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Client-Provider InteractionClient-Centered Counseling
Client-Centered Care
Seeing client-provider interactions through the eyes of the client
Effective client-provider interactions are Effective client-provider interactions are centered around the client's needs.centered around the client's needs.
Important Qualities for All Service Delivery Staff
• Respect and empathy for the client
• Communication skills
• Acceptance of valuesand beliefs differentfrom one’s own
• Impartial attitude toward all clients
Important Qualities for Reproductive Health Care Providers
• Comfortable discussing sexuality and other personal issues
• Unbiased position regarding reproductive health issues
• Ability to support client’s informed decisions
• Technical knowledge and skills
Gender Affects Client-Provider Interactions
• When sex of provider and client is different, client may be: – hesitant to discuss sensitive issues – uncomfortable having clinical procedures
• In couple counseling, provider should pay equal attention to partners’ needs
Gender –Gender – roles prescribed for women roles prescribed for women and men in culture or societyand men in culture or society
Source: FHI, 1998.
the foundation of effective reproductive health counselingthe foundation of effective reproductive health counseling
Informed and Voluntary Choice
Voluntary Voluntary decisiondecision
Range of Range of choiceschoices
Informed Informed about optionsabout options
Client-Provider Interactions Affect Informed and Voluntary Choice
• Help clients assess reproductive health goals
• Provide clients with complete, accurate, understandable information
• Guide clients through process of making a decision
• Do not express personal preferences or pressure clients
• Be respectful and accepting of all clients
Characteristics of Effective Counseling Sessions
• Client-centered
• Interactive
• Private and confidential
• Individualized
Providers need to adapt to challenging Providers need to adapt to challenging conditions.conditions.
Tools for Effective Counseling
• Communication skills
• Technical information
• Ability to guide the counseling process
Communication Skills
Skills needed:
• Active listening (both nonverbal and verbal)
• Ability to use simple language
Effective communication helps clients feel Effective communication helps clients feel more comfortable talking about needs.more comfortable talking about needs.
Types of Communication
• Nonverbal:what is observed and sensed
• Verbal:what is said and heard
Active listening involves nonverbal and Active listening involves nonverbal and verbal skillsverbal skills
Verbal Communication Skills
• Using appropriatetone of voice
• Giving verbalencouragement
• Asking questions
• Paraphrasing andreflecting feelings
Nonverbal Communication Skills
• Paying full attention
• Using facial expressionsthat show interest and concern
• Using encouraginggestures such asnodding the head
Clear and Simple Language
• Improves communication
• Prevents misunderstandings
• Avoids intimidation and confusion
Practice can help providers use clear, Practice can help providers use clear, simple language.simple language.
Technical Information
• Sexuality during all life stages• Family planning and fertility awareness• STI/HIV/AIDS prevention and treatment• Pregnancy, delivery, postpartum/postabortion care• Infertility management• Reproductive cancer detection and treatment• Gender-related abuses • Nutrition• Risk assessment, exams, and procedures
Stages in Counseling
EndEnd
after after decisiondecision
MiddleMiddle
informed informed decisiondecision
BeginningBeginning
assessment of assessment of client’s needsclient’s needs
Five As A – assess A – advise A – agree A – assistA – arrange
Remembering the Counseling Process
GATHER G – greet A – ask T – tell H – help E –explain R – return
Sequence of steps Key elements
REDI R – rapport-building E – exploration D – decision making I – implementing
CLIENTC – client-centered L – listening I – interaction E – exploration N – nonjudgmental T – trust
Balanced Model GreetDiagnose needsDiscuss/chooseScreenGive informationVerify comprehensionEnsure follow-up
Source: JHU, 1998; EngenderHealth, 2003; WHO, 2006; Population Council, 2006; FHI 1999; ARHP, 2003.
RESPECTR – rapport E – empathy S – support P – partnership E – explanations C – cultural competenceT – trust
Beginning:
Initial Assessment
Assess the client’s needs and preferences based on:• Reproductive health goals and concerns • Reproductive and sexual history and
fertility intentions • Medical history and current problems • Knowledge and previous experience• Other relevant factors
Tailor information to the client’s needs.Tailor information to the client’s needs.
Middle:
Making an Informed Choice
Avoid giving too much information.Avoid giving too much information.
