ABSTRAKWalaupun angka peserta KB aktif di Indonesia telah cukup tinggi 52,54%; sekitar 24% berhenti menggunakan kontrasepsi sebelum mencapai satu tahun, terutama karena mengalami efek samping kontrasepsi atau masalah kesehatan lainnya. Beberapa penelitian menunjukkan bahwa peserta KB yang mendapat konseling KB, angka putus pakainya lebih rendah daripada peserta yang tidak mendapat konseling KB.Masalah Penelitian Peran swasta dalam memberikan pelayanan KB semakin besar, khususnya bidan praktek swasta. Susenas tahun 2001 menunjukkan 43,56% peserta aktif KB di daerah urban memperoleh kontrasepsi dari bidan praktek swasta. Mengingat peranannya yang cukup besar, pelatihan konseling bagi bidan praktek swasta tampaknya menjadi suatu kebutuhan untuk meningkatkan pelayanan KB yang bermutu, yang pada gilirannya akan menurunkan angka putus pakai kontrasepsi. Keterampilan bidan praktek swasta di perkotaan dalam melakukan konseling KB belum diketahui, padahal peran mereka cukup besar dalam memberikan pelayanan KB. Dalam jangka pendek pelatihan konseling KB bagi petugas merupakan pilihan, untuk selanjutnya di masa mendatang didukung dengan program-program lainnya yang ditujukan bagi klien dan masyarakat pada umumnya. Sebagai dampak pelatihan diharapkan akan terjadi peningkatan partisipasi klien selama konseling berlangsung, dan peningkatan kepuasan serta kepatuhan klien. Keterampilan konseling merupakan keterampilan yang tidak mudah dipelajari. Metode penilaian diri merupakan cara yang relatif murah dan dapat dilaksanakan dengan mudah untuk meningkatkan keterampilan yang baru. Pemakaian metode penilaian diri di Indonesia belum banyak dilakukan. Penggunaan metode penilaian diri untuk memperkuat pelatihan konseling KB bidan puskesmas memberikan hasil yang cukup baik, sedangkan untuk bidan swasta belum diketahui. Metode penilaian diri mungkin dapat dipakai sebagai penguat pelatihan konseling KB bagi bidan praktek swasta, karena walaupun mereka berbeda dengan bidan puskesmas dalam beberapa hal, antara lain bekerja secara independen, tidak ada yang mengawasi dan sepenuhnya bertanggungjawab secara pribadi, tetapi keinginan mereka untuk meningkatkan keterampilannya dalam melayani klien lebih besar karena mempunyai motivasi untuk memperoleh penghasilan yang lebih besar.Tujuan penelitianTujuan umum penelitian ini adalah untuk mengetahui efektivitas metode penilaian diri. Tujuan khususnya adalah: (1) diketahuinya gambaran umum keterampilan bidan praktek swasta dalam melakukan konseling KB; (2) diketahuinya faktor-faktor yang mempengaruhi peningkatan keterampilan bidan praktek swasta dalam melakukan konseling KB dan (3) diketahuinya pengaruh metode penilaian diri terhadap peningkatan keterampilan bidan praktek swasta dalam melakukan konseling KB.Metodologi penelitianPenelitian dilakukan di Propinsi DKI Jakarta, selama sekitar 8 bulan, mulai November 2000, dengan desain pretest posttest control group design. Populasi penelitian ini adalah bidan praktek swasta di DKI Jakarta sebanyak 994 orang. Sampel diambil secara acak sebanyak 360, selanjutnya secara acak dialokasikan masing-masing 120 bidan untuk 3 kelompok studi. Kelompok intervensi 1 hanya mendapat pelatihan konseling KB. Kurikulum yang dipakai adalah kurikulum BKKBN/JHU-PCS yang telah dimodifikasi, dengan lama pelatihan 26,25 jam. Kelompok intervensi 2 mendapat pelatihan konseling KB seperti kelompok intervensi 1, yang diperkuat dengan metode penilaian din selama 8 minggu. Kelompok kontrol tidak mendapat perlakuan. Untuk satu bidan hanya diambil satu orang klien, bisa klien KB baru atau lama dengan masalah. Di akhir penelitian ada 323 bidan yang memenuhi syarat untuk dianalisis.Data kuantitatif dikumpulkan dengan pengisian kuesioner dan melakukan rekaman konseling KB pada 1 minggu sebelum dan 8 minggu sesudah pelatihan konseling. Pengumpulan data kualitatif yang digunakan untuk menerangkan keberhasilan dan kelemahan penelitian dilakukan dengan melaksanakan wawancara mendalam dan diskusi kelompok terarah pada 12 minggu setelah pelatihan konseling KB berakhir, serta penilaian terhadap formulir penilaian din. Pengukuran keterampilan konseling KB dilakukan dengan menggunakan alat ukur yang dikembangkan oleh peneliti dengan melakukan modifikasi terhadap alat ukur yang dikembangkan oleh tim dan Johns Hopkins University/PCS dan University of Wales, UK. Keterampilan konseling KB yang diukur adalah keterampilan bidan swasta dalam