The Balanced Counseling Strategy:

A Toolkit for Family Planning Service Providers

User’s Guide

Federico León, Ricardo Vernon,

Antonieta Martin, and Linda Bruce
2008
©2008 The Population Council, Inc.

Any part of this publication may be photocopied without permission from the publisher ­
pro­vided that copies are distributed without charge and that full source citation is provided.
The Population Council would appreciate receiving a copy of any materials in which the text
is used.

Suggested citation: León, Federico, Ricardo Vernon, Antonieta Martin, and Linda
Bruce. 2008. Balanced Counseling Strategy User’s Guide, part of The Balanced Counseling
Strategy: A Toolkit for Family Planning Service Providers, León et al., Washington, DC:
Population Council.

Note: This publication is one part of a larger publication titled The Balanced
Counseling Strategy: A Toolkit for Family Planning Service Providers. This BCS Toolkit
includes the following:

Balanced Counseling Strategy User’s Guide

Balanced Counseling Strategy Trainer’s Guide
Balanced Counseling Strategy Job Aids
• Algorithm for Using the Balanced Counseling Strategy
• Balanced Counseling Strategy Counseling Cards
• Balanced Counseling Strategy Method Brochures
Balanced Counseling Strategy CD-ROM

If any part is missing, please contact the Population Council at

publications@[Link]

Suggested citation: León, Federico, Ricardo Vernon, Antonieta Martin, and Linda
Bruce. 2008. The Balanced Counseling Strategy: A Toolkit for Family Planning Service
Providers. Washington, DC: Population Council.
Acknowledgements

Federico León developed the Balanced Counseling Strategy (BCS) based on the
findings obtained during several operations research projects in Peru and Guatemala.
This research could not have been conducted without the invaluable support of the
service providers who tested the BCS and the program directors who authorized
and supervised its application. We also sincerely appreciate the valuable technical
support provided by Gloria Lagos, Mariel León, Rosa Monje, Irma Ramos, and
Walter Ventosilla in Peru, and Carlo Bonatto, Carlos Brambila, Julio García Colindres,
Verónica Dávila, Marisela de la Cruz, Gustavo Gutiérrez, Elena Hurtado, Carlos
Morales, Berna Salas, and Benedicto Vásquez in Guatemala. The Balanced Counseling
Strategy: A Toolkit for Family Planning Service Providers comprises three key job aids: an
algorithm describing the counseling strategy, counseling cards, and client brochures.
Ricardo Vernon wrote and Antonieta Martin revised the Balanced Counseling Strategy
User’s Guide on how to use this new counseling strategy. The job aids and the BCS
User’s Guide were translated from Spanish, revised, and formatted for use outside Latin
America by Linda Bruce, who also developed the BCS Trainer’s Guide. The Balanced
Counseling Strategy: A Toolkit for Family Planning Service Providers is a result of these
efforts.
Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Development of the BCS Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What is the purpose of this toolkit?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
How should this toolkit be used?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Balanced Counseling Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Algorithm for using the Balanced Counseling Strategy. . . . . . . . . . . . . . . . . . . . . . . 5
Pre-choice stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Method choice stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Post-choice stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Guidelines for adapting the job aids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
How can the Balanced Counseling Strategy be implemented in
family planning services?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Introduction

The Population Council has worked for decades on projects to improve the quality
of reproductive health care, particularly family planning services. Quality of care,
including a client-centered approach to providing high quality services, is a client’s
right and a best practice that links family planning with women’s health and
fulfillment of reproductive intentions. Improving the quality of care, specifically
the client-provider interaction (CPI), has potential benefits in terms of better client
outcomes. These outcomes include: improved client satisfaction with method, better
use and continuation of appropriate method, and achievement of reproductive health
goals, such as successful birth spacing or limitation and improved reproductive
health. Studies have shown that strengthening providers’ CPI skills can improve the
counseling experience (Huntington, Lettenmaier, and Obeng-Quaidoo 1990; Barge,
Patel, and Khan 1995; Costello et al. 2001; Sathar et al. 2005).

The Balanced Counseling Strategy (BCS) was developed to improve CPI in family
planning provision. The BCS is a practical, interactive, client-friendly counseling
strategy that uses three key job aids (visual memory aids) for counseling clients about
family planning: an algorithm (decision-tree), a set of counseling cards on different
contraceptive methods, and corresponding brochures on each of the methods.

A job aid is a storage place for information other than one’s memory.
Characteristics of a job aid:
n More reliable than memory.
n Describes the desired on-the-job behavior.
n Minimizes trial and error and reduces the amount of recall necessary to
perform on-the-job tasks.

The BCS was tested in Peru and Guatemala, and then revised on the basis of
suggestions from researchers and providers who used it. More methods were added
to the BCS cards and brochures for a more international application. The BCS User’s
Guide was developed to explain how to use the job aids to counsel family planning
clients. The revised job aids and user’s guide were pre-tested with service providers in
Mexico. A detailed history of the development of this innovative counseling tool and
results of operations research studies assessing its effectiveness in improving quality
of care can be found in the appendix of the Balanced Counseling Strategy Trainer’s Guide
(BCS Trainer’s Guide).

1
Development of the BCS Toolkit
The BCS job aids and user’s guide were subsequently translated from Spanish, revised,
and formatted for use outside Latin America. A draft training guide was expanded to
include more detailed instructions for trainers who will be responsible for introducing
the Balanced Counseling Strategy in the health care facility. The BCS method cards
and brochures were edited to incorporate the latest international family planning
norms and guidance as recommended by the World Health Organization (WHO),
including Family Planning: A Global Handbook for Providers (WHO/RHR and JHU/CCP,
INFO Project 2007) and Medical Eligibility Criteria for Contraceptive Use (WHO 2004).

