Impact of the Tablet-based Balanced Counseling Strategy on Contraceptive Method Discontinuation Rates in Indonesia

Summary:

This presentation describes the design and effective use of a digital tool to improve family planning (FP) counseling and service outcomes in Indonesia. The Balanced Counseling System (BCS) was designed to reduce high contraceptive method discontinuation rates caused by two typical shortcomings of FP counseling processes: (1) failure to ensure that clients can make an informed method choice that matches their personal contraceptive needs, and (2) failure to prepare clients to use their chosen method effectively, including understanding and managing potential side effects. Three waves of data were collected (observations/videotaping of 600 counseling sessions with 60 providers, and interviews with those same providers and clients) in treatment and control facilities, before and after BCS training. Comparisons of counseling techniques and content delivered before and after training showed dramatic improvements in counseling practices among trained providers. Better counseling is hypothesized to reduce twelve-month FP dropout rates. Treatment-control comparisons are not available yet, but preliminary analysis of three-month dropout rates for long-acting methods indicate lower rates of discontinuation among women in the treatment facilities compared to the national average (implants 3.9% vs. 6.0%, IUDs 0.0% vs. 9.0%). Clients in treatment facilities were also less likely to cite side effects as the reason for discontinuation compared to the national average (20% vs. 33%). Discontinuation rates will be measured again in November 2019 and analyzed by the time of the Summit. This presentation discusses the advantages and challenges of using digital solutions to improve service delivery quality and outcomes.

Background/Objectives:

Indonesia has a relatively high contraceptive prevalence rate (57% modern methods, 63% all methods), so effective and consistent use of FP becomes a more important indicator of program success than adoption per se. Method discontinuation for preventable reasons (e.g., clients get a method not perfectly suited to their needs, providers do not prepare clients to understand and manage FP side effects) can lead to unintended pregnancy and client distrust in services and providers. The BCS digital tool was designed (originally by Population Council) to ensure that clients get the best method for them and know how to use it effectively.

Description of Intervention and/or Methods/Design:

The study used a longitudinal treatment/comparison design. In December 2018-January 2019, we randomly recruited 1 provider from each of 60 public health facilities in four treatment and two comparison districts and observed/videotaped counseling sessions with 10 clients each (n=600). Half of the treatment facilities received BCS training before the observations and half did not to assess post-training learning. All providers and clients were interviewed about the counseling session. Research instruments assessed communication and counseling practices and content delivered/received. Training was then completed in all treatment facilities. In March 2019, all 40 trained providers were observed again with new clients (n=400) to assess sustainability of training effects; Wave 1 clients from trained facilities were re-interviewed about changes in FP method use since January 2019. In November 2019, all 600 clients from treatment and comparison facilities will be re-interviewed to assess 12-month FP method continuation rates.

Results/Lessons Learned:

Trained providers in Wave 1 were statistically more likely than untrained providers to: provide structured counseling, give information about healthy timing and spacing of pregnancy, explain the pros and cons of the contraceptive methods preferred by clients, and describe the side effects of methods and how to manage them. Clients were also more proactive with BCS-trained providers. They were significantly more likely to: ask for the provider's opinion or advice about FP methods, express their concerns or worries about a method, ask providers technical questions about FP methods, and choose an FP method. These results were sustained three months after training. Three-month dropout rates for long acting methods were lower among women in the treatment facilities compared to the national average (implants 3.9% vs. 6.0%, IUDs 0.0% vs. 9.0%) and clients who did drop out were less likely to do so because of side effects (20% vs. 33%).

Discussion/Implications for the Field:

Digital job aides have the potential to significantly improve the quality and responsiveness of interpersonal communication and counseling in clinical settings. By making counseling sessions more efficient, providers are freed up to focus more on the specific needs of individual clients, increasing the likelihood that service outcomes are aligned with client needs. This in turn results in better long-term client health outcomes because they received the care they needed in the first place. Based on preliminary findings of this study, use of the BCS tool is already being institutionalized and rolled out nationally in Indonesia by national health authorities.

Abstract submitted by:

Douglas Storey - Johns Hopkins Center for Communication Programs (JHU CCP)
Yunita Wahyuningrum - JHU CCP, Indonesia
Robert Ainslie - JHU CCP, Indonesia
Rita Damayanti - Faculty of Public Health, Department of Health Education and Behavioral Sciences, Universitas Indonesia