melibatkan klien untuk mengambil keputusan.Di tahap analisis, peneliti memutuskan untuk hanya menganalisis konseling KB antara bidan dengan klien baru saja, karena jumlah sampel konseling KB dengan klien lama kurang sehingga reliabilitas instrumen pengukur konseling KB dengan klien lama tidak dapat diteliti. Jumlah bidan yang dapat dianalisis sebanyak 263 orang.Hasil PenelitianSkor keterampilan bidan melakukan konseling KB di awal penelitian temyata rendah; dan 15 subskill, hanya 1 subskill yang menunjukkan skor yang baik yakni keterampilan menanyakan apakah klien sudah mempunyai pilihan. Keterampilan yang seharusnya sudah mereka lakukan sehari-hari misalnya memberikan informasi yang lengkap, ternyata juga tidak baik. Mereka belum terbiasa memberi kesempatan kepada klien untuk berbicara, terlihat dari rendahnya skor subskill mengidentifikasi masalah, minta klien bertanya selama diskusi berlangsung, dan menggali perasaan klien tentang kontrasepsi yang ditawarkan atau akan dipakainya. Mereka juga tidak menyampaikan informasi yang disesuaikan dengan situasi klien. Kenyataan ini menggambarkan komunikasi antara petugas kesehatan dengan klien di Indonesia pada umumnya. Sudah saatnya dilakukan program untuk mengubah keadaan tersebut, karena komunikasi antara petugas dengan klien merupakan faktor yang penting dalam keberhasilan pelayanan kedokteran dan kesehatan.Pascapelatihan terjadi peningkatan pengetahuan, motivasi, persepsi peran, sikap dan efikasi diri bidan tentang konseling KB di kelompok intervensi 1 dan 2. Peningkatan variabel-variabel tersebut sama di kedua kelompok intervensi, kecuali variabel efikasi diri. Peningkatan efikasi diri di kelompok intervensi 2; besarnya 1,70 kali peningkatan di kelompok 1. Di kelompok kontrol terjadi juga peningkatan pengetahuan, sikap dan efikasi diri, tetapi peningkatan ini berbeda bermakna dengan peningkatan di kelompok intervensi 1 dan 2. Peningkatan di kelompok kontrol tersebut diperkirakan karena efek uji praintervensi dan sejarah.Ditemukan korelasi antara peningkatan keterampilan konseling KB dengan beberapa variabel, yakni peningkatan efikasi diri, peningkatan sikap, peningkatan persepsi peran, peningkatan motivasi dan peningkatan pengetahuan; dengan r berkisar antara 0,103 sampai 0,805. Tidak ada kolinearitas antar variabel bebas. Ternyata peningkatan keterampilan konseling terutama dipengaruhi oleh peningkatan efikasi diri dan peningkatan sikap. Peningkatan efikasi diri mempunyai pengaruh yang lebih besar, yang dapat dilihat pada besarnya nilai koefisien Beta (0,521 berbanding 0,323). Motivasi tidak muncul sebagai prediktor, korelasinya dengan peningkatan keterampilan konseling KB relatif rendah (r=0,103, p 0,047). Hal ini mungkin terjadi karena kelemahan instrumen yang dikembangkan peneliti. Instrumen tersebut ternyata kurang dapat menjaring motivasi bidan yang sebenarnya.Ternyata efikasi diri dipengaruhi oleh pelatihan konseling dan metode penilaian diri. Pelatihan konseling mempunyai koefisien Beta 0,609, sedangkan metode penilaian diri 0,389. Penambahan metode penilaian diri terbukti meningkatkan efikasi diri. Dapat disimpulkan bahwa metode penilaian diri meningkatkan keterampilan konseling KB melalui peningkatan efikasi diri. Usaha meningkatkan efikasi diri di kelompok intervensi 2 dilakukan dengan memberi kesempatan kepada bidan untuk melakukan refleksi diri dengan eara menilai sendiri keterampilannya dalam melakukan konseling, dan memberikan kesempatan kepada bidan untuk belajar sendiri (self-learning) dengan cara menjawab pertanyaan-pertanyaan yang ada di dalam formulir penilaian diri secara teratur.Keberhasilan uji coba metode ini adalah karena alat penilaian diri yang dipakai cukup sederhana dan mudah digunakan. Kedisiplinan merupakan kunci pokok dari keberhasilan metode penilaian diri. Sangat penting melakukan langkah-langkah penilaian diri secara teratur sesuai prosedur yang telah ditentukan. Dengan melaksanakan secara teratur, mereka akan terbiasa mengetahui kelemahannya, kemudian memperbaikinya, sehingga akhirnya terbiasa melakukan konseling KB yang benar. Kebiasaan ini akan meningkatkan efikasi diri. Lima belas persen bidan tidak mengisi formulir penilaian diri dengan lengkap; ternyata diskusi kelompok terarah menunjukkan bahwa hal tersebut terjadi karena bidan tidak disiplin mengisi formulir penilaian diri, bukan disebabkan oleh kesulitan pengisian. Penekanan tentang keuntungan yang akan diperoleh