Defining and conceptualizing patient-centered family planning counseling: A scoping review

Study design

Our scoping review is informed by the framework developed by Arksey and O’Malley (2005) and subsequently refined by others (Levac, Colquhoun et al. 2010, Peters, Marnie et al. 2020, Peters, Godfrey et al. 2021). We followed the reporting guidelines described in the PRISMA Extension for Scoping Reviews (PRISMA-ScR) (Tricco, Lillie et al. 2018, McGowan, Straus et al. 2020). Although there is no published protocol, the two lead authors discussed and reached a priori agreement about the study objectives, inclusion criteria, and analytical approach. As recommended (Peters, Marnie et al. 2020, Peters, Godfrey et al. 2021, Peters, Godfrey et al. 2022, Pollock, Peters et al. 2023), we used an iterative process to develop both the search strategy and data extraction process. An initial list of keywords for the search strategy was piloted and adjusted to ensure the search results aligned with the study objectives. We drafted a preliminary charting/extraction table, tested it with a small number of retrieved documents, and revised it before starting the full data extraction. We used basic qualitative data coding to analyze the extracted data (Munn, Peters et al. 2018, Peters, Marnie et al. 2020). Specifically, we identify different definitions of patient-centered family planning counseling used in the field and clarify the different domains addressed by these definitions.

Information sources and search strategy

We limited our search to the PubMed and SCOPUS databases. To ensure that we focused on the most recent thinking, we restricted the search to documents published between January 1, 2013, and December 31, 2022. Although we did not impose formal restrictions on the type of document, publication status, or language of the document, the databases we searched resulted in a de facto restriction to peer-reviewed English-language documents. Our search strategy is shown in Table 1. Using Boolean operators, we conducted a title and abstract search to identify documents that contained the keywords “family planning” or “contraception” as well as “user-centered” or “client-centered” or “patient-centered”. The search was completed on April 1, 2023.

Evidence selection

We used Covidence web-based software (www.covidence.org) to automate removing duplicate documents and to facilitate screening of the search results. The titles and abstracts of the remaining documents were independently screened for relevance by the two lead authors. Documents were considered eligible for full-text review if they discussed a patient-centered family planning approach, strategy, or intervention or presented evidence about the effectiveness of such approaches or interventions on quality of care or various family planning outcomes. If the two reviewers disagreed, the document was discussed to reach a consensus. If consensus could not be reached based on the title and abstract, the document was retained for the full document review. During the full document review, we identified documents irrelevant to our review objectives or did not provide sufficient detail (including documents that only recommended using patient-centered family planning counseling in the future, without further elaboration). We also identified de facto duplicate documents that presented findings on the same study. All these documents were omitted from the data extraction.

Data extraction/charting

The data were extracted (charted) using an a priori developed Excel data template. Data from each report were extracted by one reviewer and subsequently checked by the second reviewer. Extracted data for each document comprise: the author, title, year of publication, region, and document type (e.g., theoretical/conceptual paper, systematic review, methodological paper, etc.). When applicable, we extracted the type of study population (e.g., family planning clients or providers). To address our key objective, we charted how patient-centered family planning care was defined or described, including the domains of patient-centered care that were addressed. The extracted/charted data for this scoping review are available under Underlying data (Meekers et al., 2023b).

Search results

As shown in Figure 1, our initial search produced 76 references from PubMed and 58 from SCOPUS. After the removal of 48 duplicate records, 86 unique documents remained. After we screened the titles and abstracts of the remaining 86 unique documents for relevance, 45 documents were retained for full-text review. Twelve documents were excluded during the full-text review. The most common exclusion reason (6 documents) was that the document did not include a detailed discussion of a patient-centered approach and only recommended their future use. Other reasons included that the document was not relevant (one document), duplicate descriptions of the same studies (2 cases), and lack of detail (3 cases). After these exclusions, 33 full-text documents were included in our scoping review.

Figure 1. PRISMA-ScR flow diagram.

