Self-assessment and peer review: Improving Indonesian service providers' communication with clients

Context: Training alone may not be sufficient to prompt complex and lasting changes in the performance of family planning providers. Affordable and effective reinforcement mechanisms are needed to ensure that providers apply new skills on the job. Methods: in December 1997 and January 1998, 201 providers working at 170 clinics in Indonesia attended a training course on client-centered counseling. They were divided into three subgroups for follow-up. One group (controls) received no reinforcement, one conducted weekly self-assessments and the third attended peer-review meetings in addition to conducting self-assessments. Data were collected before training, immediately afterward and after four months of reinforcement to measure changes in provider and client behavior. Results: In the month after training, counseling sessions were about twice as long as before, and providers offered twice as much information and counseling on medical and family planning issues. The frequency of providers' facilitative communication (which fosters rapport and client participation) doubled from 15 to 30 instances per session, and the number of clients' questions increased from 1.6 to 3.3. After reinforcement, providers' facilitative communication, clients' active communication and clients' ratings of self-expression and satisfaction increased in the self-assessment group, but did not change significantly in the control group. Both providers' facilitative communication and clients' active communication improved further in the peer-review group, but this intervention did not affect clients' perspectives on the counseling experience. Conclusions: Self-assessment and peer review help maintain providers' performance after training and prompt continuous quality improvement.