Family Planning Providers Share Respectful Care Strategies to Improve Client Experience

Why respectful care matters

People with marginalized identities—across race and ethnicity, income, sexual orientation, geography, disability, gender identity, and age—bear a disproportionate burden of sexual and reproductive health conditions such as sexually transmitted infections, reproductive cancer, and maternal mortality and morbidity. These disparities are directly and indirectly influenced by an individual’s social environment, including poverty, neighborhood characteristics, insurance status, access to clinic services and contraception, and interactions with providers.

Many studies have highlighted how women of color experience discrimination from health care providers and receive inadequate care. Provider biases and behaviors may cause unintended harm during interactions with clients, which may in turn affect quality of care, future access to care, treatment decisions, and health outcomes. Respectful care combats this by honoring the experiences of people of color, promoting freedom and dignity, balancing power between patients and providers, and dismantling beliefs and practices driven by racism.

Who we talked to

We interviewed family planning providers from Title X family planning clinics. The Title X Family Planning Program is the only federal program designed to provide comprehensive family planning and related preventive health services to individuals with low incomes and those who are uninsured. About 83 percent of Title X clients have low incomes[1] and 27 percent are uninsured. Many clients with these characteristics live in states with high proportions of Black, Hispanic, Asian, American Indian, or Native Hawaiian residents.

Because Title X providers are trained to provide patient-centered care and to improve the quality of services, they are a key source for identifying strategies to improve care and health outcomes, particularly among marginalized populations. See Appendix A to learn more about the providers we interviewed, Appendix B to learn more about the clients that providers serve, and Appendix C for detailed recruitment, sampling, and analysis methods.

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Providers’ Respectful Care Strategies

We asked the providers in our sample to share respectful care strategies they used with their clients to honor the experiences of people of color, promote freedom and dignity, balance power between patients and providers, and acknowledge bias and racism. As seen in the boxes below, providers offered strategies at three levels: (1) clinic operations and outreach (“Clinic level”), (2) providers’ interactions with clients (“Provider-client level”), and (3) providers’ own knowledge and awareness (“Provider-specific level”).

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Clinic-level strategies for respectful care

Providers discussed a range of strategies and supportive structures for respectful care focused on clinic structures and operations. These included specific strategies to address staffing, wait times, confidentiality, and racism and bias in the clinic.

Build a clinic culture of respectful care from the top.

Building a clinic culture that encourages respectful care starts with leadership, and all staff should be committed to upholding these standards. Multiple champions modeling respectful care—in various clinic roles—can support the implementation of equitable practices clinic-wide.

Support practice and skill building to help staff gain and apply knowledge and skills.

Trainings help staff acknowledge their biases and build knowledge on topics that affect their client populations. Providers in our survey appreciated trainings on population-specific needs (e.g., LGBTQ+ health care, inclusive language), DEI and cultural competency, and patient-centered or trauma-informed care. They felt that multi-modal training (e.g., virtual, in-person) allows learning to be accessible. Ongoing scenario-based practice opportunities and regular reminders of knowledge, policies, and goals related to respectful care reinforce knowledge, awareness, and preparedness for serving clients.

Encourage and create opportunities for staff communication to foster respectful care.

Providers noted that structures to support and monitor patient experiences are crucial for addressing systemic racism and bias within the clinic. Such structures include roles and committees dedicated to championing diversity, equity, and inclusion, or simply having structured spaces for communication. Creating structured spaces for open and consistent communication between staff provides a dedicated space to help resolve issues when challenges arise (e.g., negative client feedback, insurance). These spaces might include dedicated space at monthly full staff meetings or something separate. Frequent communication allows providers to adjust staffing and pacing of appointments to better meet client needs.

Hire staff whose demographics represent the communities served, who speak clients’ languages, and who prioritize patient-centered care.

Providers reported that clients appreciate seeing their own ethnic, racial, religious, gender, and other identities reflected in clinic staff. A shared identity can foster connection, comfort, and understanding between providers and clients. Providers noted that having diverse staff who reflect or come from the communities the clinics serve is crucial for providing respectful care.

