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PROGRAM CASE STUDY
Open Access

Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling

Amanda Kalamar, Kendal Danna, Alexandra Angel, Claire W. Rothschild, Innocent Meja, Eva Lathrop and Philip Mkandawire
Global Health: Science and Practice April 2023, 11(2):e2200319; https://doi.org/10.9745/GHSP-D-22-00319
Amanda Kalamar
aPopulation Services International, Washington, DC, USA.
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Kendal Danna
aPopulation Services International, Washington, DC, USA.
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Alexandra Angel
aPopulation Services International, Washington, DC, USA.
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Claire W. Rothschild
aPopulation Services International, Washington, DC, USA.
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Innocent Meja
bPopulation Services International/Malawi, Lilongwe, Malawi.
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Eva Lathrop
aPopulation Services International, Washington, DC, USA.
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Philip Mkandawire
bPopulation Services International/Malawi, Lilongwe, Malawi.
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  • FIGURE 1
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    FIGURE 1

    Example of Counseling on Specific Method Attributes From the C4C Choice Book Job Aid

    Abbreviation: C4C, Counseling For Choice; EC, emergency contraception.

  • FIGURE 2
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    FIGURE 2

    Client Rating of Overall Counseling Experience Immediately Post-Counseling

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    TABLE 1.

    Demographics of Counseling for Choice Evaluation Participants in Malawi

     Control, No. (%) (N=578)Intervention, No. (%) (N=601)P Value
    Age, years.73
     18–24208 (36.0)228 (37.9)
     25–29146 (25.3)155 (25.8)
     30–34115 (19.9)119 (19.8)
     35+109 (18.9)99 (16.5)
    Marital status  .95
     Married or living together520 (90.0)540 (89.9)
     Not married58 (10.0)61 (10.2)
    Children, no..74
     05 (0.9)5 (0.8)
     1161 (27.9)147 (24.5)
     2153 (26.5)165 (27.5)
     3104 (18.0)119 (19.8)
     4+155 (26.8)165 (27.5)
    Method use before visit.41
     Not currently using99 (17.1)114 (19.0)
     Currently using479 (82.9)487 (81.0)
    Method chosen at baseline<.001
     None105 (18.2)33 (5.5)
     Female sterilization0 (0)2 (0.4)
     IUD2 (0.4)2 (0.4)
     Implant31 (6.6)121 (21.3)
     Injectable401 (84.8)391 (68.8)
     Oral contraceptive pills28 (5.9)43 (7.6)
     Condoms only8 (1.7)8 (1.4)
     Emergency contraceptive pills3 (0.6)1 (0.2)
    Facility type.62
     Public sector265 (45.8)267 (44.4)
     Private sector313 (54.2)334 (55.6)
    • Abbreviation: IUD, intrauterine device.

    • View popup
    TABLE 2.

    Person-Centered Contraceptive Counseling: Post-Counseling Results Among Women in the Counseling for Choice Evaluation, Malawi

    How do you think the provider did in:Control, No. (%)Intervention, No. (%)ORa(95% CI)aORb(95% CI)ICCcσu2d
    Respecting you as a person?
     1 - Poor18 (3.1)9 (1.5) 2.62e (1.38, 4.97)2.65e (1.40, 5.02)0.371.71
     2 - Fair60 (10.4)18 (3.0) 
     3 - Good153 (26.5)118 (19.6) 
     4 - Very good145 (25.1)148 (24.6) 
     5 - Excellent202 (35.0)308 (51.3)
    Letting you say what matters to you about your contraceptive method?
     1 - Poor88 (15.2)37 (6.2) 2.37e (1.34, 4.20)2.20f (1.20, 4.00)0.321.40
     2 - Fair81 (14.0)32 (5.3) 
     3 - Good147 (25.4)140 (23.9) 
     4 - Very good103 (17.8)148 (24.6) 
     5 - Excellent159 (27.5)244 (40.6) 
    Taking your preferences about contraception seriously?
     1 - Poor50 (9.0)20 (3.3) 2.97e (1.64, 5.37)2.60e (1.42, 4.75)0.341.43
     2 - Fair102 (17.7)36 (6.0) 
     3 - Good145 (25.1)143 (23.8) 
     4 - Very good124 (21.5)152 (25.3) 
     5 - Excellent155 (26.8)250 (41.6) 
    Gave enough information to make the best decision about a contraceptive method
     1 - Poor223 (38.6)75 (12.5) 5.68e (3.01, 10.73)5.14e (2.72, 9.71)0.431.63
     2 - Fair103 (17.8)56 (9.3) 
     3 - Good132 (22.8)138 (23.0) 
     4 - Very good56 (9.7)125 (20.8) 
     5 - Excellent64 (11.1)207 (34.4) 
    PCCC Measure
     At least one item with less than highest score (“5”)542 (94.8)461 (76.7) 4.76e (1.92, 11.81)4.59e (1.86, 11.33)0.552.95
     Highest score (“5”) on all items36 (6.2)140 (23.3) 
    • Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; ICC, intraclass correlation; OR, odds ratio; PCCC, person-centered contraceptive counseling.

    • ↵a Estimated from multilevel mixed effects model with ordinal or binary outcomes. Unadjusted OR estimated from bivariate models.

    • ↵b Estimated from models that include demographic variables (age, marital status, and education), a categorical variable for number of living children (defined as none, 1–2, 3–4, or 5 or more), and variables for method chosen at provider visit (including no method chosen) and type of facility (public or private). All adjusted models comprised of 1,179 observations.

    • ↵c Estimated from unadjusted model with random intercepts for health facility but without fixed effects predictors.

    • ↵d Estimated variance for the random effects at the health facility level; estimate has not been exponentiated.

