Perceptions of clients regarding family planning service delivery in a clinic of the Greater Johannesburg Metropolitan Council

Curationis 33 (2): 13-24 Unwanted pregnancies with their negative impact on both women and children occur on an ongoing basis in Gauteng, South Africa. One way to prevent unwanted preg­ nancies is to use a reliable contraceptive method available free of charge from primary health care clinics providing family planning services throughout Gauteng Province. A literature review was completed on women and access to family planning services and an interview schedule (questionnaire) was developed. The purpose of this study was to describe guidelines to meet the expectations of clients accessing family plan­ ning services provided by a clinic in Region F, Area 28 of the Greater Johannesburg metropolitan council. This quantitative, exploratory, descriptive and comparative study measured the gaps between the expectations of participants on service deliv­ ery and the extent to which these expectations were met. A convenience sample was conducted and consisted of 50 women of reproductive age (ages 15 to 49) attending the family planning clinic. Pre-testing of the instrument was conducted. Structured interviews with a interview schedule were conducted before and after women at­ tended a family planning service. Inferential statistics indicated that there was a significant gap between the client expectations of family planning service delivery and the extent to which these expectations were met. O f the sixty-four items where women indicated the extent of their expectations the findings on only three items were not statistically significant. These gaps were addressed by proposing manage­ rial guidelines to be implemented by the nurse manager in charge of the facility, on which this article will focus. Validity and reliability principles were ensured in the study. Ethical principles were adhered to during the research process. Tel: (011)559-2857 E-mail: kjooste@uj.ac.za


Introduction
Family planning service delivery is of the utmost importance in the current health care scenario o f unintended pregnancies (Health Systems Trust, 2002:1;Health Systems Trust, 2007:1).Seventy-five million unintended preg nancies occur world-wide every year, mostly because o f couples not using contraception (WHO, 2000a:6).Women o f reproductive age in Gauteng, who are using or whose partners are using contraceptive methods are calculated at 60.9%.The high percentage o f cou ples (nearly 40%) not using contracep tives leads to a large number o f unin tended pregnancies (Medical Research Council, 2001:1).A woman's ability to space and limit the number of her preg nancies has a direct impact on her health and well-being, as well as on the outcome o f her pregnancy (Braam, 2002:14-15;Kirby, 2006:54;Venugopal & Upadhyay, 2002:2).The role o f the family planning service becomes appar ent when clients have certain expecta tions that should be met.Ehlers, Maja, Sellers and Gololo (2000:43-44) state that the way in which family planning services are delivered becomes a major obstacle to their use.The number o f unplanned/unintended pregnancies could bear witness to this fact.Improv ing family planning service delivery in line with clients' expectations is essen tial to putting clients first.Services should be provided to meet health care standards and to treat clients as they want to be treated.Clients' concerns and preferences are valid and impor tant (Kols& Sherman, 1998:9-10).Akey area for improving family planning serv ice delivery identified by the WHO is assessing and understanding the be haviour and perceptions o f the clients o f family planning and other reproduc tive health services (WHO:2000b: 1).
Although investigation o f clients' ex pectations o f health care was previ ously undertaken in South Africa, it was not focussed on family planning in the Johannesburg Metropolitan area (Ehlers ,et al, 2000:43).In the fight against unintended pregnancies and its consequences and in keeping with in ternational trends it is thus considered important to take the client's expecta tions o f service into consideration when attempting to address the issue o f family planning services provided.
It is clear that, without consulting the client, bridging the gap between what clients expect and the actual service received by clients can't be planned for.

