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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013.

Cover of Counselling for Maternal and Newborn Health Care

Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills.

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5PRACTICAL CONSIDERATIONS IN THE COUNSELLING PROCESS

Image session5fu1

What is in this session?

In this session we first examine how to establish a good counselling environment. Then we review some of the tools and aids you can use to support your counselling activities and assist in communication; these include educational materials such as posters, flip charts, and home-based records. We also discuss group work as an aid to counselling.

What am I going to learn?

By the end of this session you should be able to:

  1. Organize the counselling environment both at the health facility and for home visits.
  2. Use a range of different tools and aids to support your counselling activities.
  3. Evaluate which tools and aids are most appropriate for your needs as a counsellor and tailor them to the needs of the woman or couple.

Establishing the counselling environment

As well as needing a thorough understanding of the wider context in which counselling takes place, it is important that you establish a good environment for counselling whether in the health facility or in a home. For many in the community, the health facility is a strange environment, so there is a lot you can do to improve the counselling environment. Even when visiting the home, you can create a better counselling environment by going to a separate room or asking friends and relatives to wait outside.

When we talk about the counselling environment, it is not just the physical environment we are referring to. It also includes how you greet people, how you talk to them and other aspects of non-verbal communication such as eye contact and body language. How you treat people in these ways is all part of setting up a good counselling environment, and you are demonstrating your use of empathy and respect (a key guiding principle from Session 2).

Preparing a good counselling environment lays the necessary foundation for forming an alliance and building trust.

Does the health facility offer a welcoming environment?

Does the health facility offer a welcoming environment?

Activity 1

Image session5fu3.jpgVariable

Image session5fu4.jpgAn opportunity for you to reflect on how you interact with people and the factors that influences this.

  1. Use your notebook to record how you greet and treat people and how you are greeted and treated over the course of a few days. Try to include different interactions, for example, in a shop or bank, at work, or in a new place.
  2. How did the different interactions you had make you feel? Did you feel welcome and included? Did you ever feel unwelcome or isolated?
  3. If you did not visit a new place during this time, think about a time when you have visited a new place, especially a new institution such as a government building or an official office. How did you feel? What was done or could have been done to make the experience better?
  4. If you are working in groups, share your findings and discuss them.
  5. What are the most important things that people can do to make others feel welcome and comfortable? What things should you try to avoid? What influences the way you interact with other people?

Image session5fu5.jpgOur View

You probably found that you had different types of interactions with different people depending on how well you knew them. You may also have found that the physical context in which you met influenced the interaction e.g. was it a familiar or strange environment to you? Also the nature of your social and socio-economic status relative to the other person or people will also have affected the interaction. Think how differently you would feel before meeting your friends to how you would feel before meeting the Minister of Health! You may have found that where people are friendly and courteous that the interaction felt more comfortable. Other things which improve the interaction include where someone takes time to explain a situation or procedure which is new to you. For example, if you were to meet the Minister of Health you would probably feel more comfortable if someone told you in advance how to greet the Minister, where the meeting would take place, and what would be expected of you. For some women or couples, entering a health facility can be as daunting to them as it would be for you to meet the Minister. Take time to reflect on this and think about what you can do to help put them at ease. Remember as mentioned in Session 2 it is important to maintain courtesy at all times.

THE COUNSELLING ENVIRONMENT SHOULD BE

  • welcoming (e.g. greet clients appropriately, show them where to sit)
  • comfortable (e.g. have comfortable seats, try to sit at the same level)
  • a place with few distractions (e.g. no telephone, or interruptions from other staff or family members)
  • somewhere where privacy and confidentiality can be maintained (e.g. somewhere away from other people)
  • non-threatening (e.g. a place where people can feel relaxed and comfortable).

When you visit people in their homes it is difficult to organize the counselling environment to meet all your needs. However, you can make sure you sit somewhere comfortable and quiet away from other family members. You can try to minimize distractions by switching off radios or televisions.