mereka menjadi sangat penting; dan sebaiknya disampaikan pada waktu pelatihan penggunaan alat penilaian diri, karena supervisi dalam program penilaian diri ini sangat minimal, hanya 1 kali yakni pada minggu kedua.Pelatihan konseling KB yang diperkuat dengan metode penilaian diri ternyata dapat meningkatkan keterampilan bidan swasta melakukan konseling KB. Peningkatan skor keterampilan konseling KB di kelompok bidan yang mendapat pelatihan KB dan metode penilaian diri ternyata paling tinggi yakni 1,79 kali peningkatan di kelompok yang hanya mendapatkan pelatihan konseling, dan 9,6 kali lebih tinggi daripada peningkatan di kelompok kontrol. Kelompok bidan yang hanya mendapat pelatihan konseling KB peningkatannya 5,3 kali kelompok kontrol. Kelompok kontrol walaupun keterampilannya meningkat, tetapi sangat kecil dibandingkan dengan peningkatan di 2 kelompok lainnya (6,2% berbanding 55,63% dan 33,25%). Semua peningkatan tersebut berbeda bermakna. Peningkatan keterampilan konseling di kelompok kontrol diperkirakan terjadi karena efek uji praintervensi dan sejarah.Pengamatan keterampilan konseling pascaintervensi menunjukkan bahwa ada perubahan yang bermakna antara bidan yang mendapat pelatihan konseling KB dan diperkuat dengan metode penilaian diri, dengan bidan yang hanya mendapat pelatihan konseling KB dalam hampir semua subskill kecuali untuk subskill melakukan probing terhadap kebutuhan atau prioritas klien, dan memberikan informasi secara lengkap. Berarti metode penilaian diri yang dikembangkan peneliti belum berhasil mengubah 2 subskill tersebut.Simpulan dan SaranPenelitian ini menemukan keterampilan konseling KB bidan swasta sebelum mendapat pelatihan masih jauh dari memuaskan. Kenyataan ini menunjukkan gambaran komunikasi petugas kesehatan dengan klien di Indonesia pada saat ini. Diperlukan penelitian lebih lanjut di bidang komunikasi kesehatan, khususnya antara petugas kesehatan dengan klien atau antar petugas kesehatan. Penelitian-penelitian di bidang tersebut akan lebih membuka mata kita bahwa banyak hal-hal yang perlu dilakukan untuk meningkatkan kualitas pelayanan kesehatan, selain perbaikan yang bersifat teknis.Penelitian ini juga membuktikan bahwa metode penilaian diri dapat digunakan untuk memperkuat pelatihan guna meningkatkan keterampilan bidan praktek swasta dalam melakukan konseling KB. Peningkatan keterampilan konseling KB tersebut diperoleh melalui peningkatan efikasi diri. Keuntungan penggunaan metode penilaian diri harus ditekankan pada waktu pelatihan penggunaan alat tersebut. Pengalaman ini dapat dipakai untuk memperkuat pelatihan-pelatihan di bidang kedokteran/kesehatan yang melibatkan perubahan perilaku.Instrumen yang dipakai peneliti untuk mengukur keterampilan konseling KB dapat dipakai untuk mengevaluasi pelatihan konseling KB, atau keberhasilan suatu program yang berkaitan dengan kualitas pelayanan KB. Penelitian-penelitian lebih lanjut akan memberikan sunabangan yang berarti bagi kualitas pelayanan KB, misalnya penelitian tentang dampak pelatihan konseling KB dan metode penilaian diri terhadap partisipasi, kepuasan, dan kepatuhan klien.Data pascaintervensi menunjukkan bahwa metode penilaian diri tidak mengubah keterampilan melakukan probing terhadap kebutuhan dan prioritas klien serta keterampilan memberikan informasi yang lengkap. Pengamatan mendalam perlu dilakukan terhadap alat penilaian diri tersebut untuk perbaikan dan penyempurnaan.Perlu dilakukan uji coba untuk melihat efektivitas kurikulum konseling KB yang dipakai penelitian ini. Bila terbukti lebih efektif, kurikulum ini dapat dipakai untuk penyempurnaan kurikulum asli, atau dapat dimasukkan sebagai muatan dalam kurikulum institusi pendidikan lainnya yang memberikan pendidikan bagi tenaga medik atau nonmedik dalam bidang kedokteran dan kesehatan, khususnya dalam materi konseling atau komunikasi interpersonal.Kelemahan penelitian ini antara lain adalah, keterampilan konseling KB hanya diukur 1 kali, sehingga keajegan keterampilan konseling KB dari masing-masing bidan tidak diketahui. Hanya 10% bidan diukur keterampilannya 2 kali dengan nilai r=0,909. Perlu dilakukan suatu penelitian yang melibatkan 8 sampai 10 klien untuk 1 orang bidan untuk dapat meningkatkan kesahihan penelitian. Pada penelitian ini, motivasi tidak muncul sebagai prediktor keterampilan konseling KB. Tampaknya diperlukan instrumen yang lebih akurat untuk dapat menjaring motif-motif bidan yang sebenarnya.