Through this publication, The Balanced Counseling Strategy: A Toolkit for Family Planning
Service Providers, the revised BCS job aids and guides are being made available to
those interested in implementing a family planning counseling strategy that simplifies
decision-making and responds to the client’s needs and reproductive intentions.

What is the purpose of this toolkit?

The Balanced Counseling Strategy: A Toolkit for Family Planning Service Providers is
designed to provide the information and tools needed for health care facility directors,
supervisors, and service providers to implement the Balanced Counseling Strategy in
their family planning services. This toolkit includes the following:

1. BCS User’s Guide on how to implement the Balanced Counseling Strategy. It can be
distributed during training on BCS or used on its own with the BCS job aids.

2. BCS job aids comprising:

n The BCS algorithm that summarizes the 11 steps needed to implement the
Balanced Counseling Strategy during a family planning counseling session. These
steps are organized under three stages of the consultation: pre-choice, method
choice, and post-choice. During each stage of the counseling session, the provider
is given step-by-step guidance on how to use the Balanced Counseling Strategy.
Depending on the client’s response to the questions posed, the algorithm outlines
which actions to take. The BCS algorithm is on page 5 and can also be found
with the job aids.

n Counseling cards that the provider uses during a counseling session. There are
16 counseling cards. The first card contains 6 questions that the service provider
asks to rule out if a client is pregnant (Stanback et al. 1999). The other 15 cards
each contain information about a different family planning method. Each card
has an illustration of the contraceptive method on the front side of the card.
The back of the card contains a list of 5 to 7 key features of the method. It also
describes the method’s effectiveness, which is represented by a number and also
written out.

2
 n Method brochures on each of the 15 methods represented by the counseling
cards. They are designed to help the client and provider narrow down the
appropriate method for the client. The information in the method brochures
follows the majority of family planning programming norms (Hatcher et al. 2004;
WHO/RHR and JHU/CCP 2007). Once the client has selected a method, the
provider gives the client a brochure about the method to take home.

3. BCS Trainer’s Guide that supervisors and others can use to train health care facility
directors and service providers on how to use the Balanced Counseling Strategy for
counseling family planning clients.

The BCS job aids are generic. They can be revised depending on national and/or
regional guidelines and protocols. The Balanced Counseling Strategy can also be
adapted to incorporate other health issues, such as HIV. Guidelines for adapting these
job aids are included (starting on p. 16, and in the BCS Trainer’s Guide), along with an
example of a revised BCS algorithm used by the Population Council in South Africa.

This toolkit includes a CD-ROM containing electronic copies of the BCS materials so
that the job aids and instructional guides can be easily adapted to meet local needs.

How should this toolkit be used?

1. Read this entire BCS User’s Guide on how to implement the Balanced Counseling
Strategy.

2. Refer to the BCS algorithm as a reminder of the 11 steps needed to implement the
Balanced Counseling Strategy. It is helpful to have it handy on your desk or hang it
on a wall so that you can refer to it easily.

3. Use the BCS counseling cards to help a client choose a method based on her/his
reproductive intentions. Use the first counseling card to rule out if the client is
pregnant. If she is not, use the remaining method cards to help the client choose a
contraceptive method suited to her reproductive health intentions.

4. Once the client has chosen a contraceptive method, review the corresponding BCS
method brochure with the client. Use the brochure to reinforce information about
the method chosen and to respond to questions. This helps to ensure that the client
understands the method. Give the brochure to the client. S/he can refer to it at home
or use it to talk to her/his partner.

5. For trainers, use the BCS Trainer’s Guide to familiarize health care staff with this new
counseling approach and to build the capacity of service providers to effectively use
the BCS counseling approach. The trainer’s guide covers 8 hours of training and
includes over 3 hours of practice and role plays.

6. The three BCS job aids, BCS User’s Guide, and BCS Trainer’s Guide are available as
Microsoft Word documents on the enclosed CD-ROM. Adapt these materials for use
in your region or country as needed.

3
 Balanced Counseling Strategy

The Balanced Counseling Strategy (BCS) is divided into three counseling stages. Each
stage contains specific steps to follow. The BCS assumes that the motive of a client’s
visit is family planning. The consultation may have been arranged for another reason
but has resulted in counseling on family planning. The BCS algorithm appears on the
next page. Below is a summary of the three counseling stages:

n Pre-Choice Stage: During this stage the provider creates the conditions that help
the client select a family planning method. The provider cordially greets the client.
Then s/he asks basic questions to identify the client’s family planning intentions
and needs. At this time, the provider displays all of the counseling cards illustrating
various family planning methods. Then the provider asks the four questions
described in the algorithm. As the client responds to each question, the provider
sets aside the counseling cards of methods that are not appropriate for the client.
Setting aside the counseling cards helps to avoid giving information on methods
that are not relevant to the client’s needs.

n Method Choice Stage: During this stage the provider offers more extensive
information about the methods that have not been set aside. This helps the client
select a method suited to her/his needs. Following the steps in the BCS algorithm,
the provider continues to narrow down the number of counseling cards until a
method is chosen.

n Post-Choice Stage: During this last stage the provider uses the BCS method
brochure to give the client complete information about the method that s/he has
chosen. If the client has conditions where the method is not advised or is not
satisfied with the method, the provider returns to the Method Choice Stage to help
the client select another method.

Detailed instructions on how to implement the Balanced Counseling Strategy using

the accompanying BCS job aids (algorithm, counseling cards, and brochures) follow.

4
 Algorithm for
Algorithm for Using
Usingthe
theBalanced
BalancedCounseling Strategy
Counseling Strategy
Pre-Choice 1. Establish and maintain a warm, cordial relationship. Listen for the client’s contraceptive needs.
2. Rule out pregnancy using the counseling card with 6 questions.