Confidentiality and privacy

Welcoming and greeting people is the first step to establishing a good counselling environment. But part of creating a safe and welcoming counselling environment includes the need for both auditory (hearing) and visual (seeing) confidentiality in order to promote trust. A lack of trust may decrease an individual's participation in the counselling process or may even threaten or scare them. Creating an environment of trust and confidentiality is especially important for women who are distressed or women with special needs such as those with disabilities, women who have been abused (see Session 16), or adolescents.

Activity 2

Image session5fu3.jpg20 minutes to several hours depending on the level of reorganization required

Image session5fu4.jpgTo improve the counselling environment in your health facility.

Within the health facility there is a lot that you can do to make sure the counselling environment is appropriate.

Note to facilitator: this activity can either be done as one big group or you can divide the work between smaller groups giving each group one of the questions to tackle.

  1. Go to the entrance of the health facility. Is it clear where people should go to find you? Decide what you could do to improve access, e.g., place signs which include a welcome and/or drawing; have all staff greet people in an appropriate manner; train staff, including non-medical staff (e.g. guards, cleaners etc.), with courtesy and respect.
  2. Now look around the immediate area that you work in. Is it a welcoming environment? Is it obvious where people should go? Where they should wait? Are the different rooms and areas labelled? Is it clean and tidy? Does staff look friendly and welcoming?
  3. Where do physical examinations take place? Is this area private? How could you ensure greater privacy? E.g. using curtains, ensuring everyone knocks before entering.
  4. Where does counselling usually take place? Is it appropriate? You can assess whether it is appropriate by answering the following questions: Is it comfortable? How is the room arranged? Are you able to sit next to each other and at the same eye level? Can your conversations be overheard? What could you do to ensure greater privacy? How can you minimize distractions? How could you make it a more welcoming environment?

Image session5fu5.jpgOur View

Hopefully you have been able to make some changes that will allow the women and families you see to feel more welcome and more comfortable. You will have considered how to ensure privacy and minimize distractions, how to label rooms and make signpost directions. To assess how well you have done, pretend you are a woman on her first visit! Also ask for feedback from people who use your health facility through discussions, a mini questionnaire/survey or a suggestions box.

Tools to aid counselling

The best way to communicate information as previously mentioned involves an interactive, two-way discussion. It can sometimes be helpful to have prompts to remind us of the information we need to cover. Prompts can take many forms, it could be a checklist of activities or it could be a poster or flipchart or other type of visual aid.

Visual aids

Visual aids can be used to reinforce your discussion. Visual aids can also stand alone as methods of providing information. The main disadvantage of using them alone without discussion is that they do not allow for interactive communication and therefore may be misunderstood. If you do give out visual aids without having a discussion you can overcome this difficulty by providing people with an opportunity to ask questions at a later point either in group or individual discussions.

Visual aids and other tools for counselling

  • posters
  • leaflets or fact sheets
  • flip charts
  • overhead projector and transparencies
  • slide shows
  • models (such as female pelvis, penis)
  • chalk or whiteboards
  • pictographs (picture leaflets)
  • songs, drama or poems
  • real life examples, testimonies or case studies from women
  • written notes to remind you of points to cover.

Note: Remember to ensure that all materials/tools are developed with a consideration of the literacy levels of the women and families you are counselling.

Activity 3

Image session5fu3.jpg1 hour

Image session5fu4.jpgTo review existing visual aids and materials that you may have at the health facility.

  1. Gather all the tools and materials that you have at your health facility.
  2. What topic areas do they cover? Have they been field tested with women from the zone to ensure they are suitable, appropriate and understandable? Do they need further explanation?
  3. Are there any other support materials that you like? Can you identify the topic areas?
  4. How could you go about developing or obtaining more materials? What resources would you need to do this?

