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| Behavior Change - Tools
and Approaches |
| Counseling as
Negotiation |
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| Despite improvements made by some programs,
the interaction between health worker and mother (or other
patient) is still typically a one-way conversation, with
the provider transmitting information and the mother listening
and maybe answering one or two questions. Improving this
interaction requires system changes that encourage and
reward real conversations. One tool to help with these
training and system changes is the GATHER method, developed
by PCS. Additional actions that are often required are
a reorganization of patient flow and provider responsibilities
within facilities, communication to mothers to encourage
them to ask questions and fully engage with providers
and counseling aids for providers. Although this description
will focus on the latter, it is only one piece of a strategy
for improving counseling. |
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| Counseling cards (or flip charts) are
job aids for facility or community-based health workers
to guide their communication with mothers and other caretakers.
Counseling cards systematize information to be discussed
to ensure that priority essential information is covered.
(Some cards or charts may also serve as memory aids for
diagnosis, classification, and treatment algorithms.)
Usually, the cards have photos or drawings on one side,
for the mother or caretaker to see, and words, phrases,
or sentences on the other side for the health worker to
see. |
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| The best counseling cards are designed
so that the health worker can tailor the information provided
to the specific needs of the client. This requires a system
to help the health workers choose the most appropriate
cards or sections of cards, depending on the profile of
the person whose health is of primary concern at the moment
(e.g., their age, basic feeding patterns, weight and/or
weight trend, whether they are well, sick, or recuperating,
etc.). |
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| The best counseling cards also facilitate
negotiation. They serve as a guide to a conversation rather
than being a text to be read or transmitted to the mother.
While certain information simply needs to be clearly communicated
by health workers and understood by the mother or caretaker,
much information, particularly on child feeding practices,
should be the subject of true discussion and negotiation,
which the counseling cards should facilitate. The best
counseling cards suggest a menu of possible improved practices
and motivations that the health worker might discuss with
the mother. The objective is for the mother to understand
how to make certain small changes in practices and agree
to try them. These actions are things that the mother
feels she can do and that the health worker knows should
make a difference in the mother or child's health. |
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| Counseling cards are truly a tool, and
while a careful, participatory design process can give
them the potential to facilitate clear communication and
behavior change, their effectiveness depends on how well
they are used. In other words, the effectiveness of this
tool depends not only on the cards themselves but also
on the training, motivation, and skills of health workers
and on how well the health system supports, reinforces,
and rewards good counseling. |
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| For the great majority of behavior-change
communication activities, interpersonal communication
(IPC) is essential for tailoring information and messages
to individual mothers. IPC both reinforces mass media
messages and translates these general messages into specific
actions that individual mothers and other caretakers believe
are feasible and feel confident they can do. |
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| Origins and Experience in the
Field: Like reminder materials, counseling cards
have been used for several decades. They have been used
for facility consultations and for home visits; for prevention/promotion
and adherence (compliance); in integrated settings such
as IMCI; in a cluster of technical areas such as infant
feeding and diarrhea; and in single interventions such
as immunization, breastfeeding, ARI counseling, family
planning, and adherence to taking iron sulfate tablets.
All levels of health personnel and volunteers have used
counseling cards. (Physicians and other highly trained
providers may be the least likely to use these aids, as
they may feel their use is beneath their status). Counseling
cards have varied from extremely simple ones developed
for barely literate health workers in Pakistan to quite
sophisticated and highly segmented cards used by community
volunteers (monitoras) in Honduras. |
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| As part of health facility-based IMCI,
WHO has disseminated a generic "mothers' card"
that contains basic child feeding and other advice. Each
country is advised to adapt the general card through
the
TIPS (Trials of Improved Practices)
methodology, and at least a dozen countries have done
so. In Guatemala, Ecuador, and probably other countries,
programs have expanded the mothers' card concept. In
Guatemala, NGO facility workers trained in IMCI use
sheets from three prescription pads to counsel mothers
- one on how to take the medicine, one on danger signs
that should trigger a return to the facility, and one
on giving food and drink to the sick child. After the
counseling, the mother takes home the sheets. |
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| Despite extensive experience (mostly
in NGO and pilot projects), the effectiveness of counseling
cards has not been evaluated systematically, and many
operational questions remain open, such as formats, organization,
levels of detail, schemes for selecting the appropriate
cards, and the best way to structure cards to stimulate
dialogue rather than merely serve as a didactic guide
to "tell the mother what to do." |
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