Create welcoming spaces where clients feel comfortable, respected, and seen.

Providers acknowledged that medical racism, discrimination, and past traumas can make some marginalized populations feel uncomfortable accessing services. Incorporating posters, signage, and materials that affirm diverse identities in the clinic space can help clients recognize the clinic as a safe space. Providers said that supportive clinic practices—such as explicitly noting LGBTQ+ affirming services and the provision of accessibility aids (e.g., hearing or vision amplification devices)—help clients feel they belong, and that the clinic is aware of and responsive to their needs.

Ensure client confidentiality throughout the visit.

Providers recognize that confidentiality breaches can occur unintentionally, especially in smaller clinics or close-knit communities. By implementing protocols such as confidential intake processes and providing separate waiting rooms for youth, clinics can protect clients who fear being seen by someone they know.

Offer flexibility in services to increase accessibility.

Providers recognize that limited appointments and long wait times negatively impact patients’ access to care and their experiences. Given high demand for services, clinics have provided flexible hours and/or walk-in appointments and feature accessible systems for making appointments.

Raise awareness of clinic services, particularly among youth.

Direct outreach and engagement within local communities can enhance awareness of clinic services and increase clinic utilization. Providers noted that, especially for youth, outreach in youth-serving settings—such as health education classes, school-based clinics, recreation centers, and church youth groups—can boost comfort levels and interest in receiving services, build rapport, and destigmatize clinic processes and services.

Partner with community organizations to learn about, reach, and serve marginalized populations.

Community-based organizations have well-established connections with the communities they serve and a deep understanding of their circumstances and needs. Providers noted that partnering with these organizations gives clinics access to resources and can enhance their work with local populations, particularly those who have historically (and currently) been marginalized. In addition to outreach events, partnering often involves clinics delivering services or supplies to organizations to help serve their target community’s needs (e.g., providing harm reduction supplies to an organization serving people experiencing substance use).

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Provider-client level strategies for respectful care

Providers in our survey also highlighted respectful care strategies focused on their interactions with clients. These included specific strategies that help empower clients, center their voices, reduce stigma and judgment around health and health care, and prioritize client privacy and confidentiality.

Accept clients’ experiences and choices.

Providers understand that it’s essential to accept clients at whatever stage they are on in their health journeys. This kind of acceptance is not possible if providers criticize or judge their clients’ lifestyles, experiences, and/or choices. Providers facilitate trust and build rapport with their clients by remaining calm and neutral regardless of what information a client shares (e.g., trauma, sexual behavior, complaints). Ultimately, providers must be open to clients making health care decisions they may not agree with and accept that clients may change their minds about prior decisions. By accepting clients’ experiences and decisions, providers can build a solid foundation of non-stigmatizing, patient-centered care.

Promote clients’ privacy and safety, particularly among youth.

The providers who responded to our survey work hard to prioritize their clients’ privacy. Strategies include asking about and using clients’ preferred method of communication, minimizing the number of unnecessary visits with clients, and ensuring that check-in and check-out procedures are private. These strategies are especially important for clients who have safety concerns (e.g., those who have experienced intimate partner or sexual violence), who live in smaller communities where confidentiality can be harder to maintain, and who live with others. When discussing youth populations, additional strategies include asking parents to leave the room during parts of the visit, providing youth-only clinic days, accommodating walk-in and telehealth visits, not sending bills home, and providing hands-on referrals (e.g., providers calling to set up appointments for youth with their permission). Many of these strategies support privacy for clients of all ages.

Communicate the clinic’s confidentiality policies.

Providers build trust with clients by clearly communicating confidentiality policies during each visit. This is particularly important for younger clients who may have concerns about their parents finding out about their visits. In addition to having clients sign consent forms, providers verbally inform clients of their privacy rights and protections under HIPAA (Health Insurance Portability and Accountability Act). By explaining and repeating who is allowed to know details about the visit, and describing the limits of confidentiality (i.e., mandated reporting laws), providers help clients feel more comfortable sharing information during their visit.

Adjust behaviors to mitigate power imbalance between providers and clients.