If client answers: Then:

“Yes” to any of the questions 1) Pregnancy is unlikely.
and she is free of signs and 2) Continue to Step 3.
symptoms of pregnancy
“No” to all of the questions 1) Pregnancy cannot be ruled out.
2) Give client a pregnancy test if available.
3) Ask her to return when she has her menstrual bleeding.
4) Provide her with a back-up method, such as condoms,
to use until then.
5) End the session.
3. Display all of the counseling cards. If the client wants a particular method, go to Step 7.

4. Ask all of the following questions. Set aside counseling cards based on the client's responses.
a) Do you wish to have children in the future?
If “Yes,” set aside vasectomy and tubal ligation cards. Explain why.
If “No,” keep all cards and continue.
b) Are you breastfeeding an infant less than 6 months old?
If “Yes,” set aside the combined oral contraceptives (the Pill) and combined injectable.
If “No,” or she has begun her monthly bleeding again, set aside the LAM card. Explain why.
c) Does your partner support you in family planning?
If “Yes,” continue with the next question.
If “No,” set aside the following cards: male condom, female condom, Standard Days Method, and
TwoDay Method. Explain why.
d) Are there any methods that you do not want to use or have not tolerated in the past?
If “Yes,” set aside the cards the client does not want.
If “No,” keep the rest of the cards.

Method 5. Give information on the methods that have not been set aside. Indicate their effectiveness.
Choice a) Arrange the remaining cards in order of effectiveness (number on back of each card).
b) In order of effectiveness (lowest number to highest), read the 5 to 7 features of
each method not set aside.
6. Ask the client to choose the method that is most convenient for her/him.
7. Using the brochure, determine if the client has any condition for which the method is not advised.
a) Together with the client review section under “Method not advised if you” in the brochure of the
method chosen.
b) If the method is not advisable for the client, ask the client to select another method from the cards
that remain. Repeat the process from Step 5 (Step 4 if client already had the method in mind).

Post-Choice 8. Inform the client about the method chosen using the brochure of the method as a counseling tool.
9. Determine the client’s comprehension and reinforce key information.
10. Make sure the client has made a definite decision. Give her/him the method chosen and/or a referral
and back-up method, depending on the method selected.

11. Complete the counseling session. Invite the client to return anytime. Thank her/him for the visit.
End the session.

5
Pre-choice Stage
During this stage the provider creates the necessary conditions to help the client select
a method.

Step 1: Establish and maintain a warm, cordial relationship. Listen for

the client’s contraceptive needs.
n Establish a formal but friendly manner.
n Call the client by her/his name.
n Demonstrate interest in what the client tells you.
n Establish eye contact with the client.
n Listen to and answer her/his questions.
n Show support and understanding without judgment.
n Ask questions to encourage participation in the discussion.
n Ask if the client would like a family planning method. If so, rule out pregnancy as
described in Step 2.

Step 2: Rule out pregnancy using the counseling card with 6 questions.
Pregnancy is a contraindication for the use of most family planning methods, except
barrier methods such as condoms or spermicides. It is important to rule it out. You
can rule out pregnancy by asking the 6 questions on the BCS counseling card.

Checklist to be reasonably sure a woman is not pregnant:

❑ Did you have a baby less than 6 months ago? If so, are you fully or nearly-fully
breastfeeding? Have you had no monthly menstrual bleeding since giving birth?
❑ Have you abstained from unprotected sex since your last menstrual bleeding or
delivery?
❑ Have you given birth during the last 4 weeks?
❑ Did your last menstrual bleeding start within the past 7 days (or 12 days if you plan
to use an IUD)?
❑ Have you had a miscarriage or abortion in the last 7 days?
❑ Have you been using a reliable contraceptive method consistently and correctly?

6
 Rule out pregnancy using the table below.

If the client answers: Then:

“Yes” to any of the questions and 1) Pregnancy is unlikely.

is free of signs and symptoms of 2) Continue to Step 3.
pregnancy

“No” to all of the questions 1) Pregnancy cannot be ruled out.

2) Give client a pregnancy test if available.
3) Ask her to return when she has her next
menstrual bleeding.
4) Provide her with a back-up method, such
as condoms, to use until then.
5) End the session.

Step 3: Display all of the counseling cards. Determine if the client wants
a particular method.
1. Display the BCS counseling cards on a desk or table, grouped by method type
(temporary, fertility awareness, permanent) as shown in Figure 1 below.

2. Each card has information about a different family planning method.

3. Ask if the client has a particular method in mind.

If client: Do this:

Says “No” Continue to Step 4.

Says “Yes” 1) Ask what the client knows about the method.
2) If the information is correct, go to Step 7.

n Gives incomplete information 1) Correct any misinformation.

about the method s/he has 2) If necessary, go to Step 4 to help the client
chosen choose a method.
- Or -
n Does not know other alternatives
that might be more convenient

7
 Figure 1.
Progestin-only
Injectables
DMPA or NET-EN

Hormonal Implants Monthly Injectable

Balanced Counseling Strategy

Combined injectable
contraceptives or CICs

Lactational
Balanced Counseling Strategy
Minipill
Balanced Counseling Strategy
Amenorrhea Method
Progestin-only
LAM
Oral Contraceptives

Standard Days Method

Balanced Counseling Strategy
The Pill
Balanced Counseling Strategy

SDM Combined Oral

Contraceptives

TwoDay Method ®
Balanced Counseling Strategy
Intrauterine Device
Balanced Counseling Strategy

Cervical Secretions IUD

Spermicides
Balanced Counseling Strategy
Tubal Ligation
Balanced Counseling Strategy

Female Sterilization
Female condome illus needs to be tiff

Female Condoms
Balanced Counseling Strategy
Vasectomy
Balanced Counseling Strategy

Male Sterilization

Male Condoms
Balanced Counseling Strategy
Emergency
Balanced Counseling Strategy
Contraception
Emergency Contraceptive Pills
or ECPs

Balanced Counseling Strategy Balanced Counseling Strategy

Step 4: Ask all of the following questions. Set aside counseling cards
based on the client’s responses.
1. Using the display of counseling cards, begin the process by saying something like,
“Now we are going to discuss your contraceptive needs. We will narrow down the number of
methods that might be best for you. Then, I will discuss the key features of each method with
you. This will help us to find the right method for your needs.”

