Information Provided by Nurses to Clients during Family Planning Counselling Sessions and Knowledge of Clients on Chosen Method

Background: The fundamental problem which prompted this research study lies in the observation that family planning clients do not receive the required information for decision making on the methods that meet their reproductive needs. Objectives: To determine family planning information provided to the clients by nurses during family planning counselling sessions in the Khomas region to describe the knowledge of the clients on the specific chosen method Methods: A quantitative research design recruited 184 family planning clients and 65 nurses. Closed ended questionnaire was used for data collection. Results: Majority (89%) of nurses indicated that they always explain the advantages of the method selected to the clients, contrary to the majority (77%) of the clients reported advantages never been explained to them. Ninety five percent of the nurses indicated that they always explain to clients how to use the method they had selected, while the majority (72%) of the clients were in disagreement. The majority of the nurses (78%) indicated that they always explain the possible side effects of the method to their clients while, 63% of the clients indicated that the side effects were not explained to them. Only 22% of the injectable contraceptive users indicated changes in menstrual bleeding as a common side effect, while the majority (66 %) indicated that they did not know. Conclusion: According to clients, information provided to them was inadequate. Equally, the majority of clients had not demonstrated sound knowledge about their method of choice.


Introduction
The fundamental problem which prompted this research study lies in the observation that family planning clients do not receive the required information for decision making on the methods that meet their reproductive needs.Hence, the quality of contraceptive counselling received influence selection of a new contraceptive method (Dehlendorf, Krajewski & Borrero, 2014).Subsequently, millions of women in the developing world would prefer to delay or decide not to have children anymore if they had adequate information on contraception (WHO, 2016).Equally, World Health Organization reports high unmet need of contraception in Africa (24%), Asia (10%) and Latin America and the Caribbean regions (11%).Similarly, Black et al., (2015) echoed concern of unmet need of contraception amongst the vulnerable groups in Canada.
The provision of wide range contraceptive methods enables women to choose the most appropriate, safe and reliable method, according to their health history.Therefore, it is incumbent on health service providers to provide adequate range of contraceptive methods, counselling as well as impartial information to clients (Piere & Clapis, 2010;Kim, Kols and Mucheke (1998).Moreover, it is safe that properly trained allied and health professionals provide family planning services and contraceptives (Black et al., 2015;WHO, 2016).
Despite good intentions on the part of the family planning service providers, they often supply incomplete information (Family Health, 2010).It is against this background that this study aimed to:  Determine family planning information provided to the clients by nurses during family planning counselling sessions in the Khomas region and  Describe the knowledge of the clients on the specific chosen method.

Study Design
This study utilised quantitative, descriptive and explorative design to explore and describe the family planning information provided to clients by nurses during family planning counselling sessions and the knowledge of the clients on the specific chosen method in Khomas region.

Study Population
The population comprised of 7,401 women of reproductive age (15-49 years) and 142 registered and enrolled nurses/midwives offering family planning services at public health facilities in Khomas region.

Inclusion and Exclusion Criteria
The population of clients included both new and continuing clients at health facilities, irrespective of their age, marital status, and level of education, religion and number of children.The population of service providers included all categories of nurses (registered and enrolled nurses/midwives) at the sampled facilities because all these nurses were all rendering family planning services on a rotation basis.

Sampling and Sample Size
Eight urban and three rural primary health care clinics (11) offered family planning services in Khomas region.The 4 urban facilities were selected, using systematic random sampling technique, while the 2 rural clinics were purposefully selected because it served the larger communities, with a doctor visiting each facility every second week.Creative Research Systems (2007)(2008)(2009)(2010), using computer sample size calculator with a 95% confidence level, and confidence limit of 5% for accuracy was used to calculate the sample size of 184 from the population of 7, 401.
The 184 clients were sampled through convenient sampling at the health facilities.
Of the population of all registered and enrolled nurses/midwives offering the family planning services in the Khomas region, only 65 nurses working at the six health facilities participated in the study.This total comprised nurses from the following health facilities.

