Family Planning Counseling Session I:

Family Planning Counseling: Objectives By the end of the training, trainees will be able to: Explain how to support informed choice and maintain confidentiality Discuss sexual health without embarrassment Demonstrate how to help clients discuss and negotiate FP use with partners Identify beliefs and attitudes that may interfere with effective counseling Describe the four stages of FP counseling and factors that affect FP method choice Suggested script: The learning objectives for this session are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>. The objectives of this session are as follows: By the end of this training session, participants will be able to: █ <click the mouse to advance through the objectives, reading each objective aloud; then go to the next slide>. █

Family Planning Counseling: Objectives (continued) Demonstrate how to use a counseling tool and other job aids effectively Demonstrate effective communication and counseling skills Demonstrate competence in providing informed choice FP counseling Optional: Explain the counseling needs of women who are postpartum and postabortion, men, and young people Explain how traditions or beliefs may limit a woman’s ability to freely choose and use FP Suggested script: <continued from previous slide> █ <click the mouse to advance through the objectives, reading each objective aloud; note how the participants’ list of skills and counselor qualities is related to the learning objectives>. During this training you will learn, practice, and demonstrate these skills during role plays and other activities. You will also be encouraged to think about what it will be like to perform these tasks on-the-job. <if participants are clinicians, also ask the following> How well do these objectives match your expectations for the training? █ Note to facilitator: The session is designed to address the objectives on FP counseling listed in the session plan. If it is helpful, you may inform participants about the people and organizations involved in developing the learning objectives and the training program. Also mention that the learning intervention will include a practicum or simulation (if applicable) and briefly describe how skills will be assessed.

Personal Goals for FP Counseling What motivated you to become a health worker and learn FP counseling? What are your goals for counseling community members or clients about FP? What do you hope will happen? What community problems will good FP counseling help with?

What is Informed Choice? All family planning clients have right to informed choice: Opportunity to freely choose among options and Complete, accurate information that is easy to understand about appropriate, available options What do we mean by informed choice? <allow participants to respond; use responses to help define informed choice>

Clients Have a Right to Freely Choose Whether to: Have children, and how many to have Use FP or not Be tested for STIs/HIV Use condoms Have one or more sexual partners Talk with partner about condoms or FP Reveal their HIV status Clients have the right to freely choose <click the mouse to display and read each point on the slide> What are some other examples of when a client’s choice does not seem like the appropriate decision from the provider’s perspective? <allow participants to respond and discuss as appropriate> Why is it important to support a client’s choice or choices, even when it does not seem, in your opinion, to be best for the client? <allow several participants to respond> Reference: 1.Abdel-Tawab N, RamaRao S. Do improvement in client-provider interaction increase contraceptive continuation? Unraveling the puzzle. Patient Education and Counseling, 2010. 81:381-387.

Maintaining Confidentiality Confidentiality is a client’s right All sessions with FP clients must be kept confidential Do not tell anyone what client has told you or show client records to anyone except a health provider Assuring clients of confidentiality helps them to relax and share more openly Suggested script: How would you feel if your best friend revealed a secret you had told her, and had asked her not to tell anyone, and now the whole village knows your secret? <allow participants to respond; responses may include angry, betrayed, mistrustful, embarrassed, shamed> Would you trust her again? <allow participants to respond>How would you feel if you went to a clinic and confided in the provider, but then heard that she had shared the information with others. <allow participants to respond> Now, how do you feel about a friend who always keeps your secrets? <allow for a few responses> You trust her, yes? You are more likely to speak openly with her in future conversations.

Components of Effective FP Counseling Communication and counseling skills, including skills of giving focused information Ability to guide the client through the counseling process FP methods information Illustration credit: Ambrose Hoona-Kab

How Do We Communicate? Interpersonal communication is: Nonverbal communication: Face-to-face exchange of information, ideas or feelings through facial expressions, gestures and body positions Verbal communication: Face-to-face exchange of information, ideas or feelings through use of the voice Can anyone describe nonverbal communication? <allow one or two responses> Yes, nonverbal communication is <define nonverbal communication as shown on slide> And verbal communication is <define verbal communication as shown on slide >

Effective Non-verbal Communication Paying full attention—listening Relaxed and accepting body postures facing the client Facial expressions that show interest, acceptance and concern (smiling) Encouraging gestures (nodding the head) Avoiding checking watch or looking away Help establish a good connection What might be other examples of negative nonverbal behavior or cues? <allow participants to answer, affirm appropriate responses> Can you think of any other nonverbal cues or gestures that you could you use during your counseling sessions to help put clients at ease? <discuss and answer any questions>

Effective Verbal Communication Active Listening: Giving verbal encouragement Using appropriate tone of voice Paraphrasing what the client says Reflecting feelings

Paraphrasing and Reflecting Feelings Purpose: Lets client know you are listening Checks that you have understood Reflects the client’s feelings about situation Summarizes or clarifies what client says Express empathy, not sympathy: Client: My baby wants to feed very often and it makes me feel so tired. Health worker: You are feeling very tired all the time then? NOT: I know how you feel. My baby also wanted to feed often and I was so exhausted!

