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Appendix C: Principles for Providing Quality Counseling

Counseling is a process that enables clients to make and follow through on decisions. Education is an integral component of the counseling process that helps clients to make informed decisions. Providing quality counseling is an essential component of client-centered care.

Key principles of providing quality counseling are listed below and may be used when providing family planning services. The model was developed in consultation with the Technical Panel on Contraceptive Counseling and Education and reviewed by the Expert Work Group. Although developed specifically for providing contraceptive counseling, the principles are broad and can be applied to health counseling on other topics. Although the principles are listed here in a particular sequence, counseling is an iterative process, and at every point in the client encounter it is necessary to determine whether it is important to readdress and emphasize a given principle.

Principles of Quality Counseling

Principle 1. Establish and Maintain Rapport with the Client

Establishing and maintaining rapport with a client is vital to the encounter and achieving positive outcomes (1). This can begin by creating a welcoming environment and should continue through every stage of the client encounter, including follow-up. The contraceptive counseling literature indicates that counseling models that emphasized the quality of the interaction between client and provider have been associated with decreased teen pregnancy, increased contraceptive use, increased use of more effective methods, increased use of repeat or follow-up services, increased knowledge, and enhanced psychosocial determinants of contraceptive use (2–5) .

Principle 2. Assess the Client's Needs and Personalize Discussions Accordingly

Each visit should be tailored to the client's individual circumstances and needs. Clients come to family planning providers for various services and with varying needs. Standardized questions and assessment tools can help providers determine what services are most appropriate for a given visit (6). Contraceptive counseling studies that have incorporated standardized assessment tools during the counseling process have resulted in increased contraceptive use, increased correct use of contraceptives, and increased use of more effective methods (2,7,8). Contraceptive counseling studies that have personalized discussions to meet the individual needs of clients have been associated with increased contraceptive use, increased correct use of contraceptives, increased use of more effective methods, increased use of dual-method contraceptives to prevent both sexually transmitted diseases (STDs) and pregnancy, increased quality and satisfaction with services, increased knowledge, and enhanced psychosocial determinants of contraceptive use (4,7,9–12).

Principle 3. Work with the Client Interactively to Establish a Plan

Working with a client interactively to establish a plan, including a plan for follow-up, is important. Establishing a plan should include setting goals, discussing possible difficulties with achieving goals, and developing action plans to deal with potential difficulties. The amount of time spent establishing a plan will differ depending on the client's purpose for the visit and health-care needs. A client plan that requires behavioral change should be made on the basis of the client's own goals, interests, and readiness for change (13–15). Use of computerized decision aids before the appointment can facilitate this process by providing a structured yet interactive framework for clients to analyze their available options systematically and to consider the personal importance of perceived advantages and disadvantages (16,17). The contraceptive counseling literature indicates that counseling models that incorporated goal setting and development of action plans have been associated with increased contraceptive use, increased correct use of contraceptives, increased use of more effective methods, and increased knowledge (2,9,18–20). Furthermore, contraceptive counseling models that incorporated follow-up contacts resulted in decreased teen pregnancy, increased contraceptive use, increased correct use of contraceptives, increased use of more effective methods, increased continuation of method use, increased use of dual-method contraceptives to prevent both STDs and pregnancy, increased use of repeat or follow-up services, increased knowledge, and enhanced psychosocial determinants of contraceptive use (2,3,7,11,21,22) . From the family planning education literature, computerized decision aids have helped clients formulate questions and have been associated with increased knowledge, selection of more effective methods, and increased continuation and compliance (23–25).

Principle 4. Provide Information That Can Be Understood and Retained by the Client

Clients need information that is medically accurate, balanced, and nonjudgmental to make informed decisions and follow through on developed plans. When speaking with clients or providing educational materials through any medium (e.g., written, audio/visual, or computer/web-based), the provider must present information in a manner that can be readily understood and retained by the client. Strategies for making information accessible to clients are provided (see Appendix D).

Principle 5. Confirm Client Understanding

It is important to ensure that clients have processed the information provided and discussed. One technique for confirming understanding is to have the client restate the most important messages in her or his own words. This teach-back method can increase the likelihood of the client and provider reaching a shared understanding, and has improved compliance with treatment plans and health outcomes (26,27). Using the teach-back method early in the decision-making process will help ensure that a client has the opportunity to understand her or his options and is making informed choices (28).


