Effects of IGSS' job aids-assisted Balanced Counseling Algorithms on quality of care and client outcomes

This study was funded by the U.S. Agency for International Development (USAID) under the terms of Cooperative Agreement Number HRN-A-00-98-00012-00 and In-house project number 8002 13052. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID. Context. Very short counseling sessions, counseling not focused on clients' needs, redundancy in the role of physicians and social workers as providers, skewed method mix, and low client return rate for method re-supply prevailed at the main maternity hospital of the Social Security Institute (IGSS) in Guatemala. A need to improve the quality of care was identified. Methodology. The IGSS adapted the job aids-assisted Balanced Counseling Strategy and developed two service algorithms, one for the social worker and one for the physician. Method cards and method pamphlets were made available to providers. All the providers were trained and received reinforcing revisits during two months. The effects of the intervention were assessed by means of client exit interviews, home follow-up of client cohorts, analysis of service statistics, and a time-motion study. Results. The intervention changed the counseling behavior of physicians and social workers and enhanced the quality of family planning care. Client choices did not support the hypothesis that improvements in the quality of care would cause a decreased share of the injectable in the method mix. Three decreasing trends in the 19-week pre-intervention (choice of the injectable, client's reception of her desired method, client knowledge concerning the method chosen) presented reversals in the 19-week post-intervention. However, these changes could be attributed to either the intervention, trends in the provider workload, and/or instrumentation bias. Continuation in the use of family planning diminished from month one to month six, particularly in the case of the pill, but the behavior of pre-and post-intervention client cohorts were undistinguishable. Conclusions. The IGSS should continue using the job aids-assisted Balanced Counseling Algorithms, yet adjustments in instructions concerning post-choice counseling could be introduced and tested to improve client outcomes. The skewed method mix at the IGSS reflects clients' perception of the benefits of the injectable rather than provider bias; hence, the IGSS must adapt to this situation rather than attempting to change it. The six-month post-choice contraceptive behavior on the part of an overwhelming majority of Balanced Counseling Algorithms at the IGSS i clients (users of the injectable or the IUD) is satisfactory and may not be amenable to further improvement. Users of …