Behavior Change

Tools and Approaches

Counseling as Negotiation

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.

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.

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.).

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.

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.

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.

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.

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.

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."