Characteristics of the included literature

The reviewed documents included five studies that discussed measurement of patient-centered family planning care (Dehlendorf, Henderson et al. 2016, 2018, Carvajal, Mudafort et al. 2020, Dehlendorf, Fox et al. 2021, Welti, Manlove et al. 2022), ten that addressed tools for reproductive goal screening or contraceptive decision-making (Donnelly, Foster et al. 2014, Koo, Wilson et al. 2017, Baldwin, Overcarsh et al. 2018, Dehlendorf, Fitzpatrick et al. 2019, Dehlendorf, Reed et al. 2019, Dev, Woods et al. 2019, Madrigal, Stempinski-Metoyer et al. 2019, Stulberg, Dahlquist et al. 2019, Callegari, Nelson et al. 2021, Gawron, Simonsen et al. 2022), and three that described counseling programs or curricula (Kamhawi, Underwood et al. 2013, Loyola Briceno, Kawatu et al. 2017, Worthington, Oyler et al. 2020). Nine studies described women’s experiences with family planning counseling, counseling preferences, contraceptive decision-making process, and perceived quality of care (Assaf, Wang et al. 2017, Downey, Arteaga et al. 2017, Gomez and Wapman 2017, Holt, Zavala et al. 2018, Callegari, Tartaglione et al. 2019, Ti, Burns et al. 2019, Hazel, Mohan et al. 2021, Singal, Sikdar et al. 2021, Hamon, Hoyt et al. 2022). The full-text review also included three systematic reviews (Fox, Reyna et al. 2018, Gagliardi, Nyhof et al. 2019, Soin, Yeh et al. 2022) and three theoretical and/or conceptual articles (Holt, Caglia et al. 2017, Morse, Ramesh et al. 2017, Brandi and Fuentes 2020). Documents that discussed the implementation of patient-centered family planning interventions focused mostly on the U.S. (n=20). Only four documents described Africa-based interventions (Assaf, Wang et al. 2017, Dev, Woods et al. 2019, Hazel, Mohan et al. 2021, Hamon, Hoyt et al. 2022), and one each the Middle East, Asia, and Latin America (Kamhawi, Underwood et al. 2013, Holt, Zavala et al. 2018, Singal, Sikdar et al. 2021).

Definitions and conceptualization of patient-centered counseling

In the literature, the terms “patient-centered” and “client-centered” are used interchangeably (the term “person-centered” generally focuses on more holistic, longer-term goals). Our literature review indicates that there is no universally agreed upon general definition of patient-centered care, and consequently, there are differences in what is considered patient-centered care in family planning counseling and support. That said, only 18 of the 33 documents clearly defined client- or patient-centered family planning counseling or described key features or domains of patient-centered family planning counseling or care. However, studies that identified problems with the quality of family planning care, such as negative experiences with providers, tend to address similar topics without referring to them as domains of patient-centered care (Downey, Arteaga et al. 2017, Gomez and Wapman 2017, Callegari, Tartaglione et al. 2019).

Three studies in our review referred to the 1990 Judith Bruce Quality of Family Planning Care (Assaf, Wang et al. 2017, Holt, Caglia et al. 2017, Hazel, Mohan et al. 2021). That original Bruce framework identified six distinct elements of the quality of family planning care “that clients experience as critical,” including 1) the choice of methods that are offered on a reliable basis, 2) the information provided to the client, 3) the technical competence of the provider, 4) the interpersonal relations between the providers and clients, 5) the mechanism to promote continuity of care (e.g., follow-up visits), and 6) the availability of an appropriate constellation of acceptable and convenient family planning services (Bruce 1990). The Bruce framework emphasizes the importance of the client’s perspective on the quality of care, including the provider-patient relationship. Consequently, the framework forms the basis for much of the contemporary discussions about patient-centeredness family planning care, and women’s autonomy in family planning decision-making.

Although the reviewed studies varied in how they defined patient-centered care, several either referred to the 2001 Institute of Medicine definition of patient-centered healthcare or built on that definition (Dehlendorf, Henderson et al. 2018, Ti, Burns et al. 2019, Carvajal, Mudafort et al. 2020). The Institute of Medicine (renamed to National Academy of Medicine in 2015) described patient-centered care as “care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions” (Institute of Medicine 2001: 40). A number of other studies used definitions or descriptions of patient-centered care or counseling that referred to these same elements. For example, Brandi and Fuentes (2020: s876) stated that patient-centered counseling “aims to provide education to patients that integrates evidence-based recommendations based on patient preferences, recognizing that patients’ values and preferences should be an integral factor in decisions made about their health care [and ensures that] patients function as experts on their preferences and needs and providers function as experts on the medical evidence.”

Although studies used different terminology, definitions, and approaches for patient-centered care, Holt, Caglia et al. (2017: 1) note that they all acknowledge “the essential role of individuals’ preferences, needs, and values, and the importance of informed decision-making, respect, privacy and confidentiality, and non-discrimination.” Despite these commonalities, Gagliardi, Nyhof et al. (2019) noted that a better understanding of the different domains of patient-centered care can facilitate more accurate – and more consistent – measurement, which can inform the design of strategies to strengthen patient-centered care. In their theoretical rapid review of the evidence on the patient-centeredness of women’s health care, they mapped studies against the dimensions of patient-centered healthcare previously identified by McCormack, Treiman et al. (2011). McCormack argued that there are six main domains of patient-centered care:

The authors noted that each study in their review defined and measured patient-centered care differently, and none addressed all six domains (Gagliardi, Nyhof et al. 2019). The most addressed domains were exchanging information, making decisions, and fostering the relationship. The authors noted that none of the studies in their review measured patient-centered care as comprehensively as the McCormack framework.

Implications for measurement

Many of the studies included in our review attempted to measure the extent to which family planning clients perceived the interaction with the provider as patient-centered. However, without a universally agreed-upon definition of patient-centered counseling, we found wide differences in how it has been measured. Illustrative examples of questions asked to assess provider performance concerning each of the domains of patient-centered counseling are shown in Table 2.