Literature review
According to the Department o f Na tional Health, the IPPF and the WHO family planning service delivery com prises seven fundamental elements for measuring the care that will serve as the theoretical departure o f this study (DOH, 2000:22-31;WHO:2000b: 1).
Access to family planning is recognised as aright o f all individuals and couples (Powlson, 2004:12; University of Sas katchewan, 2008:1).Client expectations start with accessibility o f services, im plying that services should be afford able and co nveniently situ ated (JHPIEGO, 1998a:4;WHO,2003:1).Ina family planning clinic nurses' behav iour with regards to the appropriate ness and acceptability o f services they provide falls into the domain o f ethics (Smit & Cronj e, 2002:490-491).Appro priateness and acceptability of services implies that services are designed with the needs o f the client in mind, rather than that o f the staff.Services should be clean and inviting to clients and should not pose a health risk for cli ents accessing the service.Waiting times should be acceptable to the cli ents visiting the clinic (FHI, 2004:2).Accurate, scientifically sound, com plete and adequate information has to be made available to the client so that she can make the best choice for her self.The nurse giving the information should be tech n ic ally com petent (RHRU, 2000:27).Information shared with clients includes information for making informed decisions, information needed for the client to use her method correctly and safely.
Sub-optimal interpersonal interac tions between family planning nurses and clients are seen as a barrier to fam ily planning access (WHO, 2008:1).Cli ents who are welcomed, treated with respect and encouraged to ask ques tions and participate in their health care are more likely to be satisfied contra ceptive users.Nurses should change their behaviour in the way they initiate a consultation (Metcalf, 2004:42).Clients have the right to decide freely which method to use and should re ceive the method o f choice unless con tra-indicated (Pow lson, 2004:13).Choice is one o f the components nec essary for quality o f care in the frame work suggested by Family Health In ternational (FHI, 2004:2).The South African Department o f Health has set it as a goal to 'expand and strengthen the current method mix to meet varying needs (DOH, 2000:27).Ensuring the availability o f a wide choice o f meth ods promotes client-centred care where the client receives a method she wants to use without compromising her health (Jarvis, 2005:255).
The prevention and treatment o f Sexu ally Transmitted infections (STIs), in cluding HIV and AIDS is essential.When a client suspects that an infec tion may be present she should seek help as soon as p ossible (W HO, 2005:48).Where clients are exposed to the risk o f STIs, HIV and unintended pregnancy, a sexual risk-reduction in tervention is recommended, that in cludes abstinence and emphasises so cial skills, such as communication and condom use, (Champion, Shain & Piper, 2004:294).Three mechanisms o f continuity o f care are important, namely follow-up con traceptive and reproductive health care, the need for clients to know when to return for services and access to a serv ice when needed (FHI, 2004:2).The Department o f National Health in South Africa focuses on the importance of discussing with clients that they may come in to the clinic when problems arise or questions need to be answered (DOH, 2004:19).Record keeping should be o f such a nature that the next pro vider is aware o f decisions made dur ing previous visits and o f the areas of concern that should be followed up (Guillebaud, 1993:398,441-448;Hatcher, Rinehart, Blackburn, Geller & Shelton, 2001 :vi).

Problem statement
Uninformed women are subject to mis conceptions and misinformation re garding family planning and contracep tion, which could lead to women dis continuing the use o f the available free services.Their expectations o f service delivery aren't met and by not using family planning services they fall vic tim to unintended pregnancies.This results in high maternal mortality and morbidity rates and unacceptably high teenage pregnancy rates, and has a di rect impact on women's health and well being as well as the outcome of their pregnancies (Medical Research Coun cil, 2001:1;Ehlers, et al, 2000:43-44;WHO: 2000b: 1) , 2000:33).

Guidelines
For the purpose o f this study guide lines refer to directives that will assist the nurse manager of the clinic to meet the expectations o f family planning service delivery o f clients receiving family planning services at a clinic in Region F, Area 28 o f the Greater Johan nesburg Metropolitan Council (Soanes, Spooner & Hawker, 2001:398).

Research design and sample
A quantitative, exploratory, descriptive and comparative design was followed.Grove, 1993:239-247).Clients coming for both first visits and repeat visits in a particular month were selected when they accessed the family planning serv ice.

Data gathering
Data were gathered in two phases.An interview schedule (structured ques tionnaire) and the recording o f field notes were undertaken during a person-to-person interview.A similar 4point scale instrument was completed before and after the client/participant received family planning services.This interview schedule included structured items on the seven elements o f family planning service delivery and a few open ended q uestions (D e Vos, 1998:297;Babbie & Mouton, 2001:249-256).1).

Data analysis
An individual gap was measured on each item using a Marginal Homoge neity test.Each item's value was com pared to the overall p-value for each section as displayed in Table 2.Where the MH-test on an individual item was less than the p-value displayed (Table 2), the gap was considered meaning ful.By using the MH-test significant differences were found between clients' expectations o f service delivery and the extent to which the clients' expec tations of service delivery were met, in 61 out o f 64 items.

