Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011-2015

OBJECTIVE

To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion.

STUDY DESIGN

Data derived from the 2011-2013 and 2013-2015 National Surveys of Family Growth (NSFG). Our study sample included 9321 women aged 15-44. Logistic regression analyses predicted current LARC use (yes vs. no). We tested interaction terms between race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and covariates (for example, education, parity, poverty level) to explore whether their effects on LARC use vary by race-ethnicity.

RESULTS

In the race-interactions model, data did not show that low income and education predict LARC use more strongly among Black and Hispanic women than among White women. There was just one statistically significant race-interaction: experience of unintended pregnancy (p=.014). Among Whites and Hispanics, women who reported ever experiencing an unintended pregnancy had a higher predicted probability of LARC use than those who did not. On the other hand, among Black women, the experience of unintended pregnancy was not associated with a higher predicted probability of LARC use.

CONCLUSIONS

With the exception of the experience of unintended pregnancy, findings from this large, nationally representative sample of women suggest similar patterns in LARC use by race-ethnicity.

IMPLICATIONS

Results from this analysis of NSFG data do not provide evidence that observed differences in LARC use by race-ethnicity represent socioeconomic disparities, and may assuage some concerns about reproductive coercion among women of color. Nevertheless, it is absolutely critical that providers use patient-centered approaches for contraceptive counseling that promote women's autonomy in their reproductive health care decision-making.

Development and field testing of a decision support tool to facilitate shared decision making in contraceptive counseling

OBJECTIVE

We developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection.

METHODS

Drawing upon formative work around women's preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process.

RESULTS

Ninety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool's content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement.

CONCLUSION

Our decision support tool appears acceptable to women in the family planning setting.

PRACTICE IMPLICATIONS

Formative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial.

Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans

BACKGROUND

Significant racial/ethnic disparities in unintended pregnancy persist in the United States, with the highest rates observed among low-income black and Hispanic women. Differences in contraceptive preferences, beliefs, and self-efficacy may be instrumental in understanding contraceptive behaviors that underlie higher rates of unintended pregnancy among racial/ethnic minorities.

OBJECTIVES

Our objective was to understand how contraceptive preferences, beliefs, and self-efficacy vary by race and ethnicity among women veterans.

STUDY DESIGN

We analyzed data from the Examining Contraceptive Use and Unmet Need Study, a national telephone survey of women veterans aged 18-44 years who had received primary care at the Veterans Administration in the prior 12 months. Participants rated the importance of various contraceptive characteristics and described their level of agreement with contraceptive beliefs using Likert scales. Contraceptive self-efficacy was assessed by asking participants to rate their certainty that they could use contraception consistently and as indicated over time using a Likert scale. Multivariable logistic regression was used to examine associations between race/ethnicity and contraceptive attitudes, controlling for age, marital status, education, income, religion, parity, deployment history, and history of medical and mental health conditions.

RESULTS

Among the 2302 women veterans who completed a survey, 52% were non-Hispanic white, 29% were non-Hispanic black, and 12% were Hispanic. In adjusted analyses, compared with whites, blacks had lower odds of considering contraceptive effectiveness extremely important (adjusted odds ratio; 0.55, 95% confidence interval, 0.40-0.74) and higher odds of considering the categories of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.94, 95% confidence interval, 1.56-2.41, and adjusted odds ratio; 1.99, 95% confidence interval, 1.57-2.51, respectively). Hispanics also had higher odds than whites of considering the category of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.72, 95% confidence interval, 1.29-2.28, and adjusted odds ratio, 1.63; 95% confidence interval, 1.21-2.19, respectively). Compared with whites, blacks and Hispanics had higher odds of expressing fatalistic beliefs about pregnancy (adjusted odds ratio, 1.79, 95% confidence interval, 1.35-2.39, and adjusted odds ratio, 1.48, 95% confidence interval, 1.01-2.17, respectively); higher odds of viewing contraception as primarily a woman's responsibility (adjusted odds ratio, 1.92, 95% confidence interval, 1.45-2.55, and adjusted odds ratio, 1.77; 95% confidence interval, 1.23-2.54, respectively); and lower odds of being very sure that they could use a contraceptive method as indicated over the course of a year (adjusted odds ratio, 0.73, 95% confidence interval, 0.54-0.98, and adjusted odds ratio, 0.66, 95% confidence interval, 0.46-0.96, respectively).