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ABSTRACT

Introduction

Twenty-four percent family planning users discontinued using contraception before one year; the major reasons were experiencing side effect and other health problems. Results of various researches revealed that clients who were counseled before or after receiving contraception showed lower discontinuation.

Problem Statement

Private midwives have a significant role in family planning services. Data from the National Social and Economic Survey 2001 showed that 43.56% current users in urban areas received contraception from them. Communication between private midwives and clients in urban areas is still unknown, whereas private midwives' role is big enough. Family planning counseling training is a need, which in turn should be supported by other programs directed to increase clients and community participation. In the long run, impact expected from family planning counseling training is the increment of clients' active communication, satisfaction and compliance.

Counseling skills is not easy. It takes time and long process to apprehend.. Training it self, will not automatically improve providers' behavior, or the improved behavior may not be maintained for longer period several self-learning methods were introduced to reinforce training. One of the methods was self-assessment, which was proved in developed countries to be effective and relatively cheap to improve new skills.

This research tried to test the use of self-assessment to improve private midwives' skills in counseling family planning clients. Experience from this research is expected specifically to be a significant contribution for the progress of family planning counseling in Indonesia, and in general for research in health communication in Indonesia. The problems can be stated as follows: (1) how is the description of private midwives' family planning counseling skills in DKI Jakarta? (2) Can self-assessment method strengthen family planning counseling training to improve midwives' counseling skills?