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  2. Adams-Skinner J, Exner T, Pili C, Wallace B, Hoffman S, Leu CS. The development and validation of a tool to assess nurse performance in dual protection counseling. Patient Educ Couns 2009;76:265–71.
  3. Brindis CD, Geierstanger SP, Wilcox N, McCarter V, Hubbard A. Evaluation of a peer provider reproductive health service model for adolescents. Perspect Sex Reprod Health 2005;37:85–91.
  4. Nobili MP, Piergrossi S, Brusati V, Moja EA. The effect of patient-centered contraceptive counseling in women who undergo a voluntary termination of pregnancy. Patient Educ Couns 2007;65:361–8.
  5. Proctor A, Jenkins TR, Loeb T, Elliot M, Ryan A. Patient satisfaction with 3 methods of postpartum contraceptive counseling: a randomized, prospective trial. J Reprod Med 2006;51:377–82.
  6. Fiore M, Jaén C, Baker T, Bailey W, Benowitz N, Curry S. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: US Department of Health and Human Services; 2008. Available at
  7. Boise R, Petersen R, Curtis KM, et al. Reproductive health counseling at pregnancy testing: a pilot study. Contraception 2003;68:377–83.
  8. Custo G, Saitto C, Cerza S, Sertoli G. The adjusted contraceptive score (ACS) improves the overall performance of behavioural and barrier contraceptive methods. Adv Contracept Deliv Syst 1987;3:367–73.
  9. Hanna KM. Effect of nurse-client transaction on female adolescents' oral contraceptive adherence. Image J Nurs Sch 1993;25:285–90.
  10. Schunmann C, Glasier A. Specialist contraceptive counselling and provision after termination of pregnancy improves uptake of long-acting methods but does not prevent repeat abortion: a randomized trial. Hum Reprod 2006;21:2296–303.
  11. Shlay JC, Mayhugh B, Foster M, Maravi ME, Baron AE, Douglas JM Jr. Initiating contraception in sexually transmitted disease clinic setting: a randomized trial. Am J Obstet Gynecol 2003;189:473–81.
  12. Weisman CS, Maccannon DS, Henderson JT, Shortridge E, Orso CL. Contraceptive counseling in managed care: preventing unintended pregnancy in adults. Womens Health Issues 2002;12:79–95.
  13. Kaplan D. Family Counseling for all counselors. Greensboro, NC: CAPS Publications; 2003.
  14. Nupponen R. What is counseling all about—basics in the counseling of health-related physical activity. Patient Educ Couns 1998;33(Suppl):S61–7.
  15. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002;22:267–84.
  16. French RS, Wellings K, Cowan F. How can we help people to choose a method of contraception? The case for contraceptive decision aids. J Fam Plann Reprod Health Care 2009;35:219–20.
  17. O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2009;CD001431.
  18. Cowley CB, Farley T, Beamis K. "Well, maybe I'll try the pill for just a few months...": brief motivational and narrative-based interventions to encourage contraceptive use among adolescents at high risk for early childbearing. Fam Syst Health 2002;20:183–204.
  19. Gilliam M, Knight S, McCarthy M Jr. Success with oral contraceptives: a pilot study. Contraception 2004;69:413–8.
  20. Namerow PB, Weatherby N, Williams-Kaye J. The effectiveness of contingency-planning counseling. Fam Plann Perspect 1989;21:115–9.
  21. Berger DK, Perez G, Kyman W, et al. Influence of family planning counseling in an adolescent clinic on sexual activity and contraceptive use. J Adolesc Health Care 1987;8:436–40.
  22. Winter L, Breckenmaker LC. Tailoring family planning services to the special needs of adolescents. Fam Plann Perspect 1991;23:24–30.
  23. Chewning B, Mosena P, Wilson D, et al. Evaluation of a computerized contraceptive decision aid for adolescent patients. Patient Educ Couns 1999;38:227–39.
  24. Garbers S, Meserve A, Kottke M, Hatcher R, Chiasson MA. Tailored health messaging improves contraceptive continuation and adherence: results from a randomized controlled trial. Contraception 2012;86:536–42.
  25. Garbers S, Meserve A, Kottke M, Hatcher R, Ventura A, Chiasson MA. Randomized controlled trial of a computer-based module to improve contraceptive method choice. Contraception 2012;86:383–90.
  26. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics 1997;100:330–3.
  27. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83–90.
  28. National Quality Forum. Health literacy: a linchpin in achieving national goals for health and healthcare, Issue Brief #13 2009. Available at

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