CONCLUSION

Women veterans' contraceptive preferences, beliefs, and self-efficacy varied by race/ethnicity, which may help explain observed racial/ethnic disparities in contraceptive use and unintended pregnancy. These differences underscore the need to elicit women's individual values and preferences when providing patient-centered contraceptive counseling.

Measuring and monitoring quality of care in family planning: are we ignoring negative experiences?

Despite decades of emphasis on quality of care, qualitative research continues to describe incidents of poor quality client–provider interactions in family planning provision. Using an emerging framework on disrespect and abuse (D and A) in maternal health services, we reviewed the global published literature for quantitative tools that could be used to measure the prevalence of negative client experiences in family planning programs. The search returned over 7,000 articles, but only 12 quantitative tools included measures related to four types of D and A (non-confidential care, non-dignified care, non-consented care, or discrimination). We mapped individual measurement items to D and A constructs from the maternal health field to identify measurement gaps for family planning. We found significant gaps; current tools are not adequate for determining the prevalence or impact of negative client experiences in family planning programs. Programs need to invest in tools that describe all aspects of client experiences, including negative experiences, to increase accountability and maximize the impact of current investments in family planning programs.

The perceived role of clinicians in pregnancy prevention among young Black women

OBJECTIVE

The purpose of this study is to identify young Black women's attitudes toward clinicians and understand how they affect contraceptive behavior.

STUDY DESIGN AND MAIN OUTCOME MEASURES

We conducted semi-structured qualitative interviews with women aged 18-23 who self-identified as Black or African-American and analyzed data using techniques informed by grounded theory. Initial codes were grouped thematically, and these themes into larger concepts.

RESULTS

Participants discussed two salient concepts related to pregnancy prevention: (1) sexual responsibility and self-efficacy and (2) the perceived limited role of health care clinicians. Women portrayed themselves as in control of their contraceptive decision-making and practices. Many viewed their life plan, to finish school and gain financial stability, as crucial to their resolve to use contraception. Participants gathered information from various sources to make their own independent decision about which method, if any, was most appropriate for their needs. Most had limited expectations of clinicians and considered in-depth conversations about details of contraceptive use to be irrelevant and unnecessary.

CONCLUSION

These findings help understand factors contributing to contraceptive decision-making. The patient-clinician interaction is a necessary focus of future research to improve sexual health discussions and understand if and what aspects of this interaction can influence behavior.

Patient-reported Communication Quality and Perceived Discrimination in Maternity Care

BACKGROUND

High-quality communication and a positive patient-provider relationship are aspects of patient-centered care, a crucial component of quality. We assessed racial/ethnic disparities in patient-reported communication problems and perceived discrimination in maternity care among women nationally and measured racial/ethnic variation in the correlates of these outcomes.

METHODS

Data for this analysis came from the Listening to Mothers III survey, a national sample of women who gave birth to a singleton baby in a US hospital in 2011-2012. Outcomes were reluctance to ask questions and barriers to open discussion in prenatal care, and perceived discrimination during the birth hospitalization, assessed using multinomial and logistic regression. We also estimated models stratified by race/ethnicity.

RESULTS

Over 40% of women reported communication problems in prenatal care, and 24% perceived discrimination during their hospitalization for birth. Having hypertension or diabetes was associated with higher levels of reluctance to ask questions and higher odds of reporting each type of perceived discrimination. Black and Hispanic (vs. white) women had higher odds of perceived discrimination due to race/ethnicity. Higher education was associated with more reported communication problems among black women only. Although having diabetes was associated with perceptions of discrimination among all women, associations were stronger for black women.

CONCLUSIONS

Race/ethnicity was associated with perceived racial discrimination, but diabetes and hypertension were consistent predictors of communication problems and perceptions of discrimination. Efforts to improve communication and reduce perceived discrimination are an important area of focus for improving patient-centered care in maternity services.