Providers recognize that power dynamics can stand in the way of patient autonomy and comfort. One strategy that disrupts this dynamic is to opt for more casual clothing rather than traditional white lab coats. Similarly, some providers allow clients to keep their clothes on during the visit, only asking them to undress when necessary for a medical examination. Other strategies include sitting in a chair that is lower than their clients’ seat, maintaining eye contact, not looking at their computer, engaging in casual conversation with clients before jumping into the visit, and keeping a gentle or soft tone of voice. When providers adjust their behaviors, they can reaffirm respect for clients.

Center clients’ family planning goals, needs, and concerns.

Providers recognize that they must center their clients’ needs during visits. This means having ample time (30 minutes or more) to allow clients to share the reason(s) for their visit—and any concerns they may have—and for providers to meaningfully respond and tailor their care. Some clients may hesitate to reveal concerns, so patience and gentle probing (e.g., “Tell me more about that.”) can help. This is important: Not addressing clients’ specific requests or concerns can make them feel dissatisfied with their care. Sometimes not all needs or concerns can be met in one visit, in which case it’s essential to schedule follow-up appointments.

Empower clients by giving them options, encouraging questions, and allowing them to decline services.

Providers can help clients advocate for themselves by providing a range of care options (e.g., birth control options) during visits, encouraging clients to ask questions, and ensuring that clients know they can decline any unwanted procedure or treatment (e.g., immunizations, pelvic exams). Providers told us they explain to clients why they are asking certain questions—which are often of a sensitive nature—and give them the option to skip any they are uncomfortable with. These strategies help clients feel heard and empowered to take the lead in their health care journey.

Reduce stigma and fear around sexual and reproductive health and health care, while also acknowledging that these fears and stigmas exist.

Providers know that some clients have beliefs or misinformation that can fuel fear and stigma around sexual activity, contraception, and STIs. To counter this, providers educate clients, making sure to correct any misinformation they hear, and encourage clients to take their time deciding on a particular birth control method. Highlighting the wide range of services offered by clinics—beyond STI testing and treatment, for example—can help reduce stigma around family planning clinics and encourage youth, in particular, to seek out care. When possible, having health educators join the provider during a visit can make clients feel more comfortable. Clients often discuss their concerns with the health educator first, which helps ease their anxiety and build trust in the provider.

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Provider-specific level strategies for respectful care

Strategies at the provider level focused on building providers’ awareness, knowledge, and recognition about client context, medical racism, and individual biases/assumptions. Each of these strategies resulted in providers adjusting the way they provide care.

Acknowledge how racism and discrimination affect clients’ experiences and choices in family planning care.

Providers understand that racism and discrimination in medical systems impact their clients’ comfort in seeking family planning care. They recognize that some clients may be uncomfortable with certain medical procedures or methods of contraception because of the history of forced sterilization and reproductive coercion in Black, Brown, and other marginalized communities. Providers in our survey emphasized the importance of listening to clients’ concerns and fears and stepping back if a client does not feel comfortable.

Self-check personal biases and assumptions about clients’ race or ethnicity, age, sexuality, gender identity, income, or other factors.

Providers in our survey were cognizant that personal biases and assumptions about clients’ identities and lifestyles can prevent some providers, including themselves, from delivering high-quality, patient-centered care. They noted the importance of being aware of internal biases and “self-checking” in the moment. Providers understood that managing these personal biases requires ongoing self-reflection and continued training and learning opportunities.

Learn and understand clients’ personal, familial, cultural, historical, and political contexts.

Providers can better connect with clients and understand their family planning needs, preferences, and concerns by learning about the history, culture, and needs of their community—and their community’s experiences with health care systems and other institutions. Learning about the cultural norms of specific populations (e.g., religious practices, norms around eye contact) and identifying areas where social support is needed (e.g., services for immigrants, intimate partner violence support) can help providers engage with clients holistically and respectfully. Participation in community outreach and completion of trainings on cultural competency support providers’ learning.

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Recommendations When Implementing Respectful Care

In addition to the identified strategies to implement and support respectful care, providers also noted some recommendations in implementing respectful care. Below, we provide provider reflections about doing this work:

1. Having ongoing and dedicated support for providers helps with the difficulty of implementing respectful care in practice.

