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Bcs+ toolkit webex presentation - kg - jan 2013
1. Balanced Counseling
Strategy Plus – Overcoming
Barriers to FP Services
Sexual, Reproductive and Maternal Health
(SRMH)
Kamlesh Giri – Senior Advisor, Clinical Training
CARE
Jan 9th 2013
2. 222 Million Women Report Unmet
Need for Contraception Worldwide
• A number of barriers contribute to this unmet need
• Medical Barriers
• Process Barriers
• Access Barriers
2
Source: Susheela Singh & Jacqueline Darroch, Guttmacher Institute, 2012.
3. Barriers
Medical Barriers
Process Barriers
• Inappropriate
contraindications or
eligibility criteria: age,
parity, marital status, etc.
• Lack of trained provider
• Provider bias
• Restrictions on where
services can be provided
• Unnecessary barriers to
initiation – e.g.
Menstruation, STI, etc.
• Rest periods required
• Unnecessary procedures
required – Pap smear, pelvic
exam, lab tests, etc.
• Inappropriate follow-up
schedule – IUD follow-up,
only 1 pill cycle given, etc.
3
4. Mean Parity Required Among Providers Who
Report Restrictions on Injectable Use Based
on Parity
6
5
# children
4
3.4
2.8
3
2
2.9
2.9
Botswana
Burkina
Faso
Zanzibar
1.9
1
0
Kenya
Senegal
Source: Population Council, 1998.
5. Percentage of Providers Who Restrict Injectable
Use Based on Minimum Age*
in Four African Studies
* Minimum age = 13 or above
Source: Population Council, 1998.
6. Percentage of Providers Who Restrict Injectable
Use Based on Maximum Age*
in Four African Studies
* Maximum age = 45 or below
Source: Population Council, 1998.
7. Compliance Is Critical to the
Contraceptive Equation
• Among pill users, every 1% decrease in
effectiveness represents ~ 100,000 unintended
pregnancies
• If two methods are equally efficacious but one
has better compliance/continuation, the net
effectiveness will be higher for that method
7
8. Receiving Contraceptive of
Choice Increases Continuous Use
Indonesia
100
80
60
% of
Continuous
Use
40
Received
Denied
20
0
Injection
Condom
Pill
Source: Pariani, Studies in Family Planning, Nov/Dec 1991.
9. Menstrual Requirement is a Major
Access Barrier in Kenya
100 Women
Seek FP Services
55
Menstruating
45
Non-Menstruating
55 Registered
as Clients
10 Registered
as Clients
35 Sent Home
to Await Menses
9
Source: Stanback, 1999.
11. Practices to Break Down Barriers
•Providing client’s method of choice to
enhance continuation and compliance
• Avoiding unnecessary medical restrictions
and tests
•Improving counseling and client-provider
interaction (CPI)
11
12. Avoiding Provider Bias
• Often, well-intending providers think they know
best - so do not elicit client preferences
• Provider needs to consider client’s specific
situation and let client select method
• Programmatic pressures favoring certain
methods (e.g., provider targets) may influence
providers
12
13. "How to be reasonably sure woman is not
pregnant" Checklist use for non-menstruating
clients can improve access
New Client Volume
500
*
400
300
*
200
7 Checklist Clinics
7 Control Clinics
100
0
*12/97 – 1/98
excluded due to
national nurses’
strike in Kenya
FebMar
96
JunJul96
OctNov
96
FebMar
97
Jun
-Jul
97
OctNov
97
Dec
97Jan
98
AprMay
98
14. % of Couples Continuing
Contraceptive After 12 Months
Contraceptive Counseling:
Including Partner Improves Continuation Rates
14
50
40
33%
30
17%
20
10
0
Partner Involved in
Counseling
Partner Not Involved in
Counseling
Terefe A, Larson CP. Am J Public Health. 1993;83:1567-1571;
Herndon N. Network. 1998;18:13.
15. Counseling About Side Effects Decreases
Discontinuation
100
50
40
Percentage
of clients
30
discontinuing
Routine counseling group
Routine counseling group
Structured counseling group
Structured counseling group
20
10
0
Baseline
Month 3
Month 6
Month 9
Month 12
15
Source: Zhen-Wu Lei et al, Contraception, Vol 53, 1996.