2. Ask the 4 questions below. Based on the client’s responses, set aside the cards of
methods that do not suit her/his needs.

a) Do you wish to have children in the future?

If: Do this:

“Yes” 1) Set aside the vasectomy and tubal ligation cards.

2) Explain that sterilization is permanent and not suitable for someone who
thinks s/he might want to have another child.

“No” Keep all cards and continue.

8
b) Are you breastfeeding an infant less than 6 months old?

If: Do this:

“Yes” 1) Set aside the combined oral contraceptives (the

Pill) and combined injectable contraceptive (CIC)
cards.
2) Explain that the hormones in these methods
affect breastfeeding.

“No” Woman has begun 1) Set aside the lactational amenorrhea method
monthly menstrual (LAM) card.
bleeding again. 2) Explain that LAM is not suitable for women who
are having menstrual bleeding again.

c) Does your partner support you in family planning?

If: Do this:

“Yes” Continue with the next question.

“No” 1) Set aside the following cards: male condoms, female condoms, Standard
Days Method, and TwoDay Method.
2) Explain that these require partner cooperation.
3) Invite the client to bring her/his partner to a counseling session to discuss
family planning with a provider.
4) Continue with the next question.

d) Are there any methods that you do not want to use or have not tolerated in
the past?

If: Do this:

“Yes” 1) Ask which methods s/he has used and her/his

experience with each.
2) Set aside the cards of the methods the client does
not want.

“No” Keep the rest of the cards.

The client has eliminated a 1) Provide the correct information.

method because of rumors or 2) Do not set aside the card of that method.
false information

9
 3. If certain methods such as the IUD, tubal ligation, or vasectomy are never offered
at your health care facility, still talk to the client about these methods. If the client
selects one of these methods, then:
a) Give her/him a brochure of the method.
b) Refer her/him to a facility where s/he can obtain the method.
c) Provide client with a back-up method until s/he can obtain the method of choice.

4. If the client selects a method that is temporarily unavailable (out of stock), then:
a) Give the client a brochure about the method.
b) Refer her/him to a facility or commercial outlet where s/he can obtain the method.
c) Provide client with a back-up method until s/he can obtain the method of choice.
d) Ask client to return when the method is in stock at your health care facility.

Method Choice Stage

Step 5: Give information on the methods that have not been set aside.
Indicate their effectiveness.
1. Arrange the remaining cards that have not been set aside on your desk or table
according to their level of effectiveness, as shown in Figure 2 below. Display
them with the lowest numbers first and the highest numbers last. (The number is
on the bottom left-hand side of the back of the card. This number indicates the
effectiveness of the method.)

Figure 2. The Pill

Combined Oral
●

●
Requires that you take 1 pill every day.
May cause irregular bleeding during the
first few months of use.
Contraceptives
● May also cause absence of periods or
Effectiveness for other side effects.
pregnancy prevention: ● Safe for a woman with HIV/AIDS,
Pregnancy rate in first year of even if she takes antiretroviral (ARV)
use is: medicines.
■ Correct use (no missed pills) — ● Does not protect against sexually
less then 1 pregnancy per transmitted infections (STIs),
100 women (1%) including HIV.
Progestin-only ● You get an injection every 2 or 3 Male Condoms ● Most condoms are made of thin latex
Injectables months, depending on type of injection.
■ Typical use (some missed pills) —
rubber. Some condoms are coated with
8 pregnancies per 100 women (8%) a lubricant and/or spermicide.
● Safe for women who are breastfeeding.
DMPA or NET-EN You may begin the method 6 weeks ● If you have had an allergic reaction to
after giving birth. latex rubber, you should not use
Effectiveness for Effectiveness for latex condoms.
pregnancy prevention: ●
1–8
May cause irregular or no menstrual
bleeding.
pregnancy prevention:
● Before having sex, place the condom
Pregnancy rate in first year of Pregnancy rate in first year of
use is: ● There is a delayed return to fertility use is:
over the man’s erect penis.
■ Correct use (no missed or late after you stop the method. It takes ■ Correct use (used with each act
● You must use a new condom for each
injections) — 1 pregnancy per about 4 months longer than with most of sex) — 2 pregnancies per act of sex.
100 women (1%) other methods. 100 women (2%) ● Protect against pregnancy and
■ Typical use (some missed or late ● Safe for a woman with HIV/AIDS, sexually transmitted infections (STIs)
Typical use (not used
Standard Days Method
■
● You keep track of your menstrual cycle to know
Intrauterine Device Provides—long-term
injections)
● protection
3 pregnancies per against
even if she takes antiretroviral (ARV) consistently) — 14 pregnancies including HIV. the days you can get pregnant (fertile days).
100pregnancy
women (3%) for up to 12 years. medicines. per 100 women (14%)
● Require partner’s cooperation.
● Ideal for women whose menstrual cycles are
IUD ● Is a small, flexible, plastic and copper
● Does not protect against sexually trans- SDM
usually between 26–32 days long.
device placed in the uterus. Most IUDs
mitted infections (STIs), including HIV.
Effectiveness for
1–3 have 1 or 2 thin strings that hang from the
cervix into the vagina.
2 – 14 Effectiveness for
pregnancy prevention:
● You use a calendar or CycleBeads®, a string of
color-coded beads, to track the days you can
pregnancy prevention: get pregnant and the days you are not likely to
● A trained provider must insert and Pregnancy rate in first year of get pregnant.
Pregnancy rate is:
remove the IUD. use is:
■ In first year of use — less than 1
● On the days you can get pregnant, you must
pregnancy per 100 women (1%)
● Typically causes longer and heavier ■ Correct use (no unprotected sex on abstain from having unprotected sex. Or, you
bleeding and more cramps or pain during fertile days) — 5 pregnancies per can use a condom or other barrier method.
■ Over 10 years of use— 2 monthly bleeding. 100 women (5%)
pregnancies per 100 women (2%) ● Safe for a woman with HIV/AIDS, even if she
Safe for a woman with HIV/AIDS even if
●
■ Typical use (having unprotected sex takes antiretroviral (ARV) medicines.
Tubal Ligation ● Permanent method for women who shewill
takes antiretroviral (ARV) medicines. on fertile days) — 12 pregnancies Spermicides ● Contain nonoxynol-9, a chemical that
● Does not protect against sexually
not want more children. per 100 women (12%) kills sperm.
● Does not protect against sexually trans- transmitted infections (STIs), including HIV.
Female Sterilization ● Involves a surgical procedure. There
mitted infections (STIs), including HIV. Vaginal tablets, foam, film ● Are available in many forms (tablet,
are both benefits and certain risks in ● Requires partner’s cooperation. foam, film).

