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Peru: Targeted Counseling Enhances Client Knowledge and Contraceptive Use
OR Summary no. 38

Background

It has been long hypothesized that improved quality in the client–provider interaction (CPI) causes increases in family planning method use and client knowledge; but data supporting this hypothesis are scarce.

In 2000 the Peruvian Ministry of Health (MOH) requested assistance from FRONTIERS in improving the quality of CPI at family planning clinics. Previous research (see León et al. 1999) showed that providers gave excessive detail about all available family planning methods, and too little detail about the method chosen by the client. As a result, clients appeared to suffer information overload and impaired learning.

To address this weakness researchers tested the “balanced counseling strategy,” a type of algorithm used in conjunction with job (visual) aids for providers and method pamphlets for clients. Twelve of Peru’s health districts were randomly assigned to an experimental group and 12 to a control group, with 334 centers participating. A total of 279 providers (about one from each center) and 75 supervisors received training on use of the algorithm and job aids. Simulated clients and observers recorded provider behavior following the training. Client contraceptive use, achievement of reproductive goals, and knowledge were tested following the intervention and 13 months later.

Findings

• The balanced counseling strategy improved family planning use at 12 months when compared to the control group. However, the differences were small in practical terms (81% versus 78%). The study examined quality-related discontinuation, such as discontinuation because of side effects or inconvenience of use. Quality-related continuation, which can be modified by program interventions, was higher in the experimental group (see Figure).
   
• Attainment of a woman’s reproductive goals is widely considered to be the most important program outcome. The study observed attainment of reproductive goals over one year. The CPI intervention failed to influence goal attainment when goals were defined at the time of first contact with the program.  
   
• Client knowledge of the IUD and hormonal methods was higher in the experimental group 13 months after the intervention (averaging 12.2 versus 10.4 on an 18-point scale). Differences in knowledge of modern natural methods and barrier methods (the least-used method types in Peru) were not significant.
   
• Provider compliance was low. Only 37 percent of all experimental group providers used the complete balanced counseling strategy with both the job aids and the pamphlets. CPI improvement and higher client knowledge occurred only when providers used all components of the strategy. A later test of the strategy in Guatemala added four supervisory visits to the intervention and improved provider compliance to about 70 percent (see León et al. 2003, Program Brief 3).

Utilization

• Thus far, the balanced counseling strategy has been implemented in two types of settings and the results have been markedly different. One involved small primary health centers in Peru and Guatemala. Studies in these settings showed clear improvements in quality of care. However, when tested in large hospitals in the same countries, evidence of improvements was weak, and some results were ambiguous or negative.

Policy Implications

• The balanced counseling strategy improved client behavior to a greater or lesser extent depending on program factors other than CPI per se. Experimental group clients who selected the IUD or a hormonal method had greater knowledge of their method than control group clients, even though only a minority of providers complied with the balanced counseling strategy. Although important differences in 12-month method use were not found, the strategy provides one model for programs attempting to improve client knowledge.
   

• The strategy appears to work better in a primary health setting than in large hospitals, and additional program changes such as improved supervision are required to maximize provider use of the algorithm and job aids.
   

• The study is one of only a few experiments to provide evidence that changes in the quality of CPI can significantly affect contraceptive continuation, albeit to a small extent.

March 2004

Sources: León, Federico R., Santiago Roca, Alex Ríos, Adriana Zumarán, and Ana Rosa Feijoo. 2003. "One-year client impacts of quality of care improvements achieved in Peru," FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 931 KB)

León, Federico R., Alex Ríos, Adriana Zumarán, Marisela de la Cruz, Carlos Brambila, and John H. Bratt. 2003. "Enhancing quality for clients: The balanced counseling strategy," FRONTIERS Program Brief no. 3. Washington, DC: Population Council. PDF (520 KB)

León, Federico R. 1999. "Providers' compliance with quality of care norms," FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 2.5 MB)

This project was conducted with support from the U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT under Cooperative Agreement Number HRN-A-00-98-00012-00.
 

For more information contact:
Frontiers in Reproductive Health (FRONTIERS)
Population Council
4301 Connecticut Ave. N.W., Suite 280
Washington, DC 20008 USA
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: frontiers@popcouncil.org

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This page updated 1 May 2006

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