Impact of Client-Provider Communication on Family Planning in Kenya

Context:

The data for this study was drawn from the Kenya Provider and Client Information, Education, and Communication (IEC) Project 1991-1994, and is in support of efforts to strengthen knowledge and understanding of the process and functioning of communication between health care providers and their clients, especially in the area of modern contraceptive promotion and usage. The study goals were to 1) discover whether and how clients participate in the counselling process and identify specific ways that clients play an active role, 2) assess whether and how providers influence client participation and how they react when clients take an active role, and 3) quantify interaction in the counselling process.

Access:

This study was an effort to contribute to the development of training programmes for family planning counsellors. The authors believe that improved client participation and more provider guidance can help to correct to major challenges facing the implementation of family planning practice (clients using methods incorrectly and clients discontinuing methods after only brief use). On this reasoning, if providers know more about clients' family planning needs, personal situation, and concerns, they can identify and clear up client misunderstandings. Again, following this line of thinking, this strategy can help clients to better understand their options and make the choices that are right for them. All but one of the 178 clients were women, and 88% were between the ages of 20 and 34. Most were married (85%) and had children (99%); 58% had 3 children or more.

Increased Discussion of Development Issues:

The overall finding was that the majority of sessions (72%) were dominated by providers, largely acting as technical experts, while clients tended to volunteer few words and speak only when responding to questions. 18% of new clients initiated conversation about family planning knowledge, while 46% of clients already had a strong preference for a specific family planning method before they entered the clinic.

Attitudes:

During in-depth interviews conducted 18 months after the initial data collection, clients in Kenya said they were not satisfied with how much they spoke. They reported wanting to say more to the provider, but being afraid to do so because the provider was too busy.

Practices:

Continuing clients had a significantly larger share of the conversation (36.5%) than did new clients (27.7%), though client "active communication" actually was lower (24.3%) amongst returning clients than new ones (30%). Observers also noted that providers made speeches that either counsel or instruct clients (relating speeches) twice as often to clients age 35-45 as to younger clients (22% compared with 11%). However, the frequency of counseling and instruction did not vary by the client's education level, new or continuing client status, or provider type. When clients made an active speech, providers responded with technical information 42% of the time, offered support (in the form of reassurance, advice, approval, or constructive suggestions) 28% of the time, and ignored the client 22% of the time. Other observations were that 29% of clients chose family planning methods they felt their husbands could accept; 10% chose based on a method recommended by a friend.

Other Impacts:

The authors suggest that a 4-step decision-making process is needed to improve enable Kenya's family planning programmes to reach their goals. In their conception, this process includes:

• Clients must come to understand their own needs and priorities. Providers rarely encouraged clients to make such a self-assessment.
• Clients need to learn about their contraceptive options and discover which methods might fit their needs. While providers did describe multiple methods to new clients, they failed to relate the information to the client's personal situation.
• Clients then should choose a method after weighing the pros and cons of the available options. Providers offered little guidance to clients and, in fact, rarely encouraged them to seriously consider more than one method.
• Acting on the decision requires that family planning clients know how to use their chosen method, when to return, and what to do in case of problems.

Methodologies:

This study analysed transcripts from 178/358 family planning counselling sessions conducted in a total of 6 local languages and recorded at 25 service delivery sites, a method known as interaction analysis. The specific sites in these locations were selected to include both clinic- and community-based service providers and to encompass all 6 leading organisations offering family planning services in Kenya. The transcripts were coded and analysed to determine interaction style, balance of talk, proportion of active client communication, types of active client communication speeches, promotion of client communication by the provider (9 categories), and whether the provider rewarded active participation. Data were also gathered at follow-up 18 months later, during which an additional 10 counselling sessions at clinics scattered throughout Kenya were observed and in-depth interviews were conducted with clients and providers.