Objectives

The goal of this research is to test the effectiveness of self-assessment method in improving family planning counseling skills of private midwives. The specific objectives are: (1) to know the description of private midwives' counseling skills in DKI Jakarta Province, (2) to study factors which influence the increment of counseling skills and (3) to study the effect of self-assessment method towards the increment of counseling skills.

Methodology

This research was done in DK1 Jakarta Province starting November 2000 for a period of 8 months, using a pretest-posttest control design. The population is the private midwives in Jakarta (N=994). Samples were taken randomly as many as 360, assigned equally and randomly to 3 groups of midwives, namely intervention 1, intervention 2 and control group. Intervention 1 group got 26.25 hours family planning counseling training, intervention 2 groups received family planning counseling training plus self-assessment for 8 weeks, while the control group did not get any intervention. Each midwife counseled t client, either new or continuing client with problem.

Quantitative data were collected using questionnaire and counseling recording. Data were collected 1 week before and 8 weeks after the training. Conducting self-assessment forms evaluation, in-depth interviews and focus group discussion 12 weeks after the training collected qualitative data, which was used to explain the success and the weakness of the intervention. The validity and reliability of measurement were controlled by (1) testing the validity and reliability of the instruments, (2) standardization of method of measurement, and (3) standardization of observers. Measuring the effort of private midwife in involving client to make decision did the measurement of counseling skills. Modifying a tool, which was developed by a team from Johns Hopkins University/PCS and University of Wales, UK, developed this measurement. Using SPSS 11Version did data analysis. At the end of the study 323 midwives fulfilled the criterion of the study, 60 of them performed counseling with continuing clients either pre or post-intervention.

Results

This study failed to analyze counseling with continuing clients because the number was too small, so the reliability of the measurement instrument could not be tested. This study featured only midwives who counseled new family planning clients.

Results showed that before the intervention, private midwives' counseling skills was low. Only 1 sub skill showed sufficient score that was sub skill to ask whether client has contraceptive choice in her mind. They did not give clients chance to talk, which can be seen from the low scores of specific sub skills such as identify problems, ask client to raise questions and explore clients' feeling about offered or preferred contraception. Moreover they did not give complete information. This portrait actually reflects provider-client communication in Indonesia. Action need to be done to improve this condition, as we realize that provider-client communication is very important for the success of health and medical services. The quality of services is in question if this item is ignored.

After the training; knowledge, motivation, role perception, attitude and self-efficacy towards family planning counseling in the intervention groups were increased. The increments of those variables in both groups were not significantly different, except the self-efficacy. The increase of self-efficacy in the intervention 2 group was 1.70 higher than the increase in the intervention I group. In the control group; knowledge, attitude and self-efficacy were increased but the increments were significantly different with the increments in the intervention groups. The increments of those variables in the control group might be caused by the testing and history effect.

The correlations of the increments of several independent variables with the increment of counseling skills were detected. Increments of knowledge, motivation, role perception, attitude and self-efficacy had significant correlations with the increment of counseling skills, with r ranged from 0.103 to 0.805. There was no collinearity between independent variables. The increment of counseling skills was influenced mostly by the increment of self-efficacy and attitude towards counseling. Self-efficacy showed stronger influence than attitude as shown by Beta coefficient (0.521 vs. 0.323). Motivation in this study did not appear to be an important predictor for counseling skills. Its correlation with the increase of counseling skills was relatively low (r = 0.103, p 0.047). The weakness of the instrument, made this study was unable to catch the real motives of the midwives' to counsel clients.

Also this study found that the increment of self-efficacy was influenced by the family planning counseling training and self-assessment, with Beta coefficient 0.609 and 0.389. The addition of self-assessment increased self-efficacy in conducted family planning counseling. It can be concluded that self-assessment increases counseling skills through the increment of self-efficacy. The effort to increase self-efficacy in intervention 2 group was done by allowing midwives to do self-reflection and self-learning. The success of self-assessment method is that because the tool is simple and easy to be used, as mentioned by the midwives during the focus group discussion. Also self-discipline poses a major role for the success of this method. It is very important that they do the task regularly as it should be. By doing the self-assessment regularly they will learn more and get used to counsel clients in a correct way. Practicing a new behavior everyday will give result the mastering of that new behavior. This will increase the self-efficacy in doing the behavior. Fact that 15% of the midwives did not perform the self-assessment well, tell us that motivation to arouse midwives to do the task is very important. This task need to be done during the training of the use of self-assessment tool; because supervision is minimal, only once in 8 weeks.

