Improving Provider and Client Communication around Family Planning in Togo: Results from a Cross-sectional Survey

"[I]t appears that the intervention was successful at improving key aspects of provider-client communication."

Francophone West Africa has high fertility rates and with low contraceptive prevalence. In Togo, it is estimated (as of January 2022) that 33.0% of married women and 25.2% of all women of reproductive age have unmet need for modern contraception. Previous research has shown that clients are better able to achieve their reproductive intentions when family planning (FP) services meet their needs and they have satisfying client provider interactions. Thus, in Togo, and 3 other countries, the United States Agency for International Development (USAID)-funded AmplifyPF project is implementing the Integrated Learning Network (ILN) model, which uses a multisectoral approach to strengthen health provider counseling related to FP. This study examines the impact of AmplifyPF's targeted training on provider-client communication in health facilities across its intervention sites in Togo.

In Togo, the ILN model is being implemented in five health districts across the country (intervention sites). Using tools developed by the Togo Ministry of Health (MoH) and the project itself, training activities focused on enabling the provider to establish rapport with the client, exploring the needs of the client, and providing support for decision making and application of the decision. In identifying the needs of clients, the FP providers are trained to: (i) complete a comprehensive client history, (ii) assess and communication about client risk for sexually transmitted infections (STIs) including HIV, and (iii) provide counseling about alternative FP methods and side effects.

A clustered sampling approach was used to select 650 FP clients from 23 intervention facilities and 235 clients from 17 control facilities in the Lomé and Kara districts of Togo, respectively. In December 2021, the FP clients' interactions with providers were observed, and client exit interviews were conducted. Multivariate results show that all 3 outcome variables representing the 3 provider-client communication areas (see (i)-(iii) above) were statistically significantly better for FP clients in intervention clinics versus control clinics (p<0.05). For example:

• For outcome (i), clients in intervention facilities had nearly 5 times the odds of having a complete FP history compared to those in control facilities (odds ratio (OR) = 4.93).
• For outcome (ii), the results show that those in intervention facilities had nearly 4 times (OR = 3.93) the odds of having been asked all 4 questions related to: the provision of information about different FP methods, the possible side effects/problems with the selected method, the action to take if one experiences side effects, and the possibility of switching to another FP method.
• For outcome (iii), clients in intervention clinics had over 7 times the odds of being asked all the partner and HIV/STI risk questions compared to control clients (OR = 7.25).

There are 3 key findings from the multivariate analysis:

1. Clients receiving FP services in intervention clinics were statistically significantly more likely to have high quality provider-client communication, as measured by the 3 outcome variables. Based on qualitative feedback collected from providers in the target ILNs, they have generally welcomed the interrelated elements of the intervention, particularly the capacity building and supervision as well as site walkthroughs conducted by community stakeholders. As such, providers in the intervention sites not only recognize the impact of improved provider-client communication but also that they will be held accountable during stakeholder engagement activities. The confluence of all these elements are likely motivations for the providers.
2. Data included in the paper indicate that provider-client communication is enhanced when privacy and confidentiality are ensured. This finding demonstrates that, in addition to provider training, structural improvements that ensure privacy and confidentiality can also be critical to enhance the quality of FP counseling.
3. Providers offer more thorough provider-client communication to clients who are not currently taking FP, and those considering switching methods receive more thorough communication based on these outcome variables. This result is not surprising, but it is important that providers strive for thorough communication for all clients by asking questions, as some clients may be experiencing difficulties with their current FP method and would be better served by a different method but are reluctant to bring it up with a busy provider.

In conclusion: "These results do not include the totality of high-quality service provision, but they do speak to the emphasis that the MoH has placed on building the provider capacity to provide quality counseling and administration of FP. The significant differences between intervention and control facilities shown here demonstrate that interventions focused on improving provider-client communication can yield positive results, which should be shared with stakeholders and beneficiaries alike through channels available to them, including community dialogues. Future work should be done to link improvements in communication to greater client satisfaction with FP services, increased uptake and continuation of FP, and for the ability of women to maintain their aspirations with regards to family size and spacing."