International Family Planning Perspectives in Ecuador, Uganda and Zimbabwe, fewer than 75% of clients in each country were given any information about the contraceptive method they re c e i v e d . 5 Results are no diff e rent when the specific content of counseling is examined. For example, to probe how well clients w e re being counseled about when and how to switch methods, a study carried out in the coastal province of Santa, Peru , used simulated clients who had recently initiated pill use and who complained of headaches. Of the 54 Ministry of Health p roviders who were approached, more than 25% failed to tell the client that the headaches might be a side effect of pill use, and more than 30% did not tell her that they might disappear shortly. 6 In a similar study based on a national sample of 25 hospitals and 74 clinics in Ecuador, 47% of providers failed to tell the client that her headaches might be a side effect of the pill, and 61% neglected to inform her that they might go away with time. 7 When confronted with such evidence of incomplete counseling, providers generally attribute their shortcomings to causes beyond their control. In rural areas of Federico R. León is program associate with the Fro n t i e r s in Reproductive Health program of the Population Council, Lima, Peru. At the time this re s e a rch was conducted, Rosa Monge was a consultant, Adriana Zumarán was an intern, Ingeborg García was an intern and Alex Ríos was a re s e a rch assistant, all at the Population Council, Lima. The authors thank Lucy López for her comments on the study tools, Jorge Parra for his help in facilitating access to the health centers and John Townsend and Cynthia G reen for their useful comments on earlier drafts of this article. The re s e a rch upon which this article was based was made possible by funding from the U.S. Agency for International Development (USAID) under cooperative a g reement HRN-A-00-98-0012-00 with the Population Council. The opinions expressed herein are those of the authors and do not necessarily re flect the view of USAID. Length of Counseling Sessions and the Amount Of Relevant Information Exchanged: A Study in Peruvian ClinicsBy Federico R. León, Rosa Monge, Adriana Zumarán, Ingeborg García and Alex Ríos T he concept of "informed choice" in family planning counseling implies that providers assist clients in selecting the method that best satisfies their needs, and that clients leave the session knowing about the side effects of their chosen method and how to use it safely and eff e c t i v e l y. 1 Worldwide, however observational findings suggest that actual counseling is far from meeting these requirements.Audiotaped counseling sessions in Kenya, for example, revealed that only 57% of clients receiving the injectable and 32% of those getting the pill were provided with information on their method's side eff e c t s . 2 A situation analysis of Nairobi clinics showed that fewer than 50% of new clients w e re provided with information on contraindications to or side effects of thei...
Objective: To describe the profile of community health workers -health promoters, traditional birth attendants and traditional healers -in rural Quechua communities from Ayacucho, Peru. Methods:Basic quantitative and qualitative information was gathered as part of a community health project implemented between 1997 and 2002 in 40 Andean communities with information from questionnaires, personal interviews and group discussions.Results: The majority of current community health workers are men with limited education who are primarily Quechua speakers undertaking their work on a voluntary basis. Health promoters are mostly young, male, high school graduates. There exists a high drop-out rate among these workers. In contrast, traditional healers and traditional birth attendants possess an almost diametrically opposite profile in terms of age, education and drop-out rates, though males still predominate. At the community level the health promoters are the most visible community health workers. Conclusion:It is very important to consider and to be aware of the profile of community health workers in order to provide appropriate alternatives when working with these groups as well as with the indigenous population, particularly in terms of culture, language and gender issues.
This study was funded by the U.S. Agency for International Development (USAID) under the terms of the Frontiers in Reproductive Health Program Cooperative Agreement Number HRN-A-00-98-00012-00 and Population Council Subagreement number AI02.09A with the Escuela de Administración de Negocios para Graduados (ESAN). The opinions expressed herein are those of the authors and do not necessarily reflect the view of USAID. One-Year Impacts of Improved Quality of Care in Peru EXECUTIVE SUMMARY Context. A study with 24 health directorates of the Peru MOH as units of experimentation and analysis that was conducted in 2000-2001 showed that two-day provider training plus one-day retraining on the job aids-assisted Balanced Counseling Strategy resulted in significant enhancement of the quality of care, an increase of four minutes in session length, and improved client knowledge of the method chosen when this was an IUD or hormonal method. This study presents results of a one-year follow-up. Methodology. New-event family planning clients were recruited as they exited counseling sessions at treated and control clinics. The clients had chosen a contraceptive method and stated intentions to use contraception for at least one year. A questionnaire that included the calendar module of DHS was applied twice in home interviews to tap six and 12-month outcomes. Twelve-month data from 215 clients were analyzed in depth. Results. Knowledge of the method chosen when this was the IUD or a hormonal method was greater in the treated cohort (p < .05, one-tailed, df = 18) at the end of the follow-up period. Mean monthly (k = 12) family planning use rates over health-directorates (n = 12) were obtained for each cohort. The latter months showed less use of needed contraception (p < .01, df = 11,11) and the treated cohort greater use (.81) than the control cohort (.78, p < .01, df = 1,11) when contemporaneous perceptions of need were considered. Cumulative continuation rates from life tables did not differ significantly between cohorts according to the Wilcoxon (Gehan) statistic. Proportions of method shifting were similar in both cohorts. Attainment of contemporaneous reproductive goal was significantly greater in the treated cohort (.96) than the control cohort (.95, p < .01, df = 1,11). Conclusions and Recommendations. The intervention caused consistent, yet small, improvements in client outcomes. Correlational findings suggested that better impacts can be achieved in provincial primary health facilities than in larger settings like clinics or hospitals in capital cities. The results are important because: 1) other studies have failed to show significant impacts of controlled quality-of-care improvements on the use of contraception; and 2) the Balanced Counseling Strategy was not implemented to its full extent. Greater impacts can be expected when the Strategy's potential is fully realized.
This study investigated the effects of introducing a family planning counseling model at clinics of Peru's Ministry of Health. Providers trained in the model presented greater quality of care and longer counseling sessions than did controls. The main effects, however, were misleading. Nearly all of the quality improvements were contributed by 37% of the trained providers; they had already been better performers at the pretest and complied with the new counseling model's requirement of job aid use at the posttest. The recognition that a majority of trained providers did not profit from training posed a challenge that led to improvements in the model. Training x Trainee Interactions should be explored in evaluations.
A central focus of high-quality family-planning care is the interaction between clients and the providers who serve them. In the ideal client-provider interaction, the provider treats all clients respectfully, responds to their reproductive needs and intentions, helps in the selection of the most appropriate family planning method, and offers sufficient information to use the method safely and effectively. To improve the quality of the client-provider interaction, Population Council staff developed a “Balanced Counseling Strategy,” a type of algorithm or decision tree, to be used in combination with several job aids, or visual memory aids. The Balanced Counseling Strategy structures the client-provider interaction to focus on the client’s needs and support the client’s choice of an appropriate method, and leads to improvements in the client-provider interaction when providers use the strategy along with job aids. This brief describes the Balanced Counseling Strategy as an ongoing approach to improving quality of care. It outlines the origin and rationale for developing the strategy and details its subsequent adaptation for use in other contexts.
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