Image session5fu5.jpgOur View

Developing good visual aids and tools is a skilled activity and many people specialize in this as a job. You may well have a department within the health service which does just that. Where possible you should try and use existing tools and visual aids because they will have been tested and reviewed. However, there are some instances where there will be no tool available for a topic. This is where you can develop your own tools. It could be something simple like a fact sheet, or a list of support organizations on a particular topic. It could be a simple poster or a prompt sheet to remind you of all the information you need to cover. You might also consider working with local women or communities to develop and create some materials although this will take time. As you work through the Handbook you will find suggestions of tools and aids that you can create yourself. Another thing you should consider doing is organizing a resource library at your health facility where you keep all your tools and aids – both professionally-developed aids as well as those that you and your colleagues have put together.

Home-based records

In some communities, women are encouraged to have their own home-based maternal health records. These records often consist of personal information such as marital status, parity and information on past pregnancies and births. These home-based records can be an excellent counselling tool. They provide a means to record what has been discussed in individual counselling sessions which can then be built upon in future discussions. You can also include the woman's birth and emergency plans as part of the records (see Session 7 which provides more details on birth and emergency plans). As the record is home-based, a literate woman can refer to the discussions between visits. If she does not read, you will need to find other ways (such as images) to remind her of the key points discussed. It is useful to remember that if the records are home-based women need to be consulted as to what will be recorded. Other people may easily read the records, and the woman may not want all of her pregnancy information available for anyone (including her husband or partner) to read. For this reason sometimes women will not inform you about their full medical history or past pregnancy history. A common example is that women will not inform you about a past termination of pregnancy or miscarriage and may only reveal this verbally to a counsellor. It is important to respect her wishes with regards to her home-based records and to remember confidentiality.

If you do not have home-based records in your community, why not consider starting them up?

Role of records in counselling

  • to stimulate discussion and interaction
  • to remind the counsellor of the information to be communicated
  • to communicate information in a simple relevant way to the woman and her family
  • to act as a reminder to the woman and family of previous communication
  • to illustrate examples and consequences of action/inaction
  • to strengthen links and communication between the different levels of the health system.

Programme tools

It is likely that you will already have a number of tools developed for the services you offer. You might not have considered their role as tools to aid counselling. For example, you may have checklists, charts or clinical decision-making tools such as the WHO PCPNC. These can all be used to help you remember information you need to cover and when to discuss it. You may also have some more specialized programme tools or guides for topics such as breastfeeding or family planning.

Why not consider making an inventory or list of all the tools that you have (building on the list you generated in Activity 3) and how you might be able to use them in counselling for maternal and newborn health?

Group information sessions

It is not always possible to spend time providing detailed information to individual women on every aspect of MNH. There are a number of topics where it is beneficial to work with groups of women, or groups in the community. For example, basic care in the home during pregnancy are topics which can be communicated in a group and which do not necessarily need individual counselling. You might just counsel the woman on the plans she has made to get the care she needs when you see her individually, following the group session. Given the volume of work that some skilled attendants have, and the limited time you have with each woman, using groups which are already in existence, such as in the waiting room, or community groups can be beneficial. This can also help to increase general awareness and support for maternal and newborn health needs.

You can also consider holding discussion and support groups for women with different needs, including new mothers, women who have had a miscarriage or abortion, or for special groups of mothers such as adolescents. Support for breastfeeding is also a good example of a group which can be formed where women can share experiences and support each other.

Some topics are more difficult to discuss in a group session but can still be addressed, such as providing general information on STIs and condom use (including demonstrating condom use). Other issues, such as more personal sexuality issues would not appropriately be discussed in a group. However, addressing some general points and raising awareness in a comfortable, non-intimidating group setting can then encourage women to seek or raise points in individual counselling sessions to address their own concerns.

FACILITATING A GROUP SESSION

  • Make sure you can be heard.
  • Make sure any visual aids you use can be seen.
  • Ask the participants for feedback as to whether they can see and hear.
  • Talk slowly and clearly.
  • Use an interesting and animated style of talking to keep people's attention.
  • Maintain eye contact (if appropriate in your culture).
  • Change the tone of your voice.
  • Move around.
  • Allow time for group to ask questions.
  • Ask questions to make sure the topic has been understood.
Sometimes it can be beneficial to share information with women in groups.