To standardize the measurement of the patient-centeredness of family planning counseling, some authors have developed and validated scales to measure the level of patient-centeredness of the family planning counseling visit. One of the most comprehensive tools for measuring patient-centeredness of family planning counseling and services visits we identified was the Interpersonal Quality in Family Planning Care (IQFP) scale (Dehlendorf, Henderson et al. 2016, 2018). The IQFP is a validated 11-item scale that measures distinct aspects of interpersonal communication between provider and patient. Specifically, the scale is based on eleven questions that ask family planning patients to rate the provider on the following issues:

Patients rated each of these 11 included items on a 5-point Likert scale, ranging from “poor” to “excellent.” Because most users rated the items as excellent, the authors dichotomized the item responses into the highest possible rating (excellent) versus all lower scores. Validity tests showed that the IQFP scale was associated with clients’ level of satisfaction with the family planning counseling they received and satisfaction with their chosen contraceptive method. Furthermore, higher IQFP scores were associated with positive provider communication practices, including eliciting the patients’ perspectives and demonstrating empathy. Multivariate analyses show that high scores on the IQFP scale were associated with positive family planning outcomes, including continuation of the chosen method at six months (OR=1.81 [1.09-3.00]) and use of an effective method at six months (OR 2.03 [1.16-3.54]). Examination of the different scale items suggested that continuation of the chosen method at six months was higher when the provider invested in the early part of the counseling session (OR=2.32 [1.24-4.32]) and elicited the patient perspective (OR=1.79 [1.01-3.16]). However, showing empathy or investing in the end of the session (e.g., by discussing follow-up, etc.) did not affect contraceptive continuation (Dehlendorf, Henderson et al. 2016).

Recognizing that the large number of items in the IQFP may limit its usefulness for assessing provider performance, a reduced version of the scale has been produced (Dehlendorf, Fox et al. 2021). The Person-Centered Contraceptive Counseling (PCCC) scale asks family planning clients to think about their last provider visit and asks them how they would rate the provider on the following items from the original IQFP scale:

Because the 4-item PCCC scale reduces the burden of data collection compared to the more comprehensive IQFP scale, it is more feasible to use it to measure the quality of the provider-patient interaction. The PCCC scale has since been incorporated into the National Survey of Family Growth (NSFG) questionnaire. Analyses of the NSFG show that while most respondents gave their provider an excellent rating on each of the four scale items, clients’ experiences related to person-centered care varied across sociodemographic groups, with low-income women, sexual minorities, and women with limited English proficiency giving their provider lower ratings for patient-centeredness (Welti, Manlove et al. 2022). The authors hypothesized that these lower ratings may reflect discrimination and/or a lack of cultural competency. The authors also noted that the association between low English proficiency and lower PCCC rating highlights that providing patient-centered care may require language concordance between providers and patients.

The fact that the 4-item PCCC was incorporated in the NSFG survey suggests it is likely to be more widely adopted. If so, it will further enhance consistency in measuring the level of patient-centeredness of family planning counseling and increase comparability across different studies.

Summary of evidence

Our scoping review aimed to assess how patient-centered family planning counseling has been conceptualized in the literature. Our findings show that there is no universally agreed upon definition of patient-centered family planning counseling. Only 18 of the 33 reviewed documents included a clear definition or described key domains of patient-centered family planning counseling. Consistent with Holt, Caglia et al. (2017), we found that although the definitions and terminology used tend to vary, the role of individual clients’ preferences, needs, and values is widely recognized. Furthermore, it is accepted that respect for the patient and informed decision-making are essential.

Possibly because of the lack of a universally accepted definition, the level of patient-centeredness of the provider-patient interaction has been measured using a wide range of approaches. However, we found numerous commonly used measurement questions that roughly correspond with key domains of patient-centered care (McCormack, Treiman et al. 2011). Dehlendorf, Fox et al. (2021) have developed a Person-Centered Contraceptive Counseling (PCCC) scale that further condensed these topics to 1) respecting the patient as a person, 2) letting the patient say what matters to them about their birth control method, 3) taking the client’s preferences about birth control seriously, and 4) giving enough information to enable the patient to make the best contraceptive decision. Wider adoption of the PCCC scale in family planning surveys would generate consistency in measurement of patient-centered family planning counseling, which would help strengthen the evidence base. It may also help move the field toward a common definition of the concept.

Limitations of the review process and evidence

We restricted our search to two well-established information sources, PubMed and Scopus, which focus heavily on peer-reviewed documents. Hence, our review may have omitted other relevant articles, particularly from the grey literature. While this de facto omission of gray literature is likely to have yielded higher quality publications, it may have resulted in the exclusion of alternative, less widely accepted conceptualizations of patient-centered family planning counseling and support. We also acknowledge that the documents retained for the review are skewed toward US-based studies and authors. Authors from other regions may conceptualize patient-centered family planning counseling differently. A larger evidence base would be needed to assess whether regional or cultural differences exist in how patient-centered family planning counseling is conceptualized.