Validity and reliability
Validity deals with the extent to which the instrument measures that which it is intended to measure.Certain princi ples had to be applied in order to en sure validity (B abbie & M outon, 2001:122;Bums & Grove, 1993:342-347).
Validity was ensured by using the same interview schedule for all participants.
All categories in the interview sched ule were standard for all interview schedules.The use o f a standard inter view schedule and training of a research assistant ensured that the researcher stayed in control o f the content and purpose o f the interview (Parahoo, 1997:297).The reliability o f an instru ment deals with the ability o f an instru ment to produce the same results over a period o f time when used with the same participants in terms o f stability, equivalence and homogeneity (Bums & Grove, 2005:374).The structured in terview instrument was given to experts in the field o f the study as well as stat isticians for scrutiny in the pre-testing o f the instrument.Participants were made aware o f the time involved for the interview process, and had agreed to be interviewed with the knowledge of how long the interview would take eliminating urgency within the client to finish the interview.The same struc tured interview schedule was used throughout the study.When planning the provision o f family planning services the comfort o f the client should always be kept in mind.This starts with the client's experience when walking into the clinic waiting area and extends through to the exami nation bed that the client is examined on.Clients view it as a sign o f respect when a service is provided with their comfort in mind (Powlson (ed), 2004:16).Safety measures in terms o f environ mental risk management should be adhered to.Measures in terms o f envi ronmental risk management that ensure a healthy and safe environment, to en sure clients' physical and mental well being, is a p a tie n t's right (DOH, 2000:18).

Information about available family planning services and contraceptive methods
Research has produced a vast body of information which has the potential to assist the client in making meaningful decisions about which contraceptive to use, how to use it so that they will enjoy the full benefit o f the method's protection and how to use it safely with out harming their health.Good patient education is a key to effective contra ception (Anon, 2005:51).
Information management in terms of information is needed for the client to make an informed method choice.In order for a client to make an informed choice, the latest information about av ailab le co n tra cep tiv e m ethods should be made available.This is es sential for participative decision mak ing (Rudy, Tabbutt-Henry, Schaefer & Me Quade, 2003:2).Participants men tioned a shortfall in receiving informa tion about the contraceptive method's mode of action and felt the clinic was too busy for nurses to take the time to educate the clients; the field notes out line the following comment o f a partici pant: "No, they do not do this.I think the clinic gets too busy and the line must move.They do not have time to do this." Information management in terms of information to use her method correctly.Full instructions should be given to clients on how to use a method consistently and correctly at home as this is crucial to the success o f the m ethod and prom otes com pliance (WHO, 2004b:3;RHRU, 2005:31,55-57 & Lete, 2006:14).Two items referred to information needed by the client for the correct use o f her method, namely, dem onstratin g the use o f the c lie n t's method o f choice to her and being given written information about her chosen contraceptive method.

Interpersonal skills demonstrated by the nurse
The nurse should demonstrate good interpersonal skills when assisting the client.In the family planning setting it is important for accurate, scientifically sound, complete, and adequate infor mation to be made available to the cli ent in a way that will be understand able to them.Then the client will be able to make an informed choice and use that method optimally and safely (RHRU, 2000a 2).Interpersonal skills in terms o f professional behaviour are needed.The tone must be set when the client has her first contact with the nurse in the clinic (WHO, 2005:48).The client must be made to feel welcome in the consultation room (FHI, 1998:2).The client should feel that she4s the most important person in the room and that she is respected as a person in the way she is addressed.Interaction, by the nurse in a non-professional man ner, together with an attitude that shows disinterest in the client is found to be a barrier to accessing services (Lester & Allan, 2005:7).Interpersonal skills in terms o f con sideration o f cultural diversity are im portant.The spoken language o f the client should be determined by the nurse.Then steps should be taken to ensure that the client receives informa tion essential for her choice o f method and the optimal use o f this contracep tive method.This information should be in a language and vocabulary at a level which the client can understand the nurse (Coetzee & Moys, 1999:44).The nurse should gain insight in the client's situation.It is important for the nurse to portray herself as understand ing and empathetic.Clients' value indi vidualised service and prefer provid ers who have made the effort to under stand their particular health care situa tion and need for service delivery (JHPIEGO, 1998b: 1;RHRU, 2000b: 10, 27).One client highlighted a particular problem she encountered in the proc ess o f trying to access a service as a foreigner: "I 'm from the Congo.I came to South Africa in the eighties and was treated very well.Now when they ask why I as an African speak English, they say it is because I 'm an alien.Their tone o f voice changes and they are not friendly anymore.They say I must go back where I came from." Interpersonal respect referred to the nurse showing the client interpersonal respect and fulfilling their expectation on service delivery in this regard.Participative decision making is an important principle in delivering family planning services.Client participation improves the outcome of the interac tion and should, therefore, be encour aged (FHI, 2004:2).Success o f contra ceptive use will be achieved when the client takes ownership of her own de cisions (Egan, 1998:48;De Freitas, 2007:180).

