Suggestions for Teaching Staff How to Counsel Without Bias, Persuasion
Research helps inform training tactics for reproductive health staff on providing contraceptive counseling in a way that patients perceive is unbiased and with cultural humility.
These methods can establish trust with patients and improve contraceptive care, says Connie Folse, MPH, CHES, training and education manager for Beyond the Pill at the Bixby Center for Global Reproductive Health at the University of California, San Francisco.
Folse offers these suggestions for improving contraceptive counseling:
• Introduce long-acting reversible contraceptives (LARC) in a non-persuasive manner. “It comes back to making sure we understand the patient’s context,” Folse says. “We have information the patient may not have in terms of the context of what would be the next step for them. We can help the patient think it through, but not in a persuasive way.”
After a provider learns what the patient wants in a contraception method, it is fine to ask neutral, nonjudgmental questions to identify barriers and issues that may be important to the patient. For example, if a patient talks about using condoms and emergency contraception as a backup, the provider may ask, “What is it about condoms that appeals to you?” The patient might say condoms can be used as needed and do not involve hormones.
“I might say, ‘Those are great reasons why someone may choose to use condoms,’” Folse says. “‘I want to ask you if it’s OK to talk about other methods that may connect with the things you said were important to you.’”
The key is to always ask this as a question because it comes across as helpful and not trying to persuade the patient to do something they might not want to do. This builds trust and will allow the patient to be more receptive to hearing potential alternative contraceptive options.
“Maybe they would be interested in the copper IUD because it doesn’t use hormones,” Folse says. “If they like condoms because they can use it as they need it, you may talk about spermicides, foams, diaphragms, and other barrier methods, such as the new [nonhormonal] contraceptive gel Phexxi.”
It is important to not share information about alternative contraceptives to convince a patient to use a method that is superior to the one the patient mentioned. “I’m sharing these options because maybe they don’t know these things exist, and they are options to them,” Folse says. “Then I might say, ‘There is always a possibility of contraception failure with any method, so what do you think you might do in the event that might happen?’”
Providers can ask, “What do you think your next steps might be if a method doesn’t work or if you forget to use it?”
If the patient mentions emergency contraception, it is a good opportunity to talk about those options.
• Provide information about abortion access in neutral tone. Providers can give information about abortion in a neutral tone and without assuming the patient has a specific plan in the event of an unintended pregnancy.
The doctor can say, “I want to bring up something with you because you live in this state, and I’m curious about what you know about abortion,” Folse says. “The patient may say, ‘I know it’s really hard to get an abortion.’”
A physician may be tempted to tell a patient that condoms are not the most effective contraception, but that is not a truly patient-centered approach. Instead, the provider can ask the patient if they know whether abortions are available in their state. If the patient has no idea, the physician can provide facts, including how a state’s abortion laws have changed.
“We don’t have to go into what’s horrible about the laws — all of that is value-related,” Folse says. “All we have to say is, ‘It’s true you used to be able to access abortions here, but that has changed, and that’s not an option. We could talk about the closest place where you could obtain an abortion.’”
• Use de-biasing techniques. Reproductive health providers can engage in de-biasing techniques through practicing self-reflection and cultural humility. They also can learn how to recognize subtleties of communication, including a person’s tone and body language.
Recognizing bias is important in situations in which there is a power imbalance, including healthcare provider-patient interactions. “Someone is in the proverbial white coat, and someone is the patient, and they’re looking to the white coat for answers and guidance,” Folse says. “What it’s important to do is intentionally try to level the playing field between the patient and the provider. The provider can do that in a lot of ways.”
For example, a provider can be intentional about body positioning. “If a patient is sitting in a chair or sitting on an exam table, and the provider is hovering over them, while talking, you can see how that will reinforce a power imbalance,” Folse says. “Make sure the patient and provider are meeting eye to eye.”
These physical communication changes will be perceived subconsciously by patients. “These seemingly small things can make a big impact on that power imbalance,” Folse says.
Sometimes, a provider’s questions can be perceived as biased. For instance, a patient wishes to discontinue a LARC method. The provider naturally wants to know why and if there is a problem or obstacle that could be solved. But if the doctor barrages the patient with questions to understand why, the patient may perceive the doctor as disapproving of this choice and feel intimidated.
“Think about an experience where you tried to cancel your cable subscription or gym membership, and it’s like, ‘I have to fight tooth and nail to just stop it,’” Folse explains. “If patients are met with that kind of inquisition, it can feel like the power imbalance is amplified, particularly with IUDs and implants because the patient is at the mercy of the provider to remove it.”
The nonbiased response is to say, “We absolutely can do that today,” and then they can ask the patients to better understand why.
“Maybe there is something the provider can do to help,” Folse says. “But without reassuring patients that they’re in control of their own bodies, the power imbalance is amplified, and it’s difficult to have a neutral patient encounter.”
Tone is more challenging. Providers can communicate displeasure in a patient’s decisions, even if their words are neutral. “A doctor may say, ‘Condoms are great, but I want to make sure you know…,’” Folse says. “The tone of my voice is communicating that I think you are making a bad decision; I’m not saying the words, but that’s what my tone is communicating.”
Another response, given in a neutral or positive tone, would be to say, “Great — a lot of people choose to use condoms for the reason you’ve highlighted,” Folse adds.
Working on awareness of one’s tone, body language, and wording is a step in the right direction for patient-centered care. It is important in an era in which Roe v. Wade no longer protects women’s reproductive health autonomy and privacy.
“I think that the Dobbs decision is a setback in the world of reproductive health for so many reasons,” Folse says. “I’m really concerned that it will move the needle backward in terms of patient-centeredness because the stakes are higher, and there will be a drive to move patients toward highly effective methods.”
That is the reality that reproductive health clinics and programs need to address and acknowledge in their training. “When people attend our trainings and we follow up several months later, we’re seeing a positive impact in terms of unbiased counseling,” Folse says. “We want people to recognize that they live within a society and it’s OK to have biases — it’d be impossible for them not to. But a first and important step is to do something about the biases we have and to grapple with the fact that no one is impervious to bias.”
Research helps inform training tactics for reproductive health staff on providing contraceptive counseling in a way that patients perceive is unbiased and with cultural humility. These methods can establish trust with patients and improve contraceptive care.
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