Effectiveness
How method is used
Other method characteristics
Medical eligibility
Side effects
End:
Discussing the Chosen Method
• Explain chosen method in more detail
• Prepare client for potential side effects
• Ensure client understands correct use
• Provide memory aids when possible
• Explain how procedures will be done
• Discuss when and why client may need to return to clinic
Range of Choices for Clients with HIV
1. Fertility decision: desire pregnancy?
PregnancyPregnancy desireddesired
NoNo YesYes
2. Informed decision(s):contraceptive method? STI/HIV prevention?
Intended Intended pregnancypregnancy
PregnancyPregnancycounselingcounseling
ContraceptiveContraceptive counselingcounseling
Ongoing HIVOngoing HIVcounselingcounseling
Safe/effectiveSafe/effectivecontraceptioncontraception
3. Treatment decision(s): ARV therapy for self and partner? PMTCT?
PMTCTPMTCT servicesservices
NoNoYesYes
ARVARVtreatmenttreatment
NoNoYesYes
Adapted from: Cates, 2001.
Essential Counseling Skills for Meeting Needs of Clients with HIV
• Be sensitive to circumstances of women and couples with HIV
• Respect clients’ rights
• Ensure that all women, regardless of HIV status, are free to make informed choices about pregnancy and contraception
• Assure privacy and confidentiality
Essential Counseling Skills for Meeting Needs of Clients with HIV
continued ...
• Help clients consider how HIV affects individual circumstances and needs
• Tailor counseling session to needs of client
• Facilitate partner involvement and offer partner counseling
• Provide comprehensive, factual, unbiased information
• Support client’s RH decisions, even if you disagree
Avoid any type of coercion.Avoid any type of coercion.
Source: Chervenak, 1996.
For clients with HIV:
Counseling about Pregnancy
Providers should discuss:
• Pregnancy does not accelerate HIV disease progression
• Condom use to prevent STI/HIV transmission between partners
• Risks/rates of mother-to-child transmission
• ARV drugs reduce transmission at delivery
Source: McIntyre, 1998; Bessinger, 1998; European Collaborative Study and the Swiss HIV Pregnancy Cohort, 1997; Vimercati, 2000; Gray, 2005; Working Group on Mother-to-Infant Transmission of HIV, 1995; Dabis, 2000.
For clients with HIV:
Counseling about Pregnancy
continued ...
• Malaria during pregnancy may increase risk of – HIV transmission to infant – miscarriage
• Artificial feeding or exclusive breastfeeding reduces postpartum transmission
• Implications of rearing a child with HIV
• Availability of family support
• Location/logistics of care and treatment
Source: ter Kuile, 2004; WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality, 2000.
For clients with HIV:
Safer Ways to Achieve Pregnancy
If planning for pregnancy, discordant couples should:
• Avoid trying to achieve pregnancy if viral load is high (early infection or AIDS with no ARV treatment)
• Consider artificial insemination in cases where male partner is not infected
• Limit unprotected sex to ovulation window of menstrual cycle in cases where female is not infected
For clients with HIV:
Counseling about Contraception
Providers should discuss:
• Characteristics of contraceptive methods
• Possible side effects and complications
• Method effectiveness and ability to use correctly
• Implications/drug interactions for women with HIV who choose hormonal contraception and: – are on ARV therapy– are taking rifampicin or rifabutin (coinfection with TB)
For clients with HIV:
Counseling about Contraception
continued ...
• Limitations of methods in preventing pregnancy and STI/HIV transmission
• Advantages of dual protection, including dual method use
• Partner’s willingness to use condoms, condom negotiation strategies
• When to return and where to access services
Counseling about contraception, for clients with HIV:
ARVs and Hormonal Contraception
For women using ARV drugs and hormonal contraception, providers should discuss:
• Importance of taking pills on schedule
• Need to return for NET-EN injection on time
• Possibility of using condoms to provide additional protection from pregnancy
(in case hormonal contraceptive effectiveness is compromised by ARVs)
For clients with HIV:
Additional Counseling Topics
• Importance of knowing partner’s HIV status – encourage partner testing if status is unknown
– discuss health implications/prevention strategies for discordant/concordant couples
• Considerations in disclosing HIV status– risk of abandonment
– violence
– loss of financial support
• Discuss available support systems: – family– community– social
– legal– nutritional– child health
continued ...
• Offer referrals to other RH services as needed: – STI management/treatment – postpartum, postabortion,
antenatal care– HIV care and treatment
For clients with HIV:
Additional Counseling Topics
Summary
General principles:
• Treat the client well
• Be interactive
• Individualize
• Avoid too much information
• Act on client’s decision
• Help the client understand and remember
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