INTRODUCTION

Welcome to Unit 6 of our Child Health Course. In Unit 3 we covered history taking, physical examination and investigations that could be done for a sick child brought into our health unit. In Unit 5 we looked at normal growth and development of children, and saw how the environment in which they live affect them. We also covered child spacing, antenatal, perinatal and postnatal care. As we learnt in that unit, growth and development of a child is influenced by a number of factors. Some of these factors are genetic while others are behavioural or environmental. However, many health problems and diseases affecting our children today are preventable through positive behaviour change – of parents, caretakers, or the children themselves.

In this unit, we shall focus on health education, promotion and counselling. Positive behaviour changes which results in better health and fewer illnesses can be influenced by health education strategies and counselling. This unit will provide you with adequate knowledge of the concept of health, health education, IEC, effective communication and counselling.

Objectives
 By the end of this unit you should be able to: Define the terms health education; information, education and communication; and counselling. Describe the principles of health education; Describe the communication process; Outline the steps involved in developing health education messages; Explain the factors promoting or hindering effective communication; Describe the different counselling skills; Describe the counselling procedure; Explain your role and the community in promoting health through health education.

6.1: HEALTH EDUCATION: SOME DEFINITIONS

We shall start by defining the terms that will be used in the rest of the unit.

Health: According to the World Health Organisation, health is “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”

Education: Education is the process of teaching and learning which results in increased knowledge, abilities, development of character and mental powers.

Health Education: According to Green (1980), health education is “a combination of any planned learning opportunities aimed at facilitating, influencing or maintaining health.” Effective health education is not talking to people but talking with people and involving them to solve a problem. It involves a careful understanding of the factors influencing health problems and planning strategically to address them through positive behaviour change.

IEC: IEC is a term used interchangeably with health education. IEC stands for Information, Education and Communication. IEC was introduced after experts in the field recognised that for beliefs, attitudes and behaviour to be changed, more is needed than health messages. For example, telling people to give their children a balanced diet, even if you offer them a list of required foods, is not enough for behaviour change. Instead, a health worker must become familiar with locally available foods, those foods commonly eaten by children, and cultural beliefs and taboos influencing the feeding patterns of children. After determining all this, a health worker will then be able to decide on what information is needed to educate the child, the parents or caretakers and then select the best communication channel.

In other words, IEC was introduced to emphasise the information that must be communicated effectively in order to educate people on health matters. You may now see that the two concepts, IEC and Health Education, are the same.

Health Promotion: Health promotion is the process of enabling people to gain control over and to improve their own health. Through health promotion, people are empowered to exercise their rights and responsibilities in shaping environments, systems and policies that are conducive to health and well being. Health education is one of many ways of realising the objectives of health promotion.

Key points
 Most health problems are preventable through positive behaviour

6.2: THE PRINCIPLES OF HEALTH EDUCATION

There are five principles of health education. These are:

1. Community diagnosis.
2. Community participation and involvement.
3. Team work and collaboration.
4. Planning.
5. Monitoring and Evaluation.

Now that these have been listed, it is necessary to explore each of these principles in more detail.

• Community Diagnosis

A “community” is defined as a group of people with common characteristics. These may be positive or negative characteristics, such as:

• A religious preference;
• Drinking groups;
• Some common activity.

To make a patient diagnosis, you first take the medical history by asking relevant questions. You then examine the patient to identify the problem and make a diagnosis. Whenever possible you carry out one or more investigations to confirm the diagnosis.

Similarly, in a community diagnosis you must define the characteristics of the community, perceived problems, resources available, etc. This can be done through observation and asking relevant questions. You may also visit members of the community to observe or examine what is practised, the resources available and any underlying problems.

Further probing or investigations are sometimes necessary. For example, it is not enough to conclude, after seeing a latrine that it is being used. For health reasons it is necessary to check if it is being used correctly.

Key points
 Community diagnosis entails assessing the health status of a community, as well as identifying problems and available resource.

