• Summary
• Credits

1. Promoting Dialogue
2. Supporting the Client’s Role
• Box: Client-Centered Counseling
3. Improving Providers’ Performance
• Make Good CPI a Job Expectation
• Feedback Keeps Performance on Track
• Range of Knowledge and Skills Needed
• Work Environment Supports CPI
• Rewards Offer Motivation
• Match Capacity with Jobs
• Select Approaches to Solve Problems


• Table: Activities to Improve CPI
• Box: Supervisors Can Improve CPI
4. Best Practices in Training
5. Evaluating the Quality of CPI
• Box: Evaluating Training Programs
6. Moving Beyond Family Planning
7. Bibliography

• INFO Project
• Order
• Online Reports
• Upcoming Reports
• POPLINE

This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.

Published by the Information & Knowledge for Optimal Health (INFO) Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

With job expectations in mind, each health care worker should receive clear, constructive, and regular feedback on her or his performance, including praise as well as suggestions for improvement. Feedback can—and should —come from peers and clients as well as supervisors. While feedback on CPI is mostly directed to providers, it is helpful to give feedback to other staff members who interact with clients—for example, praising a receptionist who provides extra information about the clinic to an anxious new client.

Supervision is the most common, and potentially the strongest, channel for formal feedback to providers. Supervisors, however, often lack the knowledge and the tools to provide effective feedback on counseling and other communication skills. In Zimbabwe, for example, a study of 16 supervisors found that they were strong at giving feedback on technical matters, such as recordkeeping and clinical procedures, but not at giving feedback on the quality of CPI (80). Supervisors felt uncomfortable giving this kind of feedback because their checklist contained few items related to CPI and they lacked strong interpersonal communication skills themselves.

To generate effective feedback on providers’ communication and counseling performance, reproductive health programs may need to strengthen the existing supervision system or add a new component to it. Effective CPI supervision requires supervisors to observe consultations and other interactions with clients, provide feedback to individual staff members and groups, identify weaknesses, and develop plans for improvement (see box, How Supervisors Can Improve and Maintain Good CPI). Additional training and practice in interpersonal communication and an observation guide for CPI helped supervisors in Haiti (16) and the Philippines (32) carry out these tasks.

Supervision of CPI also benefits from a supportive, or facilitative approach, in which supervisors work with providers and other staff members to resolve problems and improve performance (13, 40, 101). In Mexico the Instituto Mexicano del Seguro Social/ Solidaridad (IMSS/S), with assistance from the Quality Assurance Project (QAP) and the Johns Hopkins University Center for Communication Programs, trained supervisors to assess doctors’ CPI performance with an observation checklist, give them constructive feedback, and help them select specific communication skills to work on. After four months and two supervision visits, doctors working with trained supervisors were more likely than their peers to foster rapport and client participation and to offer clients information and counseling (68).

This evaluation card from Peru asks clients about the quality of care they received. Clients’ opinions powerfully motivate providers to offer better care.

Feedback should not be left solely to external supervisors who may visit facilities infrequently. On-site managers and coworkers, who are present all the time, can be good sources of feedback as long as job expectations are clearly established, known, and accepted by all (23, 38, 101). Feedback from coworkers can be especially valuable because they understand the challenges that their colleagues face and can accurately assess their performance (49). Feedback from fellow providers proved influential at the Ghana Registered Midwives’ Association, which made peer review a regular part of monthly business meetings (111).

Self-assessment, in which providers monitor their own skills and performance, provides another source of feedback (15, 101). By assessing their own performance during consultations against a list of clear standards, providers in Indonesia were able to identify their own strengths and weaknesses and decide which communication skills to improve (77). Self-assessment proved even more powerful in Mexico (68) and Haiti (16), where providers listened to audiotapes of their own consultations.

Clients also are a source of direct and powerful feedback on provider performance. When clients are taught to expect and request good CPI, providers respond accordingly (152). To capture client feedback systematically and improve the way clients were treated at health centers in the Dominican Republic, the Dominican Social Security Institute (IDSS), with technical assistance from PRIME, created a system of client comment cards and suggestion boxes. By reviewing and discussing clients’ suggestions at the weekly staff meeting, the director of each health center made providers aware of client concerns—such as impoliteness and lack of punctuality —and the need for change (98).

Providers cannot practice good CPI unless they have both communication skills and technical knowledge. They need to understand the counseling process, help clients with decision-making and problem-solving, and understand social and other issues that affect clients and their needs. At the same time, they need current, accurate knowledge—or ready access to information—on contraceptive methods and related reproductive health topics such as HIV/AIDS and other STIs. Training, support from supervisors and coworkers, and well-designed job aids are crucial to helping providers develop and apply these interpersonal and technical skills.

Preservice education offers the best opportunity to develop strong CPI skills and build technical knowledge (136). All health workers attend some sort of preservice education, while the availability of later in-service training is unpredictable. Preservice education, which may involve a year or more of study, also provides time and opportunity for students to develop important attitudes and skills and for the curriculum to address complex issues. Experience has shown that preservice education shapes the way providers practice throughout their careers. Later efforts to change knowledge and behavior often encounter a great deal of resistance.

While preservice education can lay a sound foundation, both new and experienced providers also require periodic in-service training and continuing education to update information and refresh their skills over the course of their careers (114). Learning takes place less formally as well, as coworkers and supervisors help providers apply, perfect, and retain the skills they acquire in training. To encourage this kind of informal learning, supervisors should stress the importance of good care and foster an atmosphere of mutual accountability, so that providers believe that it is right to acknowledge mistakes and ask how to improve. Because of the central importance of training, the next chapter discusses best training practices in detail (see chapter 4, Best Practices in Training).

Well-designed job aids can help providers integrate their knowledge and skills into interactions with clients (67, 83, 93). Flipcharts, for example, serve as memory aids for providers during consultations and keep interactions focused, while simultaneously giving clients essential information. In Honduras providers reported that a pocket guide helped them remember and apply key interpersonal communication skills, elicit more information from clients, and provide better care (36).

Job aids also can improve providers’ attitudes by helping them handle complex situations. In Kenya, for example, a laminated checklist of questions designed to rule out pregnancy made providers feel more favorable towards providing contraception to nonmenstruating women (146).

Reference materials at the work site, such as handbooks or information sheets, enable providers to look up information that they cannot remember or to review key concepts taught in training. Every service delivery site should have a copy of the national guidelines and protocols that operationalize essential technical and medical information on family planning. Reference materials also may cover interpersonal communication and counseling skills. In Mexico, for example, young doctors regularly consulted a series of color-coded information sheets on key communication skills after supervisors began assessing how well they interacted with clients during consultations (68).

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