Transcript Title of Presentation

Ensuring Informed and
Voluntary Decision
Making
MODULE 4
Facilitative Supervision for
Quality Improvement Curriculum
2008
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.
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.
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
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.
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.
verbal
nonverbal
Client
Provider
verbal
nonverbal
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
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
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
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
What Are the Consequences of Not Assuring
Informed and Voluntary Decision Making ?
Situation
Consequences
Client does not fully
Client fails to use another
understand the method method for three months,
(vasectomy).
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.
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
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
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
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
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
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.
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 clientcentered care.