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Indonesia: Educate Clients to Communicate Their Needs to Providers
OR Summary no. 40

Background

Social norms often discourage family planning clients from communicating their needs to service providers; yet studies suggest that open communication facilitates better quality of care and possibly, better reproductive health outcomes. In 2000, Indonesia’s National Family Planning Coordinating Board (BKKBN) worked with Johns Hopkins University, with support from FRONTIERS, to test a “Smart Patient” intervention in which clients were trained to communicate more openly with family planning providers. The intervention assessed both information-seeking and longer-term continuation of contraceptive use by the trained clients. 

One provider who is predominantly providing family planning service at each of 64 clinics in East Java participated in the study. All the providers in the study had interpersonal communication and counseling training on family planning in the past 3 years. A total of 768 new or continuing family planning clients (about 12 per provider) were assigned to either the Smart Patient group or a control group (128 new clients and 256 continuing clients participating in both experimental and control activities). 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 them on HIV/AIDS. Intervention clients met individually with a client educator who provided individual instruction on three 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. Researchers conducted follow-up visits and used life tables to analyze contraceptive continuation eight months post-intervention.

Findings

• 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.
  
• Active communication by clients increased overall in the experimental group relative to the control group. Clients in the intervention group asked more questions (6.3 versus 4.9) and expressed more concerns (6.7 versus 5.4; see Figure).

• Providers were significantly more likely to give information and counseling tailored to individual needs to clients in the Smart Patient group. This suggests that empowering clients to participate in counseling sessions can in turn enhance providers’ counseling skills. However, the two groups provided about the same amount of technical and medical information.
  
• Eight months following the intervention, 6 percent 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 two types of patients one might expect to have fewer questions for providers: new patients with prior experience of family planning and continuing patients without any problems to report.
  
• Providers supported the principles of client-centered 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. Providers requested training or job aids so they would be better prepared to respond to clients’ questions.

Utilization

• Based on the study findings, BKKBN expanded the Smart Patient intervention by means of a mass media campaign and community mobilization 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.

Policy Implications

• It is feasible to change customary patterns of client-provider communication. Educational interventions directed to family planning clients can help them become better partners in their own care, assuming they meet with receptive providers.
  
• Client education interventions need to be accompanied by provider education and systematic support to ensure that providers are responsive and able to furnish accurate information to clients.

January 2004

Sources: Kim, Young Mi, Fitri Patjuk, Endang Basuki, and Adrienne Kols. 2003. "Increasing client participation in family planning consultations: 'Smart patient' coaching in Indonesia," FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 473 KB)

Kim, Young Mi et al. 2003. “Increasing patient participation in reproductive health consultations: an evaluation of ‘Smart Patient’ coaching in Indonesia,” Patient Education and Counseling. 50(2): 113-122.

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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