Effectiveness for 1 –Protects

2 against pregnancy right away.
the procedure. 5 – 12 Effectiveness for ● Kill sperm when inserted deep in
pregnancy prevention: ●
pregnancy prevention: the vagina.
Pregnancy rate after the ● Safe for a woman with HIV/AIDS, Pregnancy rate in first year of ● Must be inserted before each act of sex.
procedure is: even if she takes antiretroviral (ARV) use is:
● Can be used alone or with a male
■ In first year — Less than medicines. ■ Correct use (with each act of condom, diaphragm, or cervical cap.
1 pregnancy per 100 women (1%) Does not protect against sexually
● sex) — 18 pregnancies per
transmitted infections (STIs), including 100 women (18%) ● Do not protect against sexually
■ Over 10 years — 2 pregnancies transmitted infections (STIs),
per 100 women (2%) HIV. Typical use (inconsistent use including HIV.
■

Hormonal Implants ● Are small rods or capsules (about the size during sex) — 29 pregnancies per
of a matchstick) put under the skin. 100 women (29%) ● Frequent use of nonoxynol-9 may
increase the risk of HIV infection.
● Provide long-term protection from
pregnancy for 3 to 7 years. Length of
Effectiveness for
1 –protection
2 depends on the implant. 18 – 29
pregnancy prevention: ● A trained provider must insert and
remove implants.
Pregnancy rate in first year of
use is: ● Safe for women who are breastfeeding.
■ Less than 1 pregnancy per You may get implants 6 weeks after
100 women (1%) giving birth.
● Often cause changes in monthly bleeding.
● Safe for a woman with HIV/AIDS, even if
she takes antiretroviral (ARV) medicines.
● Do not protect against sexually trans-
mitted infections (STIs), including HIV.
1

10
2. Explain the effectiveness of the methods. Effectiveness is measured in number of
pregnancies among 100 women in the first year of use. The lower the number, the
fewer the women who get pregnant using the method. See Figure 3 for example.

Figure 3.
Tubal Ligation ● Permanent method for women who will
not want more children.
Female Sterilization ● Involves a surgical procedure. There
are both benefits and certain risks in
the procedure.
Effectiveness for
pregnancy prevention: ● Protects against pregnancy right away.
Pregnancy rate after the ● Safe for a woman with HIV/AIDS,
procedure is: even if she takes antiretroviral (ARV)
■ In first year — Less than medicines.
1 pregnancy per 100 women (1%) ● Does not protect against sexually
■ Over 10 years — 2 pregnancies transmitted infections (STIs), including
per 100 women (2%) HIV.

1–2

Spermicides ● Contain nonoxynol-9, a chemical that

kills sperm.
Vaginal tablets, foam, film ● Are available in many forms (tablet,
foam, film).
Effectiveness for ● Kill sperm when inserted deep in
pregnancy prevention: the vagina.
Pregnancy rate in first year of ● Must be inserted before each act of sex.
use is:
● Can be used alone or with a male
■ Correct use (with each act of condom, diaphragm, or cervical cap.
sex) — 18 pregnancies per
100 women (18%) ● Do not protect against sexually
transmitted infections (STIs),
■ Typical use (inconsistent use including HIV.
during sex) — 29 pregnancies per
100 women (29%) ● Frequent use of nonoxynol-9 may
increase the risk of HIV infection.

18 – 29

3. Begin with the card with the lowest number. Read the 5 to 7 key features of each
method written on the cards displayed. You may also ask the client to read these
attributes.

4. Whether or not it has been set aside, explain that the condom (male and female)
is the only method that protects against pregnancy and sexually transmitted
infections (STIs), including HIV.

11
Step 6: Ask the client to choose the method that is most convenient for
her/him.
1. Ask the client whether s/he has any questions or comments about each method
discussed. Respond to any questions. Resolve any doubts before proceeding.

2. Ask the client to choose a method that is most convenient for her/him.

3. If the client asks that you choose the method, explain that s/he is the only person
who knows her/his needs. You may give recommendations about a method, but
allow the client to choose the method.

4. Once the client selects a method, do not take the counseling cards off the table.
You may need to return to them if the method chosen is not advised or the client
changes her/his mind.

5. If the client does not like any of the methods discussed or cannot make up her/his
mind, give the client a method to use until s/he decides. Do not let the client leave
without a method. Condoms can provide dual protection against pregnancy and
STIs until the client has another method.

Step 7: Using the brochure, determine if the client has any condition for
which the method is not advised.
1. Select the BCS brochure corresponding to the method chosen by the client.

2. Together with the client, review the section entitled, “Method not advised if you.” This
lists conditions when the method is not advised.