Family planning counseling training conducted in 26.25 hours using modified BKKBN/JHUPCS curriculum, and strengthened by self-assessment was proved to be successful in increasing counseling skills. The increment of counseling skills in intervention 2 group, was 1.79 times higher than increment in intervention I group (p 0.000); and 9.6 times higher than the control group. Group, which only received family planning counseling training, showed increment 5.3 times higher than the control group. The increase among the control group might happen because of the testing and history effect, and the increase was smaller compared to other groups (6.2% vs. 55.63% and 33.25%). Those increments were significantly different.

The post intervention counseling skills showed that there were significant differences between private midwives who only received training and private midwives who got training and self-assessment, concerning almost all sub skills of the counseling skills. Sub skill to probe the client?s needs/ priorities, and sub skill to give complete information was not significantly different. It means that self-assessment did not improve those skills. This weakness should be overcome by reviewing the self-assessment tool to see opportunities for improvement.

Conclusions and Recommendations

The private midwives' counseling skills before the intervention was low. This fact features the provider-client communication in Indonesia nowadays. More studies need to be done in the area of health communication, specifically to study provider-client communication, and provider-provider communication. Researches in this area will open our eyes that there are other things need to be done beside the improvement of technical matter in improving quality of health services.

This study have proved that self-assessment method can be used to strengthen a family planning counseling training in the effort to increase the private midwives' counseling skills; and the increase of counseling skills were reached through the increase of self efficacy. The advantages of doing the self-assessment task need to be underscore during the training to use the tool. This experience can be used to strengthen any other training, which involves a new behavior to be improved. The instrument used to measure the counseling skills will also be useful for evaluating counseling training program or other program related to the quality of family planning services. Further research will have a significant contribution to family planning quality of services, among others are to study the impact of counseling training and self-assessment towards client's participation, satisfaction and compliance.

While this study is successful in increasing the counseling skills in the intervention 2 group more than in the intervention I group, post intervention data showed that self-assessment did not improve sub skill to probe the client's needs and priorities, and sub skill to give complete information. A thorough review needs to be done to study the self-assessment tool, for opportunities to an improvement.

The modification of BKKBN/JHUPCS family planning counseling training curriculum has not been tested in this study. If this new curriculum will be implemented widely, a study needs to be done to prove its effectiveness. Soon after the test is done and proved to more effective than the previous one, the curriculum can be used for the action of perfecting curriculum in family planning counseling training or to be imbedded into the curriculum of other institutions which teach counseling training or interpersonal communication for medical and non-medical personnel.

The number of counseling session measured for each midwife was only one, so that the consistency of counseling skills of each midwife was unknown. Ten percent of midwives were asked to do 2 counseling sessions, and the reliability test showed r = 0.909. Further research, which includes 8 to 10 clients for each midwife, will increase the reliability of the study. Motivation is also known as an important predictor for performance. In this study, correlation between motives and counseling skills was relatively low even though proved to be significant. A better instrument needs to be developed so that private midwives' real motives can be caught and studied.;Effect Of Self-Assessment Towards Private Midwives' Family Planning Counseling SkillsIntroduction

Twenty-four percent family planning users discontinued using contraception before one year; the major reasons were experiencing side effect and other health problems. Results of various researches revealed that clients who were counseled before or after receiving contraception showed lower discontinuation.

Problem Statement

Private midwives have a significant role in family planning services. Data from the National Social and Economic Survey 2001 showed that 43.56% current users in urban areas received contraception from them. Communication between private midwives and clients in urban areas is still unknown, whereas private midwives' role is big enough. Family planning counseling training is a need, which in turn should be supported by other programs directed to increase clients and community participation. In the long run, impact expected from family planning counseling training is the increment of clients' active communication, satisfaction and compliance.