The first step in community diagnosis is information collection. If programmes or interventions are to address any given health problem, you must first collect relevant information about it. For instance, you must determine:

• Who is affected?
• How serious is the problem?
• What is the community's perception?
• What are the possible causes?
• What other factors may be contributing to the problem?
• What is the community doing to address the problem?
• Who are the key influential members of this community?

How can you collect this information? As mentioned earlier, you can collect such information through:

• Observing the community (home visits);
• Interviewing members of households/community;
• Discussing with members of the community;
• Studying available records, such as hospital records,

• The magnitude and severity of the problem;
• Who is most affected by the problem;
• When and where the problem started;
• Who else should be involved in solving the problem;
• How to plan an appropriate strategy to solve the problem

1. Community Participation and Involvement:

This is the second principle of health education.

Community participation and involvement is a process by which individuals and families assume responsibility for their own health as well as the welfare of the community.

If people are involved in identifying problems, implementing health education interventions, and monitoring and evaluating the whole process, then the service will be socially acceptable to them. People are more likely to value a service and feel a sense of ownership if they were playing an active role.

Activity
 1 Think for a moment about any health education intervention in your community that did not have the important principle of community participation and involvement. List the outcomes of this intervention. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ What are some ways you could involve your community in health education interventions for children. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Do your suggestions include the following?

1. Identify key, influential people in the community;
2. Learn as much as possible about their roles in solving community problems;
3. Work closely with these people to identify problems affecting children and setting priorities;
4. Together with the community find solutions to these problems;
5. Together make decisions about interventions and plan implementation;
6. Together identify the necessary resources where they will come from;
7. Identify tasks and roles and let the community decide on what themselves can do and where there is need for technical advice;
8. Identify strategies to involve the community;
9. Work out a monitoring and evaluation mechanism.

Key points
 Not all community leaders are influential people. Neither are all influential people leaders

Your role as a health worker is to facilitate community participation and involvement. You should not force your ideas onto the community, but assist the community to get their ideas together. The community members must feel a sense of ownership for the health education activity. They must feel that the activity is to promote the health of their children and solve their problems.

Activity
 2 Who are some of the influential people or groups within your community whom you can work with closely to promote children's health? List them below: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Remember that when health education programmes are dictated to a community they may not be sustainable. Community participation and involvement creates a sense of ownership of a programme if the community is involved right from inception.

• Teamwork and collaboration:

A team is a group of individuals working together to achieve the same goal. Teamwork in health education refers to all efforts geared towards improving health through Health Education. Collaboration is an action in which the health sector and other relevant sectors (such as Agriculture or Education) work for the achievement of a common goal. When the contributions of different sectors are closely co-ordinated, the approach is said to be a multi-sectoral one.

For example, you as a health worker have observed that children in your community are malnourished. Several sectors can contribute to solving this problem. The agricultural extension officer can work closely with the community to promote growing of nutritious food items, including poultry products. The health educator will address the same problem, but from the behavioural point of view. The schoolteacher can emphasise the importance of a balanced diet to the schoolchildren. The religious leader can address the problem through community sensitisation. In the long run you will find that the level of malnutrition will decrease and that there will be a positive impact on the health status of children in the community.

• Planning:

This is the process of making decisions that affect future outcomes. Effective planning aims at finding answers to five key questions:

• Where are we now? (present situation)
• Where do we want to go? (desired situation)
• How will we get there? (strategies to move from present to desired situation)
• What are the necessary resources required ?
• How shall we know when we have arrived? (evaluation of progress)

Planning has five basic steps:

a) Study the situation: We have already discussed that collection of information is very important. The process of data collection and analysis, referred to as community diagnosis, is the process of studying the situation. In this case it means studying the factors affecting children’s health in a particular community.

b) Identify the priority problems: We have already seen that community diagnosis provides a lot of relevant information regarding the health status of your community. It is not possible to solve all these problems at the same time. Therefore, it is important to decide which problems are most important. Putting problems in their order of importance is known as prioritisation.

