Introducing PSI’s New Counseling Prototype, the Choice Book

By Laura Glish, Reproductive Health Technical Advisor, PSI

PSI technical experts on reproductive health recently introduced a new contraceptive counselling prototype. Read more about what makes it different and effective:

Access to contraception is key to securing the wellbeing and autonomy of women and girls. Yet in many regions of the world, large numbers of women and girls who want to avoid pregnancy still do not use a modern method- or try one, and then discontinue it within a year because they didn’t like the method, even though they still don’t want to get pregnant.

Increasing the availability of different methods has been shown to increase overall use of contraception, yet in almost all countries, a single method dominates the market at different life stages. For example, in the US, women and girls use condoms when they are only occasionally having sex, pills when sex becomes more frequent, and sterilization when they don’t want any more children. While IUDs and implants are starting to become more common, this typical pattern of use still holds, and has held since the pill was introduced. Yet research shows that women vary greatly in what attributes they prefer in a contraceptive method. So why are they all using the same thing?

In most countries in sub-Saharan Africa, the pattern is condoms, if any method, for unmarried girls, and injectables for married women. Here the mismatch in preferences and use is even more problematic- the top reason for discontinuation and non-use is fear of side effects, yet women are consistently choosing the method with the highest chance of side effects. In a recent study in Ghana, 70% of women chose a method which was likely to cause a side effect they had previously told the surveyor would cause them to discontinue a method. To answer the question, “Why do people make irrational decisions?”, we turn to behavioral economics.

In general, humans avoid making decisions. Making choices is a complex process, especially when there are a large number of options. In studies on choices, from number of types of jam to number of retirement plans, as options proliferate, people are less likely to choose any of them. This can lead to putting off a decision, or just going with a default option- as in, the method everyone else is using.

So how can we help women and girls find the method that meets their personal needs, instead of defaulting to the one their neighbor is using? Often providers will make a 15-minute presentation of all the available methods to each client before giving her the method she came in asking for, to ensure the client is making an ‘informed choice’. This hardly ever results in the client changing her mind.

Cognitive psychology has found the human brain can only process about 7 pieces of information at a time, and prefers to make decisions by comparing 2-3 choices. The current presentation of 5-9 methods, with their mechanism of action, mode of administration, duration of action, side effects and medical eligibility makes it impossible to remember most of what is said, much less compare how the methods would impact daily life.

This not only is an overload of information, it often focuses on the technical features that the provider learned in clinical training, like: “The IUD contains copper and goes in your uterus for 10 years, making the environment inhospitable to sperm” as opposed to the benefits, such as, “The IUD has few side effects, is easy to use and can be reversed at any time”. Which is more useful for someone trying to decide if the IUD is of interest to her?

As part of our Counseling for Continuation initiative, we want to help clients see how the different methods will impact their lives, not just how they are administered. This involves rethinking the way we talk about methods, both before, during, and after the client is in the clinic. To help providers and outreach workers start that mindset shift, PSI’s RH department made some mock user videos about what makes each method special. Here are some examples:

Choice architecture has been shown to influence decision making, whether or not it is consciously designed. What attributes of an option are mentioned, and in what order, strongly impact what people chose. When the choice architecture is time (do you want something for 10 years, 5 years, 3 months, or 1 day?) and mode of administration (do you want something inserted into your uterus, or your arm, or a shot, or a pill?), it’s no surprise that many clients opt for the injectable – not too long, not too short, not too scary, not too much hassle.

To help empower women and girls to make a truly informed choice, PSI designed the Choice Book around these principles: focusing on daily user experience instead of clinical details, reframing the choice architecture, and increasing retention of key information for client satisfaction.

Here are some top elements of the Choice Book designed to make it effective:

  • Starts by comparing methods on whatever attributes matters most to that client: pregnancy prevention, future pregnancy, privacy, HIV/STI prevention, side effects, changes to periods, ease of use, ease of starting and stopping, or cost
  • Providers help the client narrow down acceptable methods using these attributes, to only go into the details of 2-3 methods
  • Present methods based on what users like about them
  • Focuses the detailed information on the methods to what a client must remember, the 3Ws: what to do, what to expect, when to come back
  • Prompts the provider to help the client make a plan for how to use her method correctly and what to do if she experiences the most common side effect of that method

Pilot versions of PSI’s Choice Book have already been applied in Mozambique and Tanzania and has seen increasingly positive remarks from health providers in the field. Early data in Mozambique showed an increase of implants over injectables, but the default method- in this case pills- stayed the same. Next year, a randomized control trial in Malawi will compare the old way and the new way, in terms of method choice and method continuation and satisfaction 6 months later. If it proves successful at better matching a client to a method, it has the potential to revolutionize the way we think about contraceptive counseling.

“I’ve had clients change their mind and choose a long acting method after going over the manual.”  – Nurse in Bilene, Mozambique

The Choice Book was debuted at the recently held USAID Global Health Mini University by PSI’s technical advisor on reproductive health, Laura Glish and program coordinator Alexandra Angel.