The choice of contraceptive methods made available
Clients should have a choice o f con traceptive methods in family planning services.Choice is one of the compo nents necessary for quality o f care in the framework suggested by Family Health International (FHI,2004:2).A broad range of methods has made serv ices more accessible (WHO, 2008:1).For clients to be able to choose a method that suits their circum stances, pro grammes need to make as many meth ods as possible available for the client to choose from (WHO, 2004a: 1).Nurses should facilitate the process o f participative decision making.Serv ices will have been made more accessi ble by a broad range o f contraceptive methods being held in stock (WHO, 2008:1).For clients to be able to choose a method that suits their circumstances, a well-run programme will ensure that many contraceptive methods are made available for the client from which a choice can be made (WHO, 2004a: 1).Client-centred care is essential.Cli ents should be given their method of choice unless contra-indicated as this leads to greater satisfaction, with a suc cessful use o f a contraceptive method (Powlson (ed), 2004:13).

Prevention and care of sexually transmitted infections including HIV
Family planning services are becoming increasingly integrated with other serv ices, especially in addressing STIs (in cluding HIV and AIDS) (Rudy et al, 2003:2;DOH, 2004a:22-31).Diagnosis and treatment o f S T I' s are needed.Screening as well as treatment according to syndromic management guidelines should be provided by all nurses providing a family planning service (Dickson et al, 2005:28;WHO, 2005:1).Nurses do not appear to rou tinely assess for the presence of STIs which is apparent with this comment from the field notes: "It is not easy to tell someone about this.No-one has asked me about this.I have never thought about it, you know, but it is important, very important.They should be asking".Risk reduction should be a focus area.Clients should be informed and helped to understand the risks that expose them to infection with STIs and HIV, and be able to protect themselves.Recommendations have been made that up to date inform ation about STIs should be combined with other sexual health services (Lester & Allan, 2004:3).The nurse should inform fam ily plan ning clients about H IV and Aids, since all family planning clients are consid ered to be sexually active and, there fore, at risk to some extent o f becoming infected with HIV (DOH, 2000:21,23, 25,28 & 36;Evian, 2000:4-7).

Mechanisms that ensure followup and continuity of care of women of reproductive age
Continuity o f care is considered to be essential for the continued successful use o f a contraceptive method.Clients should be given information on when to return to the clinic for services and to have access to a service when needed (FHI, 2004:2).Clients should be told to return when experiencing sideeffects and complications, or when to return for follow-up visit in time to re ceive the next supply of contraceptives (FHI, 2004:2).Continuous reliable sup plies being available in stock are es sential for ensuring continuity o f care.It is considered the client's right to re ceive contraceptive supplies for as long as she wants (Powlson (ed), 2004: 16-18).All barriers should be removed that will prevent the continued use o f con traception.Where service delivery has been streamlined in providing a client with a re-supply o f contraceptives; cli ents are more likely to continue using their method over the long term; pre v en tin g u n in ten d ed p reg n an cies (Ramchandran, 2007:2).Family plan ning services should be provided in a well-managed system with clear refer ral pathways so that health problems detected by the nurse that fall out of her scope o f practice may be dealt with (DOH, 2000:19 & 29).

Guidelines
Guidelines can be implemented to ef fectively deliver family planning serv ices to women o f reproductive age in a clinic in Region F, Area 28 of the Greater Johannesburg Metropolitan Council.Possible managerial actions that could be taken are by no means limited to the description below.
Guideline 1: The family planning clinic should be made accessible and available to women of reproductive age through time management and visibility.
The findings show that a statistically significant gap exists between clients' expectations o f the accessibility and availability of the family planning clinic to women o f reproductive age and the extent to which these expectations are met.Access to and availability o f fam ily planning services are/is considered a right o f the client (DOH,200 lb: 11).The nursing manager should address the daily opening times o f the family planning service and the availability of nurses during advertised hours o f the family planning service.
Guideline 2: Family planning service provision should be appropriate and acceptable to women of reproductive age taking into account ethical principles and a safe environment.
Appropriateness and acceptability of services means that services are de signed with the needs o f the client in mind, rather than that o f the staff.Cli ents have a right to privacy and respect as well as a safe, healthy environment, (DOH,200lb: 13,23).The manager should ensure that services delivered meet the highest possible ethical stand ards (DOH, 2001b: 10).The client should be respected and be allowed to undress in privacy.Ethical measures ensure that the client's right to have her privacy and dignity respected are implemented (Powlson, 2004:16).Nurses are available during advertised hours.