16. BCS+: Improving Client-Provider
Interaction
• Uses interactive and client-friendly approach for
improving FP counseling
• It uses key job-aids for counseling clients
• It integrates counseling and services for other
related services (e.g. antenatal care, STI/HIV,
immunization services)
• It incorporates latest international guidance from
the WHO
16
Frontiers/Population Council Inc. 2011
17. Counseling Approaches
• Two other FP counseling approaches
• GATHER
• REDI
• Both GATHER and REDI take a longer time for
training providers and for providing counseling at
service delivery
• Both of these approaches rely on personal
memory (or third party memory tool) to transfer
the information to clients on FP
• BCS+ is streamlined, with own job-aids,
minimizes memory burden
17
18. BCS+ Toolkit
The Toolkit consists of the following:
• BCS+ User’s Guide: It explains how to use the
job aids
• BCS+ Job Aids: these are tools used during the
counseling process
• BCS+ Trainer’s Guide: Supervisors can use this
guide to train providers on how to use the BCS+
counseling approach
18
19. BCS+ Counseling Stages
BCS+ is divided into four counseling stages:
• Pre-choice Stage:
• Method-choice Stage:
• Post-Choice Stage:
• Systematic Screening for Other Services
Stage:
These stages are outlined in the BCS+ algorithm
19
21. The Counseling Cards
• Establish and maintain a warm and cordial
relationship with client
• Rule out pregnancy - ‘pregnancy checklist’ card
• Find out woman’s reproductive goals – does she
want to have children in the future?
• Set aside counseling cards from the table that
are not relevant to the client
21
22. The Counseling Cards (contd..)
• Ask client if there is preference for a certain
method
• Provide method effectiveness for cards still on
the table
• Use method brochures to check for medical
conditions not suitable for client
• Discuss chosen method with client and provide
method or refer to another center
22
23. Adapting BCS+ Package for CARE
• CARE adapted the BCS+ training to a 3-day and
5-day training package to meet program needs
• Included skills for client-provider interaction and a
contraceptive technology update (from WHO)
• 5-day agenda has further expanded CTU component
• The 3-day and 5-day training package available
in English and French including the job-aids
23
24. Conclusion
• Barriers to contraceptive use exists at different
levels
• An effective counseling approach is at the core of
any successful family planning program
• Program managers and providers can help to
reduce many of these barriers
• Programs must empower the providers to take
steps to reduce these barriers at the clinic level
24
Editor's Notes
Good morning!On behalf of the Sexual Reproductive and Maternal Health team I would like to welcome you and thank you for making time for this presentation. Family planning counseling is at the very root of any successful family planning program. Through the SAF-PAC initiative, which stands for Supporting Access to FP and Postabortion Care in Emergencies, we have introduced and applied a very useful FP counseling tool, the Balanced Counseling Strategy Plus, or the BCS+ tool. Today we will be talking about this approach to family planning counseling and discuss the advantages of using this approach. We will also discuss common barriers to FP services especially those that can be influenced by service providers and program managers through the use of this counseling approach.
When prescribing appropriate contraceptive methods for their clients, providers tend to focus primarily on safety and effectiveness, which no doubt are important. Yet other contraceptive factors weigh just as heavily as safety and effectiveness in the contraceptive equation, and issues such as effective counseling and method choice are equally critical in helping clients achieve successful contraception.Likewise, compliance and continuation play vital roles in not only the client’s ability to successfully use a chosen contraceptive method but also in the contraceptive prevalence rate of a population. Counseling is also critical; developing a sound relationship between clinician and client and helping clients manage expectations regarding side effects and benefits may increase compliance and continuation.
There are at least 2 other FP counseling approaches GATHER and REDI Both of these counseling approaches are program tested and good counseling methods GATHER stands for Greet, Ask, Tell, Help, Explain, Return visit and Many of you may be familiar with the GATHER counseling approach as it has been around for a long timeREDI stands for Rapport building, Exploration, Decision making and Implementing the Decision and is a relatively new approach that tries to overcome some of the weaknesses of the GATAHER approach, and it has been around for many years now. From my personal experience, both of these approaches take a longer time for training providers and subsequently counseling clients during service delivery. They also need other job-aids to complete the package. The BCS+ comes with its own set of job-aids, is better streamlined to identifying client’s reproductive goals quickly and provides the necessary and accurate information for decision making at the same time minimizing memory burden to provider. We will take a look at these tools just a few slides later.