Remember that your first priority as a health worker may not be the community’s first priority. For example, you may see contaminated water as a source of diarrhoea, while the community does not see the relationship between diarrhoea and a water source they have used for decades. There must be some criteria for prioritisation. Earlier on we stressed the importance of involving the community right from the start. This way, it will be possible to guide them in choosing realistic priorities to address the health problems affecting children.

Useful questions that may guide you in prioritising include:

1. What is the most serious problem affecting the children?
2. How many children have been affected?
3. Does the community consider it serious?
4. Is the community willing to do something about it?
5. Is it possible to carry out changes with the available resources?

c) Set Objectives: Having selected priority problems and taken account of the resources available, the next step is to decide how far the problems can be reduced or whether they can be solved completely.

Many health problems cannot be solved quickly. Since solving health problems involves changing people’s behaviours, sometimes several combined activities are required. Each activity can have one or more planned objectives.

An objective states that there is a definite expected result of a planned activity. It gives you a clear idea of what is expected through or by the end of your health education programme. Objectives are necessary so that an activity can be continuously assessed and, at the end of a pre-determined period, evaluated. An objective is essential to a definite plan and setting objectives is a positive step towards improving health.

A good objective should have the following characteristics:




Objectives can be short term or long term. Before you read on, do the following activity.

Activity
 3 Based on the stated characteristics of an objective, which of the objectives listed below do you think is an example of a good objective? To improve the ability of health workers providing immunisation services. To promote people’s willingness to visit the hospital. At the end of 5 years, less than 4% of children below three years of age will be undernourished.

The first example is trying to address health workers’ skills, but examining it further we can see that it is not specific enough or measurable. The second example is also not measurable. The third example is a long-term objective specifically addressing undernourished children under the age of 3 years. It is time bound as it clearly states that it will be measured at the end of five years. This objective is measurable and specific short-term objectives can easily be designed for its implementation.

When designing objectives it is important to review obstacles or limitations that may hinder their achievement. The limitations may include the absence of resources, loss of interest on the community level, or something similar. Discovering the limitations will assist you to review the objectives and change or modify them to make them achievable.

d) Identify Activities: Once objectives have been defined, next you should identify the activities which will be carried out to meet the objectives. The list of activities designed to meet objectives and targets is sometimes called a strategy. The term strategy is a military word and means planning and using resources in a way that gives the best chance of success. Remember that the community should participate in the planning process. This will help in deciding on activities that are acceptable and affordable to the community.

The objectives and identified activities should be put together into a specific plan of action. Furthermore, the plan should outline the timing, location and those responsible for implementing the plan.

In summary, when developing an action plan you need to:

• State “SMART” objectives;
• Identify and list activities to meet each objective;
• Schedule the activities and indicate time for implementation;
• Identify and list the required resources (personnel and materials);
• Indicate success indicators.

e) Implementation: Implementation refers to putting plans into practice. Without effective implementation, plans remain theoretical. What does implementation entail? Imagine you have been working closely with your community members, activities have been identified, resources mobilised and the implementation plan drawn. Your role as the technical person is to co-ordinate and make sure that activities are being carried out according to the schedule.

For example, the first activity may to sensitise the mothers union group and then the fathers union group. Responsibilities should have been distributed among the core group prior to the sensitisation meetings. The venue should have been identified and booked. If it is a regular meeting, the chairman should have been notified about the sensitisation programme. The sensitisation materials should have been prepared prior to the meeting. The presenter should have prepared the agenda properly. Your role as the initiator of the health education programme may include any of these three tasks:

• Organising
• Supervising
• Directing

Imagine you are an in charge of health centre X. The latrine coverage in your area is very low. You have been seeing a lot of diarrhoea cases and you think poor sanitation is one of the causes. You have gone through all the steps of planning a health education intervention through the primary schools. What do you think your role will be during implementation?

• Monitoring and Evaluation:

Monitoring and evaluation is another important principle of health education.

Monitoring means finding out whether the planned activities are being implemented according to schedule. It also includes finding out whether the method of implementation being applied is suitable and whether the time frame for activities is realistic. This will help to identify any shortcomings so that corrective measures can be taken before it is too late. Monitoring can be done through observation, interviews, checking on reports and other records of what has already been done.