Using Simple, Clear Language Use words and explanations that clients can easily understand If clients do not understand, they may not: Ask for clarification Make good decisions Follow instructions

Other Key Counseling Skills Remaining nonjudgmental and avoiding using judging words Discussing sexuality and sexual practices comfortably Helping clients prepare to talk with partners about FP Asking questions effectively

Purpose of Asking Questions Assess client’s needs and concerns Involve client in conversation Help client express feelings and attitudes Show interest and concern Determine what client already knows Identify misinformation or myths to correct Instructions for facilitator: Ask the participants: What is the purpose of asking questions during FP counseling? Allow for several responses. Then click the mouse to reveal each of the bullet points, in turn.

Types of FP Counseling Questions Two types: Do you wish to have children in the future? How may I help you today?

How can I help you today? Are you using a family planning method now? Are you worried you might be pregnant? Would you like to choose a method? Do you have a question or problem about a method? Do you have any concerns about sexually transmitted infections (STIs) or HIV/AIDS? Other needs?

Tips for Asking Questions Effectively Use a tone of voice that shows interest Ask one question at a time, wait for answer Ask questions that encourage client to express needs Avoid leading questions Avoid judgmental questions or questions starting with “Why” or “Why didn’t you?” Repeat a question in different way if client has not understood If asking a delicate question, explain why Ask participants, How many of you would feel uncomfortable asking your client about the number of their sexual partners or about their sexual practices? Use the responses to lead into the next activity about practicing asking questions about sexual behavior. What advice could you give about asking questions effectively? <allow participants to respond; use responses to present the tips> To ask questions effectively, it is important to maintain your active listening tone of voice, while showing interest and concern. In addition, ask only one question at a time, wait with interest and patience for the answer. Ask questions that encourage clients to express their needs. Here’s one example: How would you feel if you became pregnant soon? What would be another example? <allow participants to respond; affirm and/or correct their responses> Avoid leading questions; these are questions that indicate the answer the provider wants to hear, such as: You wouldn’t want to use the Pill, would you? Or: You use a condom every time you have sex, right? Avoid judgmental questions or starting questions with “Why” or “Why didn’t you…” These can sound as if you are blaming the client or finding fault. Repeat a question in a different way if the client has not understood you the first time. If you need to ask a delicate question, explain why. For example, asking about the number of sexual partners to find out about STI risk. What is one way you could ask about this and also explain why it is important for you to do so? <allow time for a few responses; affirm or correct and provide an example of asking about the number of sexual partners; discuss as needed, emphasizing that it can be difficult to discuss sexual health and sexuality>

Negotiating Family Planning Use What are some reasons a woman’s partner may give her for not using FP or why he doesn’t like FP?” How can you help a client prepare to negotiate FP use with a partner? Instructions for facilitator: Divide into two groups. Give each group a blank flip chart and pens. Ask each group to assign a recorder for the group. Ask “What are some reasons a woman’s partner may give her for not using FP or why he doesn’t like FP?” Ask the groups to brainstorm and write on their flip chart answers to the question. Tell the groups to leave space for a response under each statement on the flip chart. Give the groups about five minutes to work. After two minutes, call time and ask the groups to switch places. Now, ask the groups to examine the other group’s list, and brainstorm and write one response to each of the statements on the flip chart. Give the groups another two minutes or so to do this. Bring the groups back together and discuss the two lists of statements and responses. Note similarities and differences. Note that this list can be a resource for participants to use during role plays and in their work. Explain that they can use this technique to help a client prepare to talk with her husband or boyfriend about using FP. Ask participants: “What are other ways to help a client prepare to negotiate FP use with a partner?” Allow participants to respond, then explain that it is often helpful to rehearse the negotiation conversation, with the health worker taking the role of the partner so the client can practice her responses. Tell participants that if the client is having difficulty responding to what you, as her partner, are saying, you may rehearse the conversation again, this time with the client taking the role of her partner while you play the client’s role and model possible responses. Ask two participants to do a short roleplay of a couple negotiating family planning use, using some of the dialogue from the flip charts. Ask participants if they have any questions and discuss further as needed. Tell participants that next you will demonstrate these techniques.

Counseling is Not … Solving a client’s problems Telling a client what to do or making decisions for client Judging, blaming, or lecturing a client Interrogating a client Imposing your beliefs Pressuring a client to use a specific method Lying to or misleading a client Ask participants to partner with someone sitting near them. Ask participants to reflect on a negative counseling experience and to share with their partner what made the experience negative and one or two characteristics of the counselor or health worker involved in the negative experience. Ask the participants to talk about what the counselor did or said that was not productive or did not help the situation. If participants have difficulty thinking of a negative counseling experience, give them an example. Allow two or three minutes for this discussion. In the larger group, ask the participants to share what they discussed about their negative experiences. Click the mouse to reveal the list on this slide, and relate the bullet points to the participants’ responses. Discuss. Give examples from your experience of how clients have been treated and how that influences their behaviors and use of services; if possible, use quotes from clients about their experiences, without identifying the client. Remind participants that sometimes we are not aware of how we affect clients by things we say and do, therefore it is helpful to get feedback from each other during the training and from our supervisors when we return to our communities. Inform participants that next we will look at our own beliefs and attitudes and how they may get in the way of effective, informed choice counseling if they are not managed properly.