Sometimes it can be beneficial to share information with women in groups

Encourage interaction, discussion and questions. Women can learn a lot from one another in a group session. Try to get feedback on whether the information has been understood. Try to avoid lecturing your audience with long lists of do's and don'ts – find out what they already know and what they already understand. Encourage the audience to share information with one another and facilitate a discussion among them on the topic. Be brief and avoid overloading the group with too much information. Also remember to maintain courtesy and confidentiality within the group setting. It is important to tell the group that they can see you individually after the group session if they have issues they want to discuss in private.

Activity 4

Image session5fu3.jpg2 hours preparation plus the group presentation/discussion

Image session5fu4.jpgTo improve skills for working in groups.

  1. Review all the material in this section, taking notes to help you.
  2. Plan the content of a group discussion about the foods that pregnant women should eat to maintain a healthy pregnancy. Then carry out the session with a group of women. It may be easiest to do this with a group of women attending antenatal care.
  3. If you are not working in teams or do not have a facilitator for the Handbook, ask colleagues to act as observers. Give them the following checklist to use to evaluate your session:
    1. Did the facilitator greet the women warmly, introduce herself or himself and explain the purpose of the session?
    2. Could the facilitator be heard?
    3. Was the pace and style of the language appropriate?
    4. Were visual aids used appropriately?
    5. Were women provided with an opportunity to participate?
    6. Was the group's prior knowledge assessed? Did the facilitator build upon this knowledge?
    7. Were women encouraged to participate in the group discussion?
    8. Were the women asked if they had any questions or if there was any point that could be explained more clearly?
    9. Were the women asked what they thought about the session and what they would like to see improved?
  4. Get your observers to also take notes and write down examples under broad headings of what went well and what could be improved.
  5. At the end of the session write down your own thoughts under the heading of what you thought went well and what could have been improved upon.
  6. Get feedback from the observers and also if you can from the women who were in the session.
  7. Use the feedback to reflect on your skills and how you might improve them.

Image session5fu5.jpgOur View

Like any skill, working with groups needs to be practised. When leading a group, it is easy to overlook many things such as talking as if to only one person, not talking loud enough or talking too fast. We might forget to involve the participants or assume they have prior knowledge or tell them what they already know. We might end up lecturing them or providing too much or too little information. Getting feedback from an observer or from groups themselves is an important way to improve your skills. Take time to reflect on what you have learned about your style and how you might try to change it. Use your notebook to write down how you are progressing.

Team work

One of the biggest constraints to better counselling in MNH is lack of time. Working with groups can be one way to reach more women and their families and free up more time for individual counselling sessions. Another useful aid to counselling can be to utilize the team of people you work with. Examine ways you can share the workload and contribute to improving a better service. As a team you can also discuss cases or situations together in order to pool your ideas or resources, to improve the counselling you offer. Working as a team can also help to ensure continuity of care, for example, if a woman who is attending antenatal clinic sessions is likely to see different staff each time she comes, then making sure you discuss her needs and situation or keeping accurate records means that you and your colleagues are all informed about her specific situation.

What did I learn?

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In this session you learned about the importance of organizing the counselling environment as a basis for a better counselling process. You looked at how to make people feel more welcome and how to ensure confidentiality and privacy. You also examined other practical things you can do to improve the counselling process such as the use of tools and visual aids, working with groups and team work. Each of these areas can help to support the service you provide to women, couples and their families.

This is the end of Part 2 of the Handbook. You should now be confident in the definition of counselling for MNH. You should be able to describe the six key steps to the counselling process, and guiding principles which form their foundation. You should also be familiar with the skills needed for effective counselling. You should be confident that you understand the diverse factors influencing counselling, and the importance of the counselling context. Finally, you should also be more aware of the counselling environment, and the many useful tools/aids which facilitate your role as a counsellor. Before moving onto the next part of the Handbook which focuses more on specific topics, spend some time reviewing all the work you have done in Part 2.

Copyright © World Health Organization 2013.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK304189

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