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