What Women Want: A Qualitative Study of Contraception in Jail

OBJECTIVES

We undertook this study to understand women's perceptions of receiving contraception at Rikers Island Jail.

METHODS

We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques.

RESULTS

Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by women's negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception.

CONCLUSIONS

Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.

Client and Provider Perspectives on Quality of Care: A Systematic Review

CONTEXT

A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives.

EVIDENCE ACQUISITION

Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services.

EVIDENCE SYNTHESIS

Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently.

CONCLUSIONS

Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes.

Cultural beliefs about health professionals and perceived empathy influence continuity of cancer screening following a negative encounter

Negative health care encounters have implications for preventive medical services and continuity of health care. This study examined cultural and interpersonal psychological factors involved in health care interactions that may ameliorate the detrimental effects of negative encounters. A mixed-methods approach was implemented to examine the relations among positive cultural beliefs about health professionals, perceived professional empathy, interpersonal emotions, and continuity of cancer screening among 237 Latin American (Latino) and non-Latino White (Anglo) American women who reported a negative health care encounter. Multi-group structural equation modeling revealed that for Latino and Anglo women, positive cultural beliefs about health professionals in general were associated with higher perceptions of empathy regarding a professional involved in a negative encounter. In addition, for Latino women, perceptions of higher professional empathy and less negative emotions were associated with better continuity of cancer screening. Interventions designed to improve professionals' empathy skills and diverse patients' perceptions of professionals could improve patient-professional relations.

Repeat abortions in New York City, 2010

This study aims to describe factors associated with the number of past abortions obtained by New York City (NYC) abortion patients in 2010. We calculated rates of first and repeat abortion by age, race/ethnicity, and neighborhood-level poverty and the mean number of self-reported past abortions by age, race/ethnicity, neighborhood-level poverty, number of living children, education, payment method, marital status, and nativity. We used negative binomial regression to predict number of past abortions by patient characteristics. Of the 76,614 abortions reported for NYC residents in 2010, 57% were repeat abortions. Repeat abortions comprised >50% of total abortions among the majority of sociodemographic groups we examined. Overall, mean number of past abortions was 1.3. Mean number of past abortions was higher for women aged 30-34 years (1.77), women with ≥5 children (2.50), and black non-Hispanic women (1.52). After multivariable regression, age, race/ethnicity, and number of children were the strongest predictors of number of past abortions. This analysis demonstrates that, although socioeconomic disparities exist, all abortion patients are at high risk for repeat unintended pregnancy and abortion.

Effects of ethnic attributes on the quality of family planning services in Lima, Peru: a randomized crossover trial

Most studies reporting ethnic disparities in the quality of healthcare come from developed countries and rely on observational methods. We conducted the first experimental study to evaluate whether health providers in Peru provide differential quality of care for family planning services, based on the indigenous or mestizo (mixed ethnoracial ancestry) profile of the patient. In a crossover randomized controlled trial conducted in 2012, a sample of 351 out of the 408 public health establishments in Metropolitan Lima, Peru were randomly assigned to receive unannounced simulated patients enacting indigenous and mestizo profiles (sequence-1) or mestizo and then indigenous profiles (sequence-2), with a five week wash-out period. Both ethnic profiles used the same scripted scenario for seeking contraceptive advice but had distinctive cultural attributes such as clothing, styling of hair, make-up, accessories, posture and patterns of movement and speech. Our primary outcome measure of quality of care is the proportion of technical tasks performed by providers, as established by Peruvian family planning clinical guidelines. Providers and data analysts were kept blinded to the allocation. We found a non-significant mean difference of -0.7% (p = 0.23) between ethnic profiles in the percentage of technical tasks performed by providers. However we report large deficiencies in the compliance with quality standards of care for both profiles. Differential provider behaviour based on the patient's ethnic profiles compared in the study did not contribute to deficiencies in family planning outcomes observed. The study highlights the need to explore other determinants for poor compliance with quality standards, including demand and supply side factors, and calls for interventions to improve the quality of care for family planning services in Metropolitan Lima.

Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use

Improving the quality of contraceptive counseling is one strategy to prevent unintended pregnancy. We identify aspects of relational and task-oriented communication in family planning care that can assist providers in meeting their patients' needs. Approaches to optimizing women's experiences of contraceptive counseling include working to develop a close, trusting relationship with patients and using a shared decision-making approach that focuses on eliciting and responding to patient preferences. Providing counseling about side effects and using strategies to promote contraceptive continuation and adherence can also help optimize women's use of contraception.

Racial/ethnic disparities in contraceptive use: variation by age and women's reproductive experiences

OBJECTIVE

Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a woman's life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by women's age, parity, and history of unintended pregnancy.

STUDY DESIGN

We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy.

RESULTS

Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by women's age, with younger women having more prominent disparities.

CONCLUSION

Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.

Exploring young adults' contraceptive knowledge and attitudes: disparities by race/ethnicity and age

BACKGROUND

Half of pregnancies in the United States are unintended, with the highest proportions occurring among Blacks, Hispanics, and teenagers. Understanding differences in knowledge and attitudes about contraception by race/ethnicity and age can improve efforts to reduce disparities in unintended pregnancy.

METHODS

This analysis used data from the 897 female respondents in National Survey of Reproductive and Contraceptive Knowledge, a survey exploring young adults' knowledge and attitudes about contraception and pregnancy. Bivariate and multivariate logistic regression analyses were used to assess racial/ethnic and age group differences in knowledge and attitudes about contraceptives.

FINDINGS

Hispanics and teenagers (aged 18-19) had lower awareness of available contraceptive methods, and lower knowledge about individual methods compared with White women and young adults (age 20-29). For example, Hispanics (74%) and teenagers (77%) were less likely to have heard of the intrauterine device (IUD) than were White women (90%) and young adults (90%), and were less likely to know that a woman experiencing side effects could switch brands of oral contraceptive pills (72% of Hispanics vs. 86% of White women; 76% of teenagers vs. 90% of young adults). Hispanics born outside the United States had lower knowledge about contraceptives than U.S.-born Hispanics. For example, foreign-born Hispanics were less likely than U.S.-born Hispanics to have heard of the IUD (59% vs. 82%) or the vaginal ring (55% vs. 95%).

CONCLUSIONS

Lower contraceptive knowledge among teenagers and Hispanics, particularly immigrants, suggests the importance of disseminating family planning information to these women as one means to address disparities in unintended pregnancy.

Disparities in abortion rates: a public health approach

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities. As efforts to restrict abortion will have no effect on these underlying factors, and instead will only result in more women experiencing later abortions or having an unintended childbirth, they are likely to result in worsening health disparities. We provide a review of the causes of abortion disparities and argue for a multifaceted public health approach to address them.

Disparities in safe sex counseling & behavior among individuals with substance dependence: a cross-sectional study

Background

Despite the vast literature examining disparities in medical care, little is known about racial/ethnic and mental health disparities in sexual health care. The objective of this study was to assess disparities in safe sex counseling and resultant behavior among a patient population at risk of negative sexual health outcomes.

Methods

We conducted a cross-sectional analysis among a sample of substance dependent men and women in a metropolitan area in the United States. Multiple logistic regression models were used to explore the relationship between race/ethnicity (non-Hispanic black; Hispanic; non-Hispanic white) and three indicators of mental illness (moderately severe to severe depression; any manic episodes; ≥3 psychotic symptoms) with two self-reported outcomes: receipt of safe sex counseling from a primary care physician and having practiced safer sex because of counseling.

Results

Among 275 substance-dependent adults, approximately 71% (195/275) reported ever being counseled by their regular doctor about safe sex. Among these 195 subjects, 76% (149/195) reported practicing safer sex because of this advice. Blacks (adjusted odds ratio (AOR): 2.71; 95% confidence interval (CI): 1.36,5.42) and those reporting manic episodes (AOR: 2.41; 95% CI: 1.26,4.60) had higher odds of safe sex counseling. Neither race/ethnicity nor any indicator of mental illness was significantly associated with practicing safer sex because of counseling.

