To investigate why family planning (FP) services in the Kathmandu Valley of Nepal are underused, a study was initiated under the auspices of the Nepal Family Planning/Maternal--Child Health Project. The study was intended to provide a user perspective, by examining interactions between FP clinic staff and their clientele. "Simulated" clients were sent to 16 FP clinics in Kathmandu to request information and advice. The study revealed that in the impersonal setting of a family planning clinic, clients and staff fall into traditional, hierarchical modes of interaction. In the process, the client's "modern" goal of limiting her family size is subverted by the service system that was created to support this goal. Particularly when status differences are greatest, that is, with lower-class and low caste clients, transmission of information is inhibited.
PIP: To investigate why family planning (FP) services in the Kathmandu Valley of Nepal are underused, a study was initiated under the auspices of the Nepal Family Planning/Maternal Child Health Project. The question behind the study was whether the professional providers of family planning services are themselves inhibiting effective use of contraception. The purpose of the study was to examine interactions between family planning clinic staff and their clientele. For this purpose, 6 couples and 2 individual women with different socioeconomic backgrounds posed as clients (simulated clients) and were sent to 16 of the 25 family planning clinics in the Kathmandu Valley over a period of about a month. The simulated clients were trained individually and as couples, using role-playing techniques and acting out roles that did not deviate much from their actual life situations. 3 groups of simulated clients with different taste, class and educational backgrounds were trained and sent to nearby family planning clinics. Group A consisted of 2 high caste, urban couples. Group B consisted of 2 lower middle-class couples and 2 individual women. The 2 couples in Group C were lower-class. The accounts provided by the simulated clients were analyzed qualitatively for overall content, and rated using a scale of 1 through 3, based on the accuracy of the family planning information provided, attitude of the staff toward the client and bias of the staff toward the client. The underlying assumption was that a good attitude and lack of bias on the part of family planning staff would be conducive to a desirable outcome, that is, a well-informed, free decision by the client to adopt a particular family planning method. Directly and indirectly, the study revealed a number of barriers to provision and effective use of family planning services in the urban areas of Nepal. The scores indicate that the family planning information provided at most clinics is inadequate or incorrect in many cases. The manner in which the information is presented is apt to drive clients away. In the impersonal setting of a family planning clinic, clients and staff fall into traditional, hierarchical modes of interaction. Moreover, the quality of the services was positively related to the socioeconomic status of the client. Unsophisticated lower-class clients are likely to receive scantier, less accurate information and less courteous treatment than educated middle-class clients. The former's negative perceptions of family planning and family planning clinics probably become disseminated among friends and neighbors. A neighborhood-based program would be more effective than the clinic-based system as it now functions. An alternative or complementary program might focus on upgrading the communication skills of family planning staff within clinics.