For example, for the IUD:

Method not advised if you:
n Are pregnant or think you might be pregnant.

n Have unusual vaginal bleeding.

n Have genital or pelvic infections.

n Have AIDS and are not taking ARV medicine or are not doing well clinically.

n Have a sexually transmitted infection (STI) or are at very high risk of having
an STI.

3. Using simple, clear language, ask probing questions to make sure that the client
does not have any conditions for which the method is not advised.

12
 4. Based on the client’s response, decide whether to provide the method or return to a
previous step.

If the client: Do this:

Has no conditions Go to Step 8.

Has any condition and has reached this 1) Explain the need to choose another
step from Step 6 method.
2) Return to Step 5.

Has any condition and reached this step 1) Explain the need to choose another
from Step 3 (already had the method in method.
mind) 2) Return to Step 4.

Post-Choice Stage

Step 8: Inform the client about the method chosen using the brochure of
the method as a counseling tool.
1. Use the method brochure as a counseling tool to review all the information about
the method chosen by the client. Begin by saying something like, “Mrs. (name), this
brochure is for you to take home. Before you go, I would like to review the information with
you.”

2. Using clear, simple language review the information about the method presented in
the brochure:
n General information (this is the same information as on the BCS counseling card)
n How the method works
n Important facts about the method
n When the method is not advised
n Side effects
n How to use
n When to return to the health care facility

3. Give the client the brochure. Encourage her/him to review the brochure again at
home and when s/he needs to remember anything about the method.

13
Step 9: Determine the client’s comprehension and reinforce key
information.
1. Make sure the client understands the method s/he has chosen. Comprehension is
key to healthy, effective use of the method.

2. Validate comprehension by asking the client to answer the following questions in

her/his own words. (S/he may refer to the brochure.)
n How do you use the method you have chosen?
n What side effects might you experience with the method?
n When should you return to the health care facility?

3. Assure the client that it is fine if s/he cannot remember all the details. Make sure the
client can find the information in the brochure. (Note: If the client cannot read or
has very low literacy skills, ask the client to identify a person at home who can read
the information to her/him.)

4. Ask if the client has any questions. Reinforce the basic information on the method
chosen.

Step 10: Make sure the client has made a definite decision. Give her/him
the method chosen and/or a referral and back-up method, depending on
the method selected.
1. Ask the client if her/his choice is a definite one. Make sure s/he is happy with the
choice of method.

If client is: Do this:

Happy with the method 1) Give her/him the method and brochure.
chosen 2) If IUD, tubal ligation, or vasectomy is chosen, give a
referral for the procedure.
3) If the client cannot immediately use the chosen method,
provide a back-up method (e.g., condoms).
4) Suggest that s/he may also abstain from sex until
s/he obtains the method of choice.

Not happy with the 1) Assure the client that it is fine to change her/his mind.
method chosen and The client has a right to informed choice.
wishes to consider other 2) Return to Step 5.
options

2. Do not let the client leave empty-handed. If a method is not available, make sure the
client has a back-up method and a referral.

14
Step 11: Complete the counseling session. Invite the client to return any
time. Thank her/him for the visit. End the session.
1. If needed, give the client a follow-up appointment. The purpose of the appointment
may be to:
n Check how the client is using the method.
n Provide a new supply of the method.
n Provide information and support needed for the client to continue using the
method correctly and consistently.
2. Encourage the client to return to the health care facility any time s/he has a question
or wishes to change methods.

Remember:
A client has the right to change her/his reproductive goals and to stop using a
family planning method if s/he wishes or when s/he wants to have a child.

3. To the extent possible, anticipate the client’s future needs.

For example:
Explain to a client using the Pill that, if it is more convenient for her, she can get
her supplies at a local pharmacy. Remind her that the pharmacy may have the
21-pill pack instead of the 28-pill pack. In this case she will need to follow the
instructions for use in the brochure or package insert.

4. As you end the session, remember to be warm and cordial. This attitude will
encourage the client to feel welcome to return.

15
Guidelines for Adapting the Job Aids
The BCS job aids are generic and can be revised based on a region’s or country’s needs
and norms. Below are guidelines for adapting the job aids. An example of a revised
algorithm used by the Population Council in South Africa is included at the end of this
section.

1. Conduct a technical review of family planning norms and practices in your region
or country. Below are some examples of the kinds of review that will help to gather
the appropriate information needed to adapt the Balanced Counseling Strategy and
BCS job aids to your needs.

a) Convene a meeting with representatives from the Ministry of Health and other
experts on family planning to review the BCS and determine whether it needs to
be adapted to include your country’s norms and policies on family planning.

b) Ask health care workers with experience in counseling clients on family planning
to review the BCS job aids for content.

c) If the job aids are to accompany training, work with the trainers to coordinate the
desired competencies (skills) from the training into the job aid.

2. Based on the technical review and local norms of the country, revise the steps in
the Balanced Counseling Strategy as needed. If the BCS is revised, be sure to gather
information to adjust the algorithm, counseling cards, and brochures accordingly.

3. If the BCS strategy does not change, but you wish to add method cards and
brochures on contraceptive methods available in your country’s family planning
program, gather the information needed.

4. Revise the job aids based on the technical review. Below are simple guidelines for
adapting the BCS job aids:

a) Try to adhere to the existing format of the BCS job aids as much as possible. They
are written using a very specific methodology that helps readers effectively act on
the instructions.

b) If adding/revising new steps to the algorithm, write the steps using action verbs.
For example,
– Ask the client if she has had her monthly bleeding.
– Remind the client to take the pill every day at the same time.
c) Include any substeps needed to perform the step. Do not assume that the
provider knows how to perform the desired step or task. Also, be sure to begin
each substep with an action verb.