    • e Significant at P<.01.

    • f Significant at P<.05.

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    TABLE 3.

    Informed Decision-Making and Interpersonal Communication: Post-Counseling Results Among Women in the Counseling for Choice Evaluation, Malawi

    Control, No. (%)Intervention, No. (%)ORa(95% CI)aORb(95% CI)ICCcσu2dObservationse
    Provider addressed all concerns about using contraception
     Yes229 (39.6)460 (76.5)7.26f (3.57, 14.80)6.43f (3.08, 13.41)0.481.851,176
     No348 (60.2)140 (23.3)
    Provider asked about past contraceptive experience
     Yes219 (37.9)448 (74.5)

    6.76g (3.35, 13.65)

    6.23f (3.00, 12.92)

    0.451.841,176
     No359 (62.1)153 (25.5)
    Trust provider will keep information discussed during consultation a secret
     Yes501 (86.7)575 (96.7)

    3.23f (1.50, 6.97)

    3.06f (1.41, 6.67)

    0.341.141,163
     No27 (4.7)8 (1.3)
     Don't knowh50 (8.7)18 (3.0)
    Provider helped make a plan for how to remember to use the method, among short-term method usersi
     Yes258 (54.6)453 (79.8)

    6.32f (2.60, 15.35)

    6.45f (2.57, 16.20)

    0.492.581,034
     No215 (45.5)115 (20.3)
    Confidence using chosen method, among those who received a method during the consultation
     1 - Not at all25 (5.3)10 (1.8)

    1.94g (1.04, 3.62)

    1.84 (0.99, 3.44)

    0.331.491,035
     2 - No opinion27 (5.7)23 (4.1)
     3 - Somehow confident104 (22.1)63 (11.2)
     4 - Confident138 (29.4)189 (33.5)
     5 - Very confident176 (37.5)280 (49.6)
    • Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; ICC, intraclass correlation; OR, odds ratio.

    • ↵a Estimated from multilevel mixed effects models including facility-level random effects. “Gave enough information” and “confidence to use chosen method” were modeled as ordinal variables. The “provider addressed all concerns” outcome was modeled as a binary variable. Odds ratios estimated from multilevel mixed effects model with ordinal or binary outcomes. Unadjusted odds ratios estimated from bivariate models.

    • ↵b Estimated from models that include demographic variables (age, marital status, and education), a categorical variable for number of living children (defined as none, 1–2, 3–4, or 5 or more), and variables for method chosen at provider visit and type of facility (public or private).

    • ↵c Estimated from unadjusted model with random intercepts for health facility but without fixed effects predictors.

    • ↵d Estimated variance for the random effects at the health facility level in the adjusted model; estimate has not been exponentiated.

    • ↵e Number of observations in the adjusted model; complete case analysis.

    • ↵f Significant at P<.01.

    • ↵g Significant at P<.05.

    • ↵h For modeled estimates, we use a binary version of the indicator that combines "no" and "don't know" responses in a single category (versus “yes”).

    • ↵i Asked only of women who received injectables, oral contraceptive pills, condoms, or emergency contraceptive pills.

    • View popup
    TABLE 4.

    Side Effects Expectations and Management: Baseline Results Among Women in Control and Intervention Groups, Among Women Who Received a Method

     Did the Provider Tell You About Side Effects You Might Experience With Your Chosen Method? Did the Provider Help You Make a Plan to Manage Side Effects? If You Experience Side Effects, Will You Discontinue Your Method Immediately?
     Control, No. (%)Intervention, No. (%) Control, No. (%)Intervention, No. (%) Control, No. (%)Intervention, No. (%)
    Yes180 (38.1)412 (72.5) 194 (41.0)441 (77.6) 52 (11.0)40 (7.0)
    No293 (62.0)156 (27.5) 279 (59.0)127 (22.4) 421 (89.0)528 (93.0)
    ORa (95% CI)6.62b (3.24, 13.53) 8.89b (3.77, 20.96) 0.67 (0.40, 1.13)
    aORc (95% CI)5.98b (2.97, 12.03) 8.79b (3.68, 21.01) 0.79 (0.45, 1.40)
    ICCd0.45 0.55 0.09
    σu2e1.56 2.59 0.26
    Observationsf1,038 1,038 1,024
    • Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; ICC, intraclass correlation; OR, odds ratio.

    • ↵a Estimated from multilevel mixed effects model with ordinal or binary outcomes. Unadjusted odds ratios estimated from bivariate models.

    • ↵b Significant at P<.01.

    • ↵c Estimated from models that include demographic variables (age, marital status, education), a categorical variable for number of living children (defined as none, 1–2, 3–4, or 5 or more), and variables for method chosen at provider visit and type of facility (public or private).

    • ↵d Estimated from unadjusted model with random intercepts for health facility but without fixed effects predictors.

    • e Estimated variance for the random effects at the health facility level; estimate has not been exponentiated.

    • ↵f Number of observations in the adjusted model.

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Global Health: Science and Practice: 11 (2)
Global Health: Science and Practice
Vol. 11, No. 2
April 28, 2023
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Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling
Amanda Kalamar, Kendal Danna, Alexandra Angel, Claire W. Rothschild, Innocent Meja, Eva Lathrop, Philip Mkandawire
Global Health: Science and Practice Apr 2023, 11 (2) e2200319; DOI: 10.9745/GHSP-D-22-00319

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Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling
Amanda Kalamar, Kendal Danna, Alexandra Angel, Claire W. Rothschild, Innocent Meja, Eva Lathrop, Philip Mkandawire
Global Health: Science and Practice Apr 2023, 11 (2) e2200319; DOI: 10.9745/GHSP-D-22-00319
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