Counseling skills is not easy. It takes time and long process to apprehend.. Training it self, will not automatically improve providers' behavior, or the improved behavior may not be maintained for longer period several self-learning methods were introduced to reinforce training. One of the methods was self-assessment, which was proved in developed countries to be effective and relatively cheap to improve new skills.

This research tried to test the use of self-assessment to improve private midwives' skills in counseling family planning clients. Experience from this research is expected specifically to be a significant contribution for the progress of family planning counseling in Indonesia, and in general for research in health communication in Indonesia. The problems can be stated as follows: (1) how is the description of private midwives' family planning counseling skills in DKI Jakarta? (2) Can self-assessment method strengthen family planning counseling training to improve midwives' counseling skills?

Objectives

The goal of this research is to test the effectiveness of self-assessment method in improving family planning counseling skills of private midwives. The specific objectives are: (1) to know the description of private midwives' counseling skills in DKI Jakarta Province, (2) to study factors which influence the increment of counseling skills and (3) to study the effect of self-assessment method towards the increment of counseling skills.

Methodology

This research was done in DK1 Jakarta Province starting November 2000 for a period of 8 months, using a pretest-posttest control design. The population is the private midwives in Jakarta (N=994). Samples were taken randomly as many as 360, assigned equally and randomly to 3 groups of midwives, namely intervention 1, intervention 2 and control group. Intervention 1 group got 26.25 hours family planning counseling training, intervention 2 groups received family planning counseling training plus self-assessment for 8 weeks, while the control group did not get any intervention. Each midwife counseled t client, either new or continuing client with problem.

Quantitative data were collected using questionnaire and counseling recording. Data were collected 1 week before and 8 weeks after the training. Conducting self-assessment forms evaluation, in-depth interviews and focus group discussion 12 weeks after the training collected qualitative data, which was used to explain the success and the weakness of the intervention. The validity and reliability of measurement were controlled by (1) testing the validity and reliability of the instruments, (2) standardization of method of measurement, and (3) standardization of observers. Measuring the effort of private midwife in involving client to make decision did the measurement of counseling skills. Modifying a tool, which was developed by a team from Johns Hopkins University/PCS and University of Wales, UK, developed this measurement. Using SPSS 11Version did data analysis. At the end of the study 323 midwives fulfilled the criterion of the study, 60 of them performed counseling with continuing clients either pre or post-intervention.

Results

This study failed to analyze counseling with continuing clients because the number was too small, so the reliability of the measurement instrument could not be tested. This study featured only midwives who counseled new family planning clients.

Results showed that before the intervention, private midwives' counseling skills was low. Only 1 sub skill showed sufficient score that was sub skill to ask whether client has contraceptive choice in her mind. They did not give clients chance to talk, which can be seen from the low scores of specific sub skills such as identify problems, ask client to raise questions and explore clients' feeling about offered or preferred contraception. Moreover they did not give complete information. This portrait actually reflects provider-client communication in Indonesia. Action need to be done to improve this condition, as we realize that provider-client communication is very important for the success of health and medical services. The quality of services is in question if this item is ignored.

After the training; knowledge, motivation, role perception, attitude and self-efficacy towards family planning counseling in the intervention groups were increased. The increments of those variables in both groups were not significantly different, except the self-efficacy. The increase of self-efficacy in the intervention 2 group was 1.70 higher than the increase in the intervention I group. In the control group; knowledge, attitude and self-efficacy were increased but the increments were significantly different with the increments in the intervention groups. The increments of those variables in the control group might be caused by the testing and history effect.

The correlations of the increments of several independent variables with the increment of counseling skills were detected. Increments of knowledge, motivation, role perception, attitude and self-efficacy had significant correlations with the increment of counseling skills, with r ranged from 0.103 to 0.805. There was no collinearity between independent variables. The increment of counseling skills was influenced mostly by the increment of self-efficacy and attitude towards counseling. Self-efficacy showed stronger influence than attitude as shown by Beta coefficient (0.521 vs. 0.323). Motivation in this study did not appear to be an important predictor for counseling skills. Its correlation with the increase of counseling skills was relatively low (r = 0.103, p 0.047). The weakness of the instrument, made this study was unable to catch the real motives of the midwives' to counsel clients.