Evaluation involves an assessment to find out whether the health education activity has had the desired impact. An assessment is based on the expected outcomes as stated in the objectives. If you have put effort and resources into a programme, you will want to find out if there are any benefits or success. An evaluation should provide a specific measure of observed achievements or failures.

In the section on planning, we mentioned that indicators of success can be identified and included in the work plan. An effective evaluation should focus on these indicators.

Before carrying out an evaluation, you need to develop a tool or instrument that you will use. This could be a questionnaire, guided focus group discussions or a checklist. Checklists are developed using specific indicators.

Evaluation results will help you to review the planning process and use this information to make changes in the plan, if necessary.

Activity
 4 You have now completed reading and studying the steps involved in planning a health education programme. Now, list the five principles of health education and the five steps in planning health education interventions. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

• Application of Health Education Principles

These principles will enable you to address several health issues affecting the community.

Activity
 5 Name the group/communities where you can use these principles _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ What subjects will you address during the meeting _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

The Groups or communities can include:

• A village/parents
• School children
• School teachers

The Subjects to address may include:

Health of children in school: here you may want parents and teachers to improve sanitation, nutrition

Cultural practices that may hinder child health. Think of any practice in the area you are working or your personal culture that you may want to address

Adolescent health: Adolescents are going through a difficult period in their life. There are quite a number of issues you may want to discuss with them and help them to transit into adult life safely. Can you think of any problem faced by adolescents? These problem include poor health seeking behaviour, drug abuse, sex and unwanted pregnancies

You have now completed learning about the steps involved in health education interventions. The next section will discuss the communication process, barriers to effective communication and counselling skills. This is important because planning a health education intervention is not enough unless you can communicate the information effectively.

6.3: EFFECTIVE COMMUNICATION

Communication is the process by which a message is transmitted from a source to a receiver in order to obtain mutual understanding. Communication is, therefore, a process by which human beings try to establish common understanding. We say that a person has communicated when the person receiving the message has understood it in the way intended by the sender.

There are several ways one can communicate. For example, a message can be communicated verbally, in writing, or through facial and eye expressions. The way we communicate will sometimes depend on the mood we are in or the mood of the receiver. Whatever the situation, we must communicate effectively if we want to be understood.

The diagram below illustrates effective communication.

Fig.6.2 Message transmission through an appropriate channel

Effective communication is a two way process whereby a message is initiated by one person or persons and sent through an appropriate channel to a targeted receiver. This form of communication can sometimes bring about change. We know that our communication has been effective if there is feedback from the receiver in the form of a response or action. The process requires both information and understanding.

Activity
 6 What are the four major elements that contribute to effective communication? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Now read through the section and find out if the elements you listed are mentioned.

There are four major elements that contribute to effective communication. These include the sender, the message, the channel and the receiver. We shall now examine each element individually.

• The Sender:

The communication process is initiated by a sender, sometimes called the communicator. In this unit we shall refer to you, the health worker, as the sender. As a health worker conducting health education, you are often the initiator of the message. You are the communicator.

A good communicator should have the following qualities:

1. Know the “knowledge” level of the receivers. In other words, you should know who your receiver is and how much he or she knows about the subject already. This way your message can be at the level of your target audience.
2. Be a good listener. This is a useful skill, especially if you are to involve the receiver in solving a problem.
3. Try to feel and see things as the receiver sees and feels (empathy). This does not mean that you must always agree, but you must try to understand each other.
5. Respect the culture and beliefs of the receiver. For example, dress in a way the people you address expect you to dress.
6. Use a language the receiver understands.
7. Talk with the audience /receiver. Do not simply talk to them. Health education involves correct information, right perceptions and adoption of desired actions. Therefore there should be room for questions and discussion.
• The Message:

The message should be relevant to the receiver. If the people receiving the message think it has nothing to do with them, they will ignore it. The message should also be interesting. In addition,

1. The message should hold the receiver’s attention.
2. It should be simple and clear. Use the language the receiver understands.
3. A health message should communicate a benefit. Many of our messages appear as commands. For example