Data Collection Tools
Self-administered questionnaires were used to gather data from the sample of nurses and exit interviews was conducted for the clients.The data collection instrument covered general information for example the name of the region, type of facility, namely: health centre or clinic, and area in which the facility was located, namely, urban or rural.In addition to the demographic information, the exit interview questionnaire for the clients covered the information such as: availability of Information Education and Communication (IEC) materials that should be used by the nurses and for the clients at facilities, explanation of essential information regarding family planning, counselling of revisit clients and assessment of clients' knowledge of the specific method(s) they have chosen.
The questions in both the nurses' questionnaire and the exit interview for the clients were closed-ended.The majority of the exit interview questions for the clients were dichotomous.Linkert and semantic differential scales with three rating levels such as: Never, Sometimes and Always; and Agree, Unsure and Disagree were also covered in the instrument.

Validity and Reliability
Content validity was guaranteed by developing questions that provided information to answer the research questions that are guiding the study.Experts from the Ministry of Health and two lecturers from the University of Namibia assured the content and face validity of the questionnaires.The reliability of the instrument was enhanced by enhancing the internal consistency through following the same procedures for data collection and by making sure that all questionnaire items are completed by all participants as well as by enhancing stability of instruments through pre-testing them.

Procedure for Data Collection
Ten clients were interviewed on daily basis at each facility after the purpose of the study was explained and informed consent obtained.The questionnaires were completed in the presence of the researcher.The aim of the researcher's presence was to clarify any ambiguity and ensures that the participant provided her/his own answers without consulting either other people or books.Data was collected over 2 week period.

Data Analysis
The data was analysed, using SPSS v21 programme.Descriptive statistics were calculated and frequencies and percentages were generated.

Results of the Study
In this section, the sample achievement, demographic information of the study participants and the findings on the study variables are presented.

Sample Achievement
The study yielded a final sample of 184 from the population of clients and 65 from the population of nurses.Table 2 presents the demographic data of the clients.

The Findings on the Information Provided to Clients and the Knowledge of Clients on Chosen Methods
The study assessed the element of providing appropriate information by examining the availability of Information Education and Communication (IEC) materials to be used by the nurses to educate clients at the health facilities; explanation of essential information regarding family planning, counselling of revisit clients and assessment of clients' knowledge of the specific method(s) they have chosen.
3.2.1The Availability of IEC Materials, and Policy and Guidelines for Family Planning According to the findings, a mere 74 (40%) of all clients had seen IEC materials in a health care facility compared to 110 (60%) who indicated that they have never seen such materials.
An issue closely related to IEC material is the availability of relevant policy and guideline documents.The availability of these documents at the facilities is illustrated inTable 3: The majority of nurses, 52 (80%) confirmed the availability of FP policy and 50 (77%) the availability of FP guidelines, while only 32 (49%) indicated that the reproductive health policy was available.

Explanation of Essential Information Regarding Family Planning and Counselling.
This section presents the findings about the information that should be provided to clients on family planning by nurses.Family planning information to clients should include advantages and disadvantages of FP methods, protection offered by selected method against STI/HIV infections, the use of the method, side effects or complications of the chosen method, encouraging clients to make follow up visits, revisit clients' experience regarding method used and exploring alternative methods for client who experience problems with family planning methods.
Table 4 presents the key information which the nurses explained to family planning clients and the frequency of the clients' acknowledgement of receiving such information from the providers: Table 4 revealed that 58 (89%) of the nurses always explain the advantages of the method selected to the clients, while only 43 (23%) of the clients reported that the advantages of the method they had selected had been explained to them.In contrary, the majority, 141 (77%) of the clients, reported that the advantages of the method they had selected had never been explained to them.Majority (62%) of the nurses stated that they always explain the disadvantages of the method selected.However, only 73 (40%) of the clients confirmed that they had been given such information while the majority -111 (60%)indicated that they had never been given such information.
The findings indicated that 62 (95%) of the nurses claim to have explained to clients how to use the method they had selected.However, only 52 (28%) of the clients indicated that they had been advised on the usage of the method while the majority -132 (72%)indicated that they had never been given such advice.
The majority of the nurses -51 ( 78%)indicated that they always explain the possible side effects of the method to their clients while only seven (11%) of them indicated that they never explained the side effects.On the other hand, 116 (63%) of the clients indicated that the side effects were not explained to them while only 68 (37%) acknowledged being given such information.
The majority of the nurses -61 (94%)indicated that they always encourage clients to come back for follow up visits.This finding was confirmed by the majority of the clients, 177 (96%).It emerged that 44 (68%) of the nurses indicated that they always ask if clients experience problems with the method they were using.However, only 13 (20%) of the nurses stated that they asked those clients who were experiencing problems whether they wanted to switch to another method or stop using the method they were using.
Of the 140 revisit clients, 39 (28%) indicated that they had been asked whether they were experiencing any problem with the methods they were using while the majority 101 (72%)indicated that they had never been asked.Of the 39 clients who indicated that they had been asked whether they had experienced problems with their method, 15 (38 %) had been asked whether they would like to stop using the method or whether they wanted to switch to another method while 24 (62%) had not been asked.