1.3
Visibility o f the clinic The clinic is clearly marked on the outside.12 n ess and ac Ethical measures o f privacy and respect The nurse allows the client to undress in privacy.

services to the
The client isn't unnecessarily exposed during the examination.

2.2
The client is examined in a way that respects her dignity.
2.3 No-one can see what the nurse is doing with the client.
2.5 The nurse respects the client's privacy (auditory privacy).
2.6 No-one walks in and out o f the room.

2.7
The bed the client is examined on is comfortable.

Ethical measures o f comfort
There are enough chairs for everyone to sit in the waiting area.2.9 There is enough light in the waiting area to be able to read.

2.10
The waiting area is clean.
2.8 The waiting area is not smelly.

Environmental safety
There are clean toilet facilities available.2.12 The nurse's consultation/examination room is clean.
2.13 bout available Information management in terms of infor The client is told about different contraceptive methods in stock.
3.1 g services and mation needed for the client to make an The client is informed of her method compared to other methods.32 methods informed method choice.The biological process of the client's method is explained.

3.3
The client is told about the benefits o f using her method o f choice.
3.4 The client is told about common side-effects of method o f choice 3.5 The client is told about falling pregnant after stopping her method. 3.8 Information needed for the client to use The nurse demonstrates the use o f the client's method o f choice.

her method correctly
The client is given written information about her chosen method.

Limitations of the study
The research was conducted at only one clinic.The results can therefore not be generalised to other clinic settings.

Conclusion
Family planning nurses should be en couraged to meet the expectations of service delivery o f clients accessing family planning services provided by family planning clinics.This can be done by implementing the guidelines o f this study.Policies to promote ef fective family planning services should be written by the unit manager, and nursing personnel must be made aware o f the policies and where they can be located for easy reference.The policies can then be revised as more informa tion becomes available with regards to effectively delivering family planning services to women of reproductive age.

Bibliography
ents when their needs begin to fall out side o f the scope o f practice o f the nurse's competence(DOH, 2001 b:32).

Objectives of the study
The t-test was used to determine the disparities/gap between clients' expectations o f family planning serv ice delivery with the established norm of 4. The p-values which resulted from the t-test represented the probability of error in accepting our explanation for the existence o f a gap (Table non-parametric tests such as Marginal Homogeneity (MH) testing were used to analyse data which were gathered th ro u g h the stru ctu re d in terv iew schedules (questionnaires).Partici pants' expectations o f family planning service delivery and the extent, to which these expectations were met, were analysed using single-sample ttest.

Table 3
The clinic environments should be made inviting and waiting times should be acceptable to the clients visiting the clinic(FHI, 2004:2).Ethical measures o f privacy and respect should be im portant to clients.Past research has

Table 2 : p-values for each section of the instrument
"Perhaps we should ju st get used to it.After all, we are all women." Ethical measures o f comfort should be taken into consideration.

The unit manager should promote interpersonal skills in terms of professional behaviour, consideration of cultural diversity, gaining insight in the client's situation, interpersonal respect and participative decision making when dealing with women of reproductive age.
It is considered important that clinics deliver comprehensive, integrated Pri mary Health Care(DOH, 2001b: 12).The Department o f Health urges the accel erated implementation o f comprehen sive plans for management o f HIV and AIDS, as well as strengthening pro grammes in women's health(DOH,  2004b: 14).It has been stated by the United Nations that all health services should take steps to halt and reverse the spread o f HIV(UN, 2008:28).The manager should ensure that all nurses are trained to assess the client's risk of contracting STIs and HIV, as well as counselling the client with regards to strategies to reduce this risk.The De partment of Health urges PHC facilities to counsel clients with regards to safer sex practices, which includes promot ing the acceptance and use o f condoms(DOH, 2001b:25; 32).
In order to improve the possibility of the client having access to her method

The unit manager should ensure mechanisms for follow-up care and continuity of care of women of reproductive age.
The manager should remain evervigilant for administrative barriers to follow-up care and continuity of care that should be removed.The manager should establish referral mechanisms for the next level o f care needed by cli The results o f this research are appli cable to the women o f reproductive age who participated in the research only.Because o f the amount o f time needed to complete each interview and time constraints, only fifty women of repro ductive age were interviewed.