The BCS+ toolkit consists of the following:BCS+ User’s Guide BCS+ Job Aids BCS+ Trainer’s Guide
The BCS+ Counseling relies on the effective use of these 4 job-aids by the providers during every counseling interaction. I will provide a very short overview of the 4 tools: The BCS+ Algorithm: summarizes 19 steps recommended to implement the BCS+ and organized under four stages of the consultation. (pre-choice, method choice, post-choice, and systematic screening stage) The Counseling cards: there are 26 counseling cards, 16 of which are method specific cards,9 cards are for counseling on related services and the first card holds questions on how to be reasonably sure woman is not pregnant. Each health facility equipped to provide FP counseling and services should have at least one set of the counseling cards The Method brochures: one for each of the 16 contraceptive methods. The provider gives the client the brochure to take home for the selected method. These brochures can be easily photocopied on a regular A4 size (or legal size) copying paper The WHO Medical Eligibility Criteria Wheel: is a provider job aid based on the four eligibility categories for contraceptive use in relation to medical conditions Extra notes not during presentationCategory one – use the method in any circumstanceGenerally use the method – benefits outweigh the risks Use of the method not usually recommended unless other, more appropriate methods are not available or acceptable Method NOT to be used – risks outweigh the benefits
In the next 2 slides I will attempt to briefly describe you the steps in counseling clients using the counseling cards as well as other job-aids. This is best done while demonstrating the steps, but I will do my best to provide a simple and understandable description of the process, given the limitations of an oral description. Overall, the place to start is with the algorithm. The BCS+ Algorithm serves as a guide to progress through the counseling steps. (ask audience to review the counseling algorithm). The counseling process involves asking pertinent questions to client to understand client’s needs and preferences for FP methods. Then use this information to cross-check with client’s medical conditions and rule out methods that may not be suitable for client based on her medical conditions until the client selects the method that is best suited for her. That’s the process summary. Now getting back to the steps: Start by displaying all the method specific counseling cards on a table. After establishing a warm, cordial relationship with the client, the first step in the process is to rule out pregnancy – by using the pregnancy checklist – you can refer to the 6 questions listed on the card – this is the same card we talked about earlier in relation to access barriers in Kenya. Then find out woman’s reproductive goals – does she or do they plan to have children in the future? This will help to include or rule out the permanent methods of contraception As we progress with these questions and answers, set aside counseling cards that are not relevant to the client, e.g. if she wants more children set aside permanent method cards, if she is breastfeeding her baby then set aside methods with oestrogen (COCs and monthly injectables), and so on.
Ask if she has a preference for a certain FP method or if there are methods that she has not tolerated in the past – set aside cards based on answers Provide method effectiveness for those methods that are still remaining on the table – the effectiveness is given as failure rate of method in the back of the card in the bottom left hand side of the card – the number denotes the pregnancy rate for the method – so a low number denotes a low pregnancy rate, which means it is a very effective method. For example IUD has a pregnancy rate of 1 for 1st year of use and only 2 over 10 years of use. The method brochures help to review “methods that are not advised to client” based on client’s clinical conditions – these are given on top of the right-hand facing page of the method-specific brochure (encourage audience to review method brochure).
CARE adapted the BCS+ training to a 3-day and 5-day training package for SAF-PAC initiative Because many of our FP providers are either working in crisis or post-crisis settings, they are either new providers or have not received any recent updates in FP services. These updates are critical in implementing good family planning services. We have added skills for client-provider interaction and a contraceptive technology update (from WHO) in order to better prepare our providers. Given that we are working in crisis or post-crisis settings, a 1-day training agenda was inadequate to prepare the provider to the desired level of proficiency. In fact, upon recommendation by our country programs, even the 3-day agenda that we started with was felt inadequate and so we expanded the training to a 5-day training agenda. The 5-day agenda has more contraceptive technology update components. Both the 3-day and 5-day training packages are in English and French. For providers who have been exposed to FP counseling and services before, a 3-days training package is recommended. The 5-day package is for providers who are new to FP service delivery. The job-aids are all available in French and Marcie was kind enough to share the French version with our Franco-phone colleagues.
Finally, to conclude, Barriers to contraceptive use exists at different levels – process barriers, medical barriers, barriers due to prevailing social norms. There are many important social and community barriers we focus on reducing in our work at CARE. But we also want our client, that woman in a remote place in Kenya, to get the right contraceptive method, or even any method at all, once she had made it to the clinic. The BCS+ counseling approach is the first step in helping us overcome the other big barriers at the clinic itself. An effective counseling approach is at the core of any successful family planning program Program managers and providers can help to reduce many of these barriers at the clinic level Programs must empower the providers to take steps to reduce these barriers at the clinic level Thank you for your attention! I think we have some time for questions and discussion