Conclusions

Those with past manic episodes reported more safe sex counseling, which is appropriate given that hypersexuality is a known symptom of mania. Black patients reported more safe sex counseling than white patients, despite controlling for sexual risk. One potential explanation is that counseling was conducted based on assumptions about sexual risk behaviors and patient race. There were no significant disparities in self-reported safer sex practices because of counseling, suggesting that increased counseling did not differentially affect safe sex behavior for black patients and those with manic episodes. Exploring the basis of how patient characteristics can influence counseling and resultant behavior merits further exploration to help reduce disparities in safe sex counseling and outcomes.

Trial registration

NCT00278447

Assessing cultural perspectives on healthcare quality

This study explores cultural differences in perceptions of quality of care and examines whether existing surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS(®)) questionnaires, adequately capture conceptions of healthcare quality among members of racial/ethnic minority groups. Eight focus groups with African Americans, Asian Indians, Latinos, and whites were organized into two 45-minute segments. In one segment, participants rated the quality of care depicted in a video; in the other they discussed the concept of "healthcare quality." We found that members of racial/ethnic minority groups are more likely than whites to identify cultural competency and providing a holistic approach to care as important to healthcare quality. Neither of these concepts is currently included in the core CAHPS(®) questionnaire. The CAHPS(®) and other quality surveys may not accurately capture concepts of healthcare quality that members of racial/ethnic minority groups deem most important.

Recommendations for intrauterine contraception: a randomized trial of the effects of patients' race/ethnicity and socioeconomic status

OBJECTIVE

Recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to health disparities. This study investigated the effect of these factors on recommendations for contraception.

STUDY DESIGN

One of 18 videos depicting patients of varying sociodemographic characteristics was shown to each of 524 health care providers. Providers indicated whether they would recommend levonorgestrel intrauterine contraception to the patient shown in the video.

RESULTS

Low socioeconomic status whites were less likely to have intrauterine contraception recommended than high socioeconomic status whites (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.06-0.69); whereas, socioeconomic status had no significant effect among Latinas and blacks. By race/ethnicity, low socioeconomic status Latinas and blacks were more likely to have intrauterine contraception recommended than low socioeconomic status whites (OR, 3.4; and 95% CI, 1.1-10.2 and OR, 3.1; 95% CI, 1.0-9.6, respectively), with no effect of race/ethnicity for high socioeconomic status patients.

CONCLUSION

Providers may have biases about intrauterine contraception or make assumptions about its use based on patient race/ethnicity and socioeconomic status.

Disparities in family planning

Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider 3 factors that contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider-related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility.

Women's perspectives on family planning service quality: an exploration of differences by race, ethnicity and language

CONTEXT

Despite calls to make family planning services more responsive to the values, needs and preferences of clients, few studies have asked clients about their experiences or values, and most have used surveys framed by researchers', rather than clients', perspectives.

METHODS

Forty in-depth interviews exploring lifetime experiences with and values regarding services were conducted with 18-36-year-old women who visited family planning clinics in the San Francisco Bay Area in 2007. Women were categorized as black, white, English- or Spanish-speaking Latina, or of mixed ethnicity to allow examination of differences by racial, ethnic and language group. Interviews were audiotaped, transcribed and coded thematically; matrices were then used to compare the themes that emerged across the subgroups.

RESULTS

Eight themes emerged as important to women's views of services: service accessibility, information provision, attention to client comfort, providers' personalization of care, service organization, providers' empathy, technical quality of care and providers' respect for women's autonomy. Women reported that it was important to feel comfortable during visits, to feel that their decision-making autonomy was respected, to have providers show empathy and be nonjudgmental, and to see the same provider across visits. The only notable difference among racial, ethnic and language groups was that Spanish-speaking Latinas wanted to receive language-appropriate care and contraceptive information.

CONCLUSIONS

Future surveys of family planning service quality should include measures of the factors that women value in such care, and efforts to improve providers' communication and counseling skills should emphasize the personalization of services and respect for clients' autonomy.