Knowledge of Clients about Specific Method Used
The users of injectables, oral contraceptive pills, intrauterine contraceptive devices, condoms, and voluntary female sterilisation were asked specific questions related to the specific method they were using.The results were presented separately as explained in the next sessions.

Knowledge on common side effects of injectables
Hundred, forty six (79%) of the clients who used the injectables were asked what they could remember about the common side effects of this method.Their responses are presented in Table 5. Thirty two (22%) of the 146 injectable contraceptive users indicated changes in menstrual bleeding as a common side effect; 17 (12%) provided irrelevant answers, for example, that injectables cause sterility while the majority -97 (66 %)indicated that they did not know.

What to do if one pill has been missed
The findings indicated that only three (9%) of the 33 clients who used the pill were aware that if a pill is missed, one should take the missed pill immediately once remembers and the next pill at the regular time.

Knowledge on what to do to ensure that the IUCD is in place
It emerged that the only client in this study who indicated that she had chosen the IUCD did not know how to make sure that the IUCD was in place.

Knowledge of the number of times a condom may be used
Of the two clients who had chosen condoms, one knew that a condom should be used once only while the other one did not respond to the question.

Knowledge on whether sterilisation is a temporary or permanent method
Two clients who were referred to the hospital for sterilisation did not know whether sterilization was temporary or permanent.

Discussion
This study aimed at determining family planning information offered to the clients by nurses during family planning counselling sessions as well as to determine and describe clients' knowledge on the specific chosen method in the Khomas region.Therefore, the discussion section interprets the results and explains the relationship of the actual findings to the purpose of the study.As such, the study then intended to ascertain whether or not FP clients confirm the receipt of information during the FP counselling sessions from the nurses and their subsequent knowledge on chosen FP methods.
Information Education and Communication materials, and policy and guidelines are vital in supporting health education and counselling provided by the nurses to the clients, as it enables better understanding of the subject matter been discussed.Therefore, in the absence of flyers and pamphlets, it is important that posters with family planning information should always be displayed (Rodriques, Abutouk, Roque, & Stridhar, 2016).Such materials reinforce good understanding of family planning issues by showing relevant pictures or allowing clients to read the information for themselves.
In addition, reference materials at the family planning site would enable the nurses to look up for information they may not remember or to review key concepts which they were taught during training.In this regard, the literature concludes that clients who receive accurate information before consulting a provider are empowered and could make better decisions while those who do not have prior knowledge rely on decisions by health care providers (Gemzell-Danielson, Thunell, Lindeberg, Tyden, Marintcheva-Petrova, & Oddens, 2011).
Regarding the availability of policy and guideline documents, the majority of nurses, and (80%) indicated the availability of FP policy and 77% the availability of FP guidelines respectively.However, the available policy and guidelines on family planning should be easily accessible when needed but not be locked up somewhere.Moreover, all providers should be aware of the contents of policy and guidelines and regularly make use of these documents in their day to day operations.Similarly, it is pointless that documents are availability, if their directives are not being applied.
In contrary to the majority (89%) of nurses' claim that they provide key information pertaining to family planning, including counselling and advantages of the method selected to the clients, the majority (77%) of the clients reported that the advantages of the method they had selected had never been explained to them.
Equally, there was a total disagreement regarding the issue of explanation of disadvantages of FP among the clients and the nurses.The majority (62%) of nurses stated that they always explain the disadvantages of the method selected, while the majority (60%)indicated that they had never been given such information.
It also emerged that 69% of the nurses indicated that they never explained about STIs/HIV, while 52% of the clients stated that the nurses had explained about the protection against STIs/HIV afforded by the method they had selected.
With the rising prevalence of STIs, including HIV, risk assessment for STI/HIV and prevention messages have become an integral component of family planning counselling.Essentially, health care providers ought to inform clients whether the method selected will protect the clients against STIs (Family Health International, 2010;Dehlendorf, Krajewski, & Borrero, 2014).Therefore, even if the 52% of clients acknowledged receipt of HIV/STI prevention information, this figure raise concern as it implies that significant proportion of the participants were not aware of the importance of dual protection.It would appear that the problem of insufficient information given to clients may not be restricted to Namibian context only.A study conducted in Bali and Indonesia revealed that the women who had participated in the study had expressed the need for more information on HIV and other STIs (Nanbakhsh, Salarilak, Islamloo, & Aglemand, 2008, p. 7).
While 95% of the nurses indicated that they always explain to clients how to use the method they had selected, the majority (72%) of the clients were in disagreement, indicating that they had never been given such instructions.
Information on how to use a method is vital to ensure that the clients use their methods correctly for effective use of the method.Many women use oral contraceptives incorrectly as a result of a lack of information about how the pills work and why it is important to take the pill every day.As a result, clients often take the pill erroneously only when they were sexually active.Therefore, such as taking should be deleted and erroneously put between the pill and only.(Family Health International, 2010) Furthermore, the current findings indicate that there were contradictory responses from the nurses and clients in respect of explanations being given about how to use the method selected and possible side effects.It is, however, possible that re-visit clients may have forgotten the information they were given by the nurse on the first day they had visited the facility for FP and, thus, tended to indicate that they had not been given the information.In addition, the nurses may have thought that there was no need to explain what they would already have explained to the revisit clients on their first visits.
Regarding the clients' knowledge of the side effects on specific chosen contraceptive method, there was clear evidence that the FP clients did not know the common side effects of the injectables.Only 22% of the 146 injectable contraceptive users indicated changes in menstrual bleeding as a common side effect, while the majority (66 %) indicated that they did not know.Hence, contraceptive side effects are one of the most important factors that influence a client's decision either to use or not to use a specific method or even whether or not to continue using family planning.Therefore, reassurance about side effect is important.The women must be supported, once receiving contraceptive counselling, through providing information about risks associated with methods and efficacy to enable them to make informed decision (Dehlendorf, Krajewski, & Borrero, 2014;Rodriquez, Abutouk, Roque, & Sridhar, 2016).
On very crucial issues such as what to do if pill has been missed and number of times a condom may be used, little knowledge was revealed.This revelation indicates that the dual protection against pregnancy and STI, including HIV infection is not reinforced among FP clients.Hence, the importance of dual protection is emphasised by some studies (Dehlendorf, Krajewski, & Borrero, 2014;Barber, 2007).