Also this study found that the increment of self-efficacy was influenced by the family planning counseling training and self-assessment, with Beta coefficient 0.609 and 0.389. The addition of self-assessment increased self-efficacy in conducted family planning counseling. It can be concluded that self-assessment increases counseling skills through the increment of self-efficacy. The effort to increase self-efficacy in intervention 2 group was done by allowing midwives to do self-reflection and self-learning. The success of self-assessment method is that because the tool is simple and easy to be used, as mentioned by the midwives during the focus group discussion. Also self-discipline poses a major role for the success of this method. It is very important that they do the task regularly as it should be. By doing the self-assessment regularly they will learn more and get used to counsel clients in a correct way. Practicing a new behavior everyday will give result the mastering of that new behavior. This will increase the self-efficacy in doing the behavior. Fact that 15% of the midwives did not perform the self-assessment well, tell us that motivation to arouse midwives to do the task is very important. This task need to be done during the training of the use of self-assessment tool; because supervision is minimal, only once in 8 weeks.

Family planning counseling training conducted in 26.25 hours using modified BKKBN/JHUPCS curriculum, and strengthened by self-assessment was proved to be successful in increasing counseling skills. The increment of counseling skills in intervention 2 group, was 1.79 times higher than increment in intervention I group (p 0.000); and 9.6 times higher than the control group. Group, which only received family planning counseling training, showed increment 5.3 times higher than the control group. The increase among the control group might happen because of the testing and history effect, and the increase was smaller compared to other groups (6.2% vs. 55.63% and 33.25%). Those increments were significantly different.

The post intervention counseling skills showed that there were significant differences between private midwives who only received training and private midwives who got training and self-assessment, concerning almost all sub skills of the counseling skills. Sub skill to probe the client?s needs/ priorities, and sub skill to give complete information was not significantly different. It means that self-assessment did not improve those skills. This weakness should be overcome by reviewing the self-assessment tool to see opportunities for improvement.

Conclusions and Recommendations

The private midwives' counseling skills before the intervention was low. This fact features the provider-client communication in Indonesia nowadays. More studies need to be done in the area of health communication, specifically to study provider-client communication, and provider-provider communication. Researches in this area will open our eyes that there are other things need to be done beside the improvement of technical matter in improving quality of health services.

This study have proved that self-assessment method can be used to strengthen a family planning counseling training in the effort to increase the private midwives' counseling skills; and the increase of counseling skills were reached through the increase of self efficacy. The advantages of doing the self-assessment task need to be underscore during the training to use the tool. This experience can be used to strengthen any other training, which involves a new behavior to be improved. The instrument used to measure the counseling skills will also be useful for evaluating counseling training program or other program related to the quality of family planning services. Further research will have a significant contribution to family planning quality of services, among others are to study the impact of counseling training and self-assessment towards client's participation, satisfaction and compliance.

While this study is successful in increasing the counseling skills in the intervention 2 group more than in the intervention I group, post intervention data showed that self-assessment did not improve sub skill to probe the client's needs and priorities, and sub skill to give complete information. A thorough review needs to be done to study the self-assessment tool, for opportunities to an improvement.

The modification of BKKBN/JHUPCS family planning counseling training curriculum has not been tested in this study. If this new curriculum will be implemented widely, a study needs to be done to prove its effectiveness. Soon after the test is done and proved to more effective than the previous one, the curriculum can be used for the action of perfecting curriculum in family planning counseling training or to be imbedded into the curriculum of other institutions which teach counseling training or interpersonal communication for medical and non-medical personnel.

The number of counseling session measured for each midwife was only one, so that the consistency of counseling skills of each midwife was unknown. Ten percent of midwives were asked to do 2 counseling sessions, and the reliability test showed r = 0.909. Further research, which includes 8 to 10 clients for each midwife, will increase the reliability of the study. Motivation is also known as an important predictor for performance. In this study, correlation between motives and counseling skills was relatively low even though proved to be significant. A better instrument needs to be developed so that private midwives' real motives can be caught and studied.