Published in International Family Planning Perspectives (Volume 31, Number 4, pp. 162-171), this 10-page evaluation examines the strategy of using the Decision-Making Tool for Family Planning Clients and Providers, a 2-sided, 100-page flipchart designed to function as a decision aid for clients and a job aid for providers.

Developed by the Department of Reproductive Health and Research at the World Health Organization (WHO), this tool is designed to foster informed choice in family planning through use of "a decision-making algorithm to systematically guide clients and providers through the counseling process." By supplying providers with directions, technical information, sample questions and statements, and counseling tips, the chart aims to stimulate the provider to seek input from the client regarding his or her needs and preferences at each decision point along the way; simple language and illustrations are designed to help the client raise key issues and questions. The goal is that the client - rather than the provider - drive the flow of the counseling process.

This document examines a field test in Mexico City carried out in 2003-2004 that assessed the tool's effectiveness in changing the counseling and decision-making process, and collected feedback from providers and clients. Conducted at 9 government health facilities, the study investigated whether training on and use of the flipchart has an impact on information given by providers, on client participation and on the quality of decision making; how the flipchart helps or hinders family planning counseling; how comprehensible, usable and acceptable it is to providers and clients; and what changes could increase its acceptability and impact.

Specifically, the 13 participating providers (3 men, 10 women) received a copy of the WHO flipchart and then attended a two-and-a-half-day training session. They were videotaped with family planning clients 3 months before and 1 month after this training session; the videotapes were coded for client-provider communication and eye contact, and decision-making behaviours were rated. Focus group discussions and in-depth interviews and explored clients' and providers' opinions of the tool.

Researchers found that, after providers began using the decision-making tool:

• Client-provider interaction was enhanced - Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. For instance, the total amount of client communication increased from an average of 35 utterances per session at baseline to 59 per session during the postintervention round. Active client communication increased from 2 to 5 utterances per session. The decision-making tool directly prompted some of this active communication: In the videotapes, clients sometimes asked for explanations of the illustrations or text in the flipchart. Similarly, providers spoke more in the consultations using the flipchart than at baseline, with total provider communication increasing from 60 to 131 utterances per session. Facilitative communication (when providers encouraged client participation) increased from 10 to 21 utterances per session.
• Decision making scores increased on the part of both clients and providers - To cite one finding, during the baseline round, providers were solely responsible for decisions (e.g., to adopt or switch methods) in 44% of sessions and largely responsible in the remaining 56%. After the intervention, providers were largely responsible for the decision in only 19% of sessions and shared the decision with clients in 81% of sessions.
• More information was provided - Providers gave clients significantly more information on family planning in the postintervention sessions - with the aid of the flipchart - than in the baseline sessions. They also tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use.
• Eye contact was not impaired - During the development of the flipchart, there was some concern that its two-sided design would create a barrier between providers and clients, breaking eye contact and undermining the interaction. However, providers reported in the group discussions that it was easy to look back and forth between the tool and the client.
• The tool was deemed useful and appropriate by both clients and providers - Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. For instance, providers felt the tool should more clearly and explicitly communicate clients' responsibility for and role in decision making, the concept of decision making (by narrowing the number of options as opposed to considering each option individually) and how to weigh the pros and cons of different options. In addition, they had many suggestions on how to adapt the flipchart to the Mexican setting.

Following a discussion section, the document concludes with several recommendations on how to overcome potential barriers to providers' use of the WHO flipchart, "which looks complicated, lengthens consultation times and contradicts previous training and established practice in Mexico." Though designed in a generic format, the flipchart could be adapted to local settings in various simple or complex ways; an adaptation guide is available to shape this process. In addition, teaching providers how to use the tool through a minimum of one day of training, in concert with additional counseling skills and use of contraceptive technology, can help foster its use. Other strategies are being tested, such as distance learning via training videos to instruct midwives in Indonesia on use of the flipchart. The authors also reference "reinforcement strategies that might encourage providers to keep using the tool with clients include supervisory checklists that assess use of the flipchart and counseling skills, mentorship programs, peer support meetings and quality improvement programs that incorporate use of the tool."

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