Conclusion
Provision of adequate information to FP clients and subsequent acknowledgment of such information seems to be problematic in the Khomas region.There were mixed responses regarding information provided by the nurses to the FP clients during counselling sessions and subsequent acknowledgment of such information by the clients.What clearly stood out is the non-existing knowledge base of the clients on the chosen methods.It also transpired that FP information seem not be repeated to the re-visit clients as they too can forget what they were told at the initial visit.
In conclusion, the findings of this study are an important lesson for health care providers in general, in the sense that their interaction with their clients which they regarded as satisfactory were not been experienced in the same way by the clients.

Recommendations
According to clients' version, inadequate information was provided to them and subsequently, the majority of clients had not demonstrated sound knowledge about their method of choices.Therefore this study recommended that: Family planning providers should explain information related to the FP method selected as well as general information on other methods, in particular, to new clients and to clients who switch to another method.
The regional management team -programme officersshould institute programmes for community education on reproductive health matters and involving community leaders.
The Information Education and Communication Unit in the Ministry of Health and Social Services should develop booklets and leaflets on family planning to be given to clients to read on their own.

Limitations
The generalisation of the study results to the rest of the country was limited because the study was conducted only in one of the fourteen regions.Furthermore, the probability of inclusion of all the family planning clients at the health facilities where the study was conducted may have been limited because the clients were not registered on entry but just served as they came.However, findings from this study have contributed to an understanding of the information provided by nurses to clients during family planning counselling sessions and knowledge of clients on chosen methods.

Table 1 .
Table 1 presents the service providers by health facility.Samples of service providers by facility

Table 2 .
Demographic data of population I: Clients

Table 3 .
Availability of policy and guidelines as reported by nurses N =65

Table 4 .
Key information pertaining to family planning as reported by the nurses and clients

Table 5 .
Injectable users' knowledge of common side effects