (Methods offered in Peru included the intrauterine device (IUD) as well as barrier, natural, and hormonal methods. See the sample cared on the injectable method, Figure 3) The provider would display the cards at the start of counseling, discarding those that were identified as irrelevant and retaining those describing relevant methods.
   
3. A set of 11 four-page pamphlets, one for each method available, describing each method, its use, benefits, disadvantages, and contraindications. Each client receiving a method was to receive the corresponding pamphlet to take home. 
   

Figure 3. Method card presenting the DMPA injectable contraceptive (front) and describing four essential aspects of the method (back) Source: Leon et al. 2003b

Testing the Strategy and Job Aids in Peru

Between 2000 and 2002 the Population Council conducted an experiment to test the effectiveness of the balanced counseling strategy and the accompanying job aids. Researchers randomly assigned 12 of Peru’s 34 regional health directorates to an experimental group, after matching them to 12 comparable control directorates. The experimental and control directorates were matched on the basis of geography, culture, and client volume. 

Training workshops

Between June 2000 and March 2001, project staff conducted two workshops on the balanced counseling strategy. The first workshop, a two-day event, targeted providers and involved about 25 providers from each of the 12 experimental areas. The second workshop involved both MOH family planning coordinators and providers: coordinators received two days of training and then provided in-service training to providers. Seventy-five family planning coordinators and 278 providers (of whom 60% had participated in the first training session) attended the second workshop. Each participating provider received the counseling poster, method cards for use in the clinic, and a year’s supply of pamphlets. 

Testing the intervention’s effects

From April to September 2001, researchers collected data to measure the effect of the intervention. The experiment compared the performance of providers in the control clinics with that of providers in the experimental clinics. The researchers focused on three aspects of the intervention: (1) changes in quality of care; (2) changes in providers’ and clients’ satisfaction and knowledge; and (3) consequences for the services in terms of time and patient flow.

Observers, interviewers, and simulated clients recorded the quality of care provided based on eight sets of indicators derived from the MOH’s 1999 guidelines (see Box). Observers of client sessions assessed the quality of the interaction between providers and clients using a checklist based on the indicators. Simulated clients filled out a more detailed inventory with 72 items pertaining to quality (León et al. 2003b).  

Findings

Quality of care

• Quality of care improved—if providers used the job aids. The post-intervention findings showed statistically significant improvements within the experimental group as a whole, compared to the control group. These improvements were greatest when clients chose the IUD or hormonal methods—possibly because of the greater complexity of instructions for using these methods, compared to instructions for barrier and natural methods. Within the experimental group, the largest improvement took place among providers who used the method cards and the pamphlets. Reports from simulated clients showed that following the intervention, job aids users scored 68 percent higher than experimental providers who did not use job aids—and nearly 83 percent higher than providers in the control group (see Figure 4).

Figure 4. Quality scores of Peruvian providers at experimental and control clinics by use or non-use of job aids Source: León et al. 2003b.

• Not all providers used the job aids. Simulated clients reported that 64 percent of providers used one of the two job aids, and only 37 percent used both the cards and the pamphlets. When asked why they failed to use job aids, providers most commonly replied that they did not know about them, or that the aids were not available at the facility.
  
• The intervention benefited the providers who used the job aids. Providers who did not use the job aids did not benefit from the training. They performed at about the same level as providers in the control group. The providers who did use the job aids were already performing better at the time of the pre-intervention test; and their performance improved significantly when they used the counseling strategy combined with the job aids.
  
• Labor status was the most consistent predictor of higher performance. Providers under temporary contracts were more likely to use job aids than tenured employees. Nearly half (46%) of contract providers used the job aids, compared to only 27 percent of tenured providers. It may be that the absence of secure employment constituted an important incentive for compliance. This is a significant finding because about two-thirds of MOH providers were contract employees (León et al. 2003b).

Knowledge and satisfaction 

• Effects on clients’ knowledge were mixed. Researchers assessed clients’ knowledge of their chosen method during exit interviews. The knowledge of clients requesting the IUD and hormonal methods was significantly higher when they consulted providers who used the job aids. However, the knowledge of clients who chose other methods did not differ significantly between control and experimental groups.
  

Consequences to programs

• Program consequences for providers’ time and client flow were acceptable. Use of the balanced counseling strategy and the job aids added an extra four minutes, on average, for each counseling session. The increased time spent, however, did not detract from the number of clients who received family planning service either on a daily or quarterly basis, probably because new family planning clients constituted a low proportion of the total clinic clientele (estimated at 10 to 15 percent [1]). The intervention did not effect discernable changes in method mix; thus no additional funds were necessary to purchase supplies or methods (León et al. 2003b). 

Costs of the First Year of Implementation

Researchers also conducted an economic analysis of the costs of implementing the balanced counseling strategy with its accompanying job aids in Peru. The overall cost of designing and implementing the strategy was approximately US$80,000. Development of the job aids and training curricula accounted for about $15,300 of this cost, while training (time, travel, per diem for consultants and participants, and a one-year supply of job aids) accounted for the remaining $64,000. The development costs would likely be much lower in the event of a scale-up.

The review included a sensitivity analysis to determine the cost of reproducing the job aids in the large numbers typical of a larger-scale implementation. During the experimental phase, the project produced 200,000 method pamphlets to supply about 300 clinics; but a scale-up process will involve as many as 2,000 clinics. The per-unit cost of the job aids decreases as more are produced. For example, a set of job aids for each provider (including 11 method cards and a poster) costs $0.50 per set for 1,000 sets (totaling $500), and $0.20 per set if 10,000 sets are produced (for a total of $2,000). The per-unit cost of each method pamphlet is $0.03 if 100,000 pamphlets are printed, but drops to $0.02 if 500,000 are produced (for a total of $10,000). It is vital to understand and incorporate these costs in planning for broader implementation, as the presence and use of the job aids significantly improve providers’ performance.[2]

[1] Federico León, personal communication, June 2003.
[2] Federico León and John Bratt, personal communication, June 2003.

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Hard copies available free of charge from frontiers@popcouncil.org; also available in PDF (520 KB)

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Frontiers in Reproductive Health (FRONTIERS)
Population Council
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This page updated
03 January 2009