Providers acknowledged that wrestling with biases and accepting clients’ decisions and choices is hard—particularly around contraceptive choices, abortion, and treating clients for repeat health concerns (e.g., frequent STI treatments). These concerns can be more intense with younger clients, and especially in situations where providers feel they would make a different choice for their client. Well-intentioned and culturally competent providers who understand the importance of centering clients’ needs emphasized that acceptance can be challenging in certain situations.

Additionally, providers shared that some of their tenured colleagues continue to lack awareness of their biases or problematic behaviors that negatively impact care, and have difficulty “see[ing] something different” or “fear of doing something a different way.” This can slow momentum and impact the culture of the clinic. Having support structures and dedicated reflection time in the clinic can help providers share experiences and navigate challenges implementing respectful care practices.

2. Care for providers to prevent burnout.

Providers shared that they often feel burnt out. Professional burnout due to limited support in the workplace and personal stress can cause providers to be distracted—and make it harder for them to show up as their best selves for clients. Providers felt that support and trainings specifically focused on self-care would be beneficial to help them manage stress in and out of the workplace.

3. Create structures that support the time needed to implement these strategies.

Many of the provider strategies shared in this brief require time. The populations our sample of providers serve have multifaceted needs; addressing each of those needs, and validating and making space for concerns, requires more time with clients and clinic structures that support that time.

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Conclusion

Collectively, the providers we talked with shared three levels of respectful care strategies that have the potential to mitigate longstanding disparities in sexual and reproductive health. Some strategies help providers increase their own knowledge and limit biases, which affects their behaviors; others help them more effectively engage with diverse clients or enhance their operations to more intentionally support populations they serve; others still help clinics increase their connections with local communities.

The strategies shared in this brief can serve as inspiration for the broader field of family planning providers and clinic staff looking to provide respectful care to clients with diverse needs. Some strategies will not be relevant for all clinics, while providers and clinic staff in various settings will likely have many more strategies that have worked for them. The respectful care strategies discussed here are deeply interlinked and should be considered in relation to one another. Strategies at one level may be impacted and supported by a strategy at another level, and advancing respectful care will require a multipronged approach as much as possible.

As you and your team review these strategies, we encourage reflection on what organizational structures are needed to support these strategies and the barriers that may stand in their way. For example, providers shared strategies around acknowledging one’s own biases, and many emphasized the difficulty of doing so. For many, making a change like this—internalizing the principles of respectful care—may be a lifelong journey that takes ongoing training and reflection. To support staff on this journey, one training on bias will not suffice. Rather, trainings require follow-up and informal and formal structures to become a regular practice for staff and a cultural norm within the clinic. Additionally, providers should feel safe and supported in sharing their realities in implementing practices. Lastly, providers need holistic support and established clinic procedures and practices to help them thrive and limit burnout, thereby empowering them to show up as their best selves for their clients.

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Acknowledgments

We would first and foremost like to thank the providers that gave us their time and critical insights. This brief would also not have been possible without the assistance of many colleagues at Child Trends who contributed to the interviews and analyses, including Asari Offiong, Emma Pliskin, Jane Finocharo, Jennifer Manlove, and Kate Welti. We additionally thank Asari Offiong and Brent Franklin for their reviews; Julie Blechman, Mayson Stowers, and Catherine Nichols for their design work; and Melissa Perez for their factcheck. Lastly, we would like to thank our project officer, Callie Koesters, for her leadership.

Disclaimer

This publication was supported by the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,548,353 with 100 percent funded by OPA/OASH/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by OPA/OASH/HHS, or the U.S. Government. For more information, please visit https://opa.hhs.gov/.

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Footnotes

[1] We define households as having low incomes if their household income is below 250 percent of the federal poverty level.

[2] A question about the extent to which providers and clinics consider racism and systemic inequities in their care of clients with marginalized identities was incorporated into the recruitment process after data collection started and became an inclusion criterion for the study.

[3] The “Other” category in this figure represents instances where the participant did not respond to the question in the screener survey.