Ensuring Informed and Voluntary Decision Making

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.
Client
verbal
nonverbal
EXCHANGE
verbal
Provider
nonverbal
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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

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What Are the Consequences of Not Assuring
Informed and Voluntary Decision Making ?
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.