16
 For example:
Step or task:
Remind a client what to do if she misses taking the pill once.
Substeps:
n Take a pill as soon as possible.
n Keep taking pills as usual. (You may end up taking 2 pills at the same time or on
the same day.)

d) If a service provider needs to make a decision as part of a step, make a decision

table. The first column (the “If” column) is to describe when to take action. The
second column (the “Then” column) is used to describe what action to take and
usually follows the cookbook format of Step 1, Step 2, etc. For example:

If the client is: Then:

Breastfeeding an infant 1) Set aside the combined oral contraceptives (the Pill)
less than 6 months old card and explain the hormones in the pills affect
breastfeeding.
2) Discuss the option of the minipill.

Not breastfeeding an 1) Set aside the LAM card.

infant 2) Explain that LAM is not appropriate for women who
are not breastfeeding.

e) Be sure to number all steps and substeps that are sequential. If the order of the
steps is not important, use bullets instead of numbers.

Place information that is important, but not an actual step or substep, in a box.

5. Pretest (validate) the revised job aids.

a) Ask service providers experienced in family planning counseling to use the
revised job aids as they counsel a couple of family planning clients.
b) Observe whether they follow the instructions in the job aids.
c) Note any actions the provider does not take (and that were in the job aid). After
the counseling session, ask why the provider did not take the described action.
Be sure to explore the following:
– Whether s/he understood the step/task.
– Whether s/he disagrees with the step/task and why.
– Whether the instructions were clear or confusing. If they were confusing
inquire how they could be made clearer.
d) Similarly, note any actions that the health worker added to the counseling session
that are not in the job aids.

17
 e) Ask why s/he added any steps not in the job aid to the counseling session. It is
possible that the service provider added a step for clarity. If so, please add the
step to the job aid. The idea is to describe the desired behavior of the service
provider to accurately use the revised Balanced Counseling Strategy.
f) Revise any instructions based on pretests with several service providers.
g) Add or delete any steps/tasks or substeps to enable the provider to carry out the
Balanced Counseling Strategy most effectively.
6. Ask two to three less experienced service providers to use the revised BCS job aids
and observe whether they were able to perform the tasks based on the instructions
in the job aids.

7. Revise the job aids accordingly, taking into consideration any additional input
service providers give you on how to improve the instructions.

8. Incorporate the use of the job aids into existing training, or develop a short course
to show service providers how to use the job aids.

Important!
A job aid should always be accompanied by training support.

Note: The BCS algorithm was adapted for use in South Africa. Additional steps were
added to include HIV counseling. An example of the revised algorithm follows.

18
Assisted Balanced Counseling — South African Algorithm*
Pre-Selection

1. Warmly welcome the client.

2. Screen for pregnancy. Use the card with the checklist of questions. If pregnant, refer the
client to antenatal care (ANC) clinic.

3. Assess use of current method. Determine if client wants to change.

If And client is Then

Yes _ Continue to Step 4.

No Current User Administer or give method, or make a referral.

New user Continue to Step 4.

4. Display all of the counseling cards, each with information about a different family planning
method.

5. Screen for contraindications.

If Then

Yes Skip card(s). Explain why.

Proceed to Step 6

No Proceed to Step 6.

6. Ask all of the following questions and discard cards based on the client’s response.
a) Do you wish to have children in the future?

If Then

Yes Skip vasectomy and tubal ligation cards and explain why.

No Keep all cards and continue.

b) Are you breastfeeding an infant less than 6 months old?

If Then

Yes Skip the combined oral contraceptives (the Pill) card and explain why.
Discuss the option of the minipill.

No Skip the LAM card and explain why.

19
 c) Does your partner cooperate in contraceptive use?

If Then

No Skip the fertility awareness methods and barrier

contraceptives cards. Explain why.

Yes Keep the fertility awareness methods and barrier

contraceptives cards.

Selection

7. Describe each non-discarded method.

8. Assist client to choose a method.

9. Ask the client to choose the method. Respond to her/his concerns.

If Then

Method chosen Go to Step 10.

Method chosen but Give referral to hospital. In the meantime, give the next
not available best choice and go to Step 10.

10. Double check if there are any contraindications for the method chosen by the client.

If Then

Yes Explain and return to Step 7.

No Continue to Step 11.

Post-Selection

11. Describe action mechanisms of method chosen.

12. Give instructions on how to use the method chosen.

13. Describe side effects and warning signs.

14. Verify client’s comprehension of information. Reinforce information, if needed.

20
15. Ask if the client is satisfied with her/his choice of method.

If Then

Yes n Administer or give the method or make a referral.

n Discuss emergency contraception.
n If appropriate, discuss back-up method for waiting
period.

No Return to Step 9.

STI/HIV Prevention and Assessment

16. Discuss STI/HIV prevention and VCT awareness.

17. Conduct STI/HIV/AIDS risk assessment. If RTI symptoms, treat syndromically (according to
National Guidelines).

18. Ask if the client knows how to use a condom. Demonstrate use if required.

19. Discuss dual protection. Offer condoms and instruct in correct and consistent use.

20. Give follow-up instructions, voucher, and method pamphlet. Also give all clients a
pamphlet on condoms in addition to the pamphlet on the method they have chosen.

END SESSION.

* Population Council’s FRONTIERS Program. For more information contact frontiers@[Link]

21
How can the Balanced Counseling Strategy be implemented in family
planning services?
The Balanced Counseling Strategy improves the quality of family planning services—
when providers use the job aids. To help ensure that providers are effectively using
the Balanced Counseling Strategy, the following recommendations are offered. These
are based on the lessons learned from the Peru and Guatemala studies (León et al.
2003b):

1. Provide health care facility staff, service providers (professional, nonprofessionals,

and paraprofessionals) and auxiliary staff sufficient training and support on how to
use the BCS approach and job aids. For supervisors and others who wish to train
health care facility directors and service providers on the Balanced Counseling
Strategy, refer to the BCS Trainer’s Guide. The BCS training is 8 hours in length
(not including lunch and breaks), very participatory, and includes over 3 hours
of practice time. It can be conducted as a stand-alone workshop, given during
supervisory visits, or integrated into other training events.

