1. Ensuring Informed and Voluntary Decision Making MODULE 4 Facilitative Supervision for Quality Improvement Curriculum 2008

2. Essential Elements of Informed and Voluntary Decision Making Service and method options are available. The decision-making process is voluntary. People have appropriate information. Good client-provider interaction, including counseling, is ensured. The social and rights context supports autonomous decision making.

3. Why Do We Care about Informed and Voluntary Decision Making? It is a human right. It is an essential element of quality of care and client satisfaction. It significantly contributes to program effectiveness. It is a policy requirement.

4. Informed Choice as a Reproductive and a Human Right Individuals and couples have the right: To decide about the number, spacing, and timing of their children To have the information, education, and necessary services to achieve their desired number and spacing of births ICPD, 1994

5. Clients’ Rights Information Access to services Informed choice Safe services Privacy and confidentiality Dignity, comfort, and expression of opinion Continuity of care Adapted from: Huezo, C., and Diaz, S. 1993. Quality of care in family planning: Clients’ rights and providers’ needs. Advances in Contraception 9(2):129-139.

6. Client-Provider Interaction Client-provider interactions (CPIs) are all exchanges, both verbal and nonverbal, that clients have with health care providers at all levels, regarding any health care service. nonverbal Client Provider verbal

7. Informed Consent and Counseling Informed Consent: Agreement by the client to receive medical treatment, to use an FP method, or to take part in a study Counseling: Two-way, one-on-one communication between a health care provider and a client, to facilitate or confirm a decision by the client

8. Client-Centered Communications Make a Difference! Research tells us that... The interpersonal communication and information provided are the key issues to clients’ perception of the quality of services. Client-oriented communication that tailors information to the individual has positive impact on method adoption, continuation, and client satisfaction. Abdel-Tawab, N., and Roter, D. 1996. Provider-client relations in family planning clinics in Egypt. Paper presented at the annual meeting of the Population Association of America, New Orleans, LA, USA, May 9-11, 1996; and Koenig, M. A., et al. 1997. The influence of quality of care upon contraceptive use in rural Bangladesh. Studies in Family Planning 28(4):278-289

9. Giving People a Choice Makes a Difference! Research tells us that... Use of contraception is highest when people have access to a range of contraceptive methods. Ross, J., et al. 2002. Contraceptive method choice in developing countries. International Family Planning Perspectives 28(1):32-40 Clients who receive the method they want are more likely to continue use. Pariani, S., et al. 1991. Does choice make a difference to contraceptive use? Evidence from East Java. Studies in Family Planning 22(6):384-390

10. Quality Counseling Makes a Difference Research also tells us that... A major reason that clients discontinue pills and injectables is that they are not adequately informed about side effects. EngenderHealth studies in Cambodia, 2000, and in Nepal, 2001 Conversely, counseling about side effects significantly increases continuation. Lei et al, 1996, FHI Network, 1991

11. What Are the Consequences of Not Assuring Informed and Voluntary Decision Making ? SituationConsequences Client does not fully understand the method (vasectomy). Client fails to use another method for three months, resulting in pregnancy. Client is given an incentive (e.g., travel money or food). Client may be induced to accept the method rather than choosing it based on real need or preference, which can lead to regret. When incentives are discontinued, interest in the method may wane.

12. Factors Affecting Informed and Voluntary Decision Making Barriers to informed and voluntary client decision making persist in many programs around the world, due to the following factors: Individual/community/cultural factors Service-delivery factors Policy factors

13. Community/Cultural Factors That Affect Informed and Voluntary Decision Making Sociocultural factors, beliefs, and norms Rights context, status of women, and individual status Availability and accessibility of services Literacy level Awareness of reproductive health and rights Sources and quality of information

14. Service-Delivery Factors That Affect Informed and Voluntary Decision Making Provider attitudes, knowledge, and skills Counseling: quality and allocated personnel and time Supervision Client information/education materials Method mix and access Informed consent

15. Policy Factors That May Challenge Informed and Voluntary Decision Making Targets or quotas Per-case referral or provider payments Client payments or noncash incentives Limited method mix and “camp” services Fees Eligibility criteria

16. Informed and Voluntary Decision Making as a Good Program Strategy Ensuring informed choice leads to: Better method use and client compliance with treatment regimens Continued method use Satisfied clients, who are good promoters

17. Some Safeguards Inform the public of their right to make informed FP/RH decisions. Strengthen communications and counseling training and supervision. Orient providers and managers to the benefits of ensuring informed choice (IC) and voluntary decision making. Make protecting IC a performance indicator.

18. More Safeguards Increase service-delivery points and method options. Remove policy restrictions that limit access to information, services, or methods. Increase male involvement to inform men and gain their support for partners’ decisions and method use. Practice QI approaches that emphasize client- centered care.