Evaluating Client-Centered Counseling Approaches to Improve Contraceptive Uptake at Family Planning Centers in Rawalpindi, Pakistan: Protocol for a Pilot Cluster-Randomized Trial

Background: Despite active national initiatives, the low prevalence of modern contraception in Pakistan remains unchanged, leading to high rates of unintended pregnancies and poor maternal and neonatal outcomes. Conventional directive counseling does not sufficiently cater to women's needs, whereas structured client-centered strategies like GATHER (greet, ask, tell, help, explain, return) and the balanced counseling strategy (BCS) may improve outcomes. Existing literature assessing the comparative effectiveness of these strategies in the Pakistani population lacks evidence. Objective: The study aim is to compare the effectiveness of routine counseling, GATHER, and the BCS in improving client satisfaction with, and uptake of, modern contraceptives. Methods: This is a pilot, 3-arm, single-blinded, parallel, cluster-randomized trial conducted in tertiary care hospital-affiliated family health centers in Rawalpindi, Pakistan. It is a 3-phased trial, first assessing baseline data on contraceptive uptake and discontinuation determinants among 333 women of reproductive age. The second phase will provide structured training to service providers based on either GATHER or the BCS in each arm. After training, assessments will be performed at 3- and 6-month intervals to evaluate contraceptive uptake and counseling quality improvements. In the last phase, a qualitative analysis will be done through focus group discussions and in-depth interviews to identify barriers to implementation and to assess scalability. Analyses will be done using SPSS (version 26; IBM Corp). Analyses of quantitative and qualitative data will be done using mixed effects models and thematic analysis, accounting for clustering, to evaluate the interventions' effects on contraceptive uptake and client satisfaction. Results: Delivery of the intervention is underway, and baseline data from the 333 participants have been collected. The first follow-up assessments are planned at intervals of 3 and 6 months. However, no outcome data have been obtained or analyses performed at this stage. Conclusions: This pilot trial is expected to generate evidence on the effectiveness of structured, client-centered counseling strategies in comparison to conventional routine practices, showing improved uptake of contraceptive use and satisfaction in Pakistan. The findings are expected to facilitate the design of comprehensive and scaled-up trials and guide national family planning programs and the integration of rights-based counseling strategies.