2. Provide retraining and support to providers after the initial BCS training. Intensity
of training affects compliance. Researchers believe that the close and continual
supervision given in the Guatemala interventions contributed to the high level of
compliance and improved quality of care made at the experimental clinics. Support
can be provided during supervisory visits or during other training opportunities.

3. Make sure that providers have enough BCS method brochures to use in their
services. Not having enough brochures handicapped providers during the
Guatemala Ministry of Health study. The brochures can easily be printed from the
CD-ROM available in the toolkit or photocopied.

4. Galvanize institutional support for the implementation of the Balanced Counseling

Strategy in your services and/or health district. Institutional leadership reinforces
compliance. Although Peruvian Ministry of Health (MOH) authorities expressed
their commitment to the BCS innovation, field observations suggested that
institutional involvement was not apparent after the experiment began. In
Guatemala, on the other hand, the MOH and health area directors accompanied
the intervention team during revisits to the trained providers. This probably
increased providers’ perception of higher-level support and involvement.

22
References

Barge, Sandhya, Bella C. Patel, and Irfan Khan. 1995. “Use of private practitioners
for promoting oral contraceptive pills in Gujarat.” Final report, Asia and Near East
Operations Research and Technical Assistance Project. New York: Population Council.

Costello, Marilou, Marlina Lacuesta, Saumya RamaRao, and Anrudh Jain. 2001. “A
client-centered approach to family planning: The Davao Project.” Studies in Family
Planning 32(4): 302–314.

Guatemalan Association of Female Physicians (AGMM). 2004. “Scaling up a successful

counseling model in Guatemala,” FRONTIERS Final Report. Washington, DC:
Population Council.

Hatcher, R.A. et al. 2004. Contraceptive Technology. Eighteenth Revised Edition. New
York: Ardent Media.

Huntington, Dale, Cheryl Lettenmaier, and Isaac Obeng-Quaidoo. 1990. “User’s

perspective of counseling training in Ghana: The ‘Mystery Client’ trial.” Studies in
Family Planning 21(3): 171–177.

León, Federico R. 1999. “Peru: Providers’ compliance with quality of care norms,”
FRONTIERS Final Report. Washington, DC: Population Council.

León, Federico R. et al. 2001. “Length of counseling sessions and the amount of
relevant information exchanged: A study in Peruvian clinics,” International Family
Planning Perspectives 27(1):28-33,46.

León, Federico R. et al. 2003a. “Effects of IGSS’s job aids-assisted balanced counseling
algorithms on quality of care and client outcomes (Guatemala),” FRONTIERS Final
Report. Washington, DC: Population Council.

León, Federico R. et al. 2003b. “Enhancing quality for clients: The Balanced
Counseling Strategy,” FRONTIERS Program Brief no. 3. Washington, DC: Population
Council.

León, Federico R. et al. 2003c. “Testing balanced counseling to improve provider-client

interaction in Guatemala’s MOH clinics,” FRONTIERS Final Report. Washington, DC:
Population Council.

León, Federico R. et al. 2004. “One-year client impacts of quality of care improvements
achieved in Peru,” FRONTIERS Final Report. Washington, DC: Population Council.

23
 Sathar, Zeba, Anrudh Jain, Saumya RamaRao, Minhaj ul Haque, and Jacqueline Kim.
2005. “Introducing Client-centered Reproductive Health Services in a Pakistani
Setting.” Studies in Family Planning 36(3): 221–234.

Stanback J. et al. 1999. “Checklist for ruling out pregnancy among family-planning
clients in primary care,” Lancet 354(9178):566.

World Health Organization, Department of Reproductive Health and Research

(WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for
Communication Programs (CCP) INFO Project. 2007. Family Planning: A Global
Handbook for Providers. Baltimore and Geneva: CCP and WHO.

World Health Organization. 2004. Medical eligibility criteria for contraceptive use.
3rd ed. Geneva: WHO.

The projects in Guatemala and Peru referred to above were carried out under the Frontiers in
Reproductive Health Program (FRONTIERS), a U.S. Agency for International Development
(USAID)-funded program administered by the Population Council in partnership with Family
Health International. Work in Guatemala was done in close collaboration with Elena Hurtado,
Berna Salas, and Carlo Bonatto of the Calidad en Salud Project, managed by University Research
Co., LLC, with financial support of USAID and the Community and Progress Foundation. These
documents are available at [Link]

24
Population Council
The Population Council conducts research
worldwide to improve policies, programs and
products in three areas: HIV and AIDS; poverty,
gender and youth; and reproductive health.

Frontiers in Reproductive Health

The Frontiers in Reproductive Health Program
(FRONTIERS) applies systematic research
techniques to improve delivery of family planning
and reproductive health services and influence
related policies. FRONTIERS is funded by the U.S.
Agency for International Development (USAID) and
led by the Population Council in collaboration with
Family Health International. FRONTIERS staff and
collaborating organizations conduct operations
research in Africa, Asia and the Near East, Eastern
Europe, and Latin America and the Caribbean.
For additional information please contact:
Population Council
Frontiers in Reproductive Health Program
4301 Connecticut Ave., N.W., Suite 280
Washington, D.C. 20008 U.S.A.
Telephone: (202) 237-9400
Facsimile: (202) 237-8410
E-mail: publications@[Link]
[Link]/frontiers

This publication is made possible by the generous support of the

American people through the United States Agency for International
Development (USAID) under the terms of Cooperative Agreement
[Link]-A-00-98-00012-00. The contents are the responsibility of the
FRONTIERS Program and do not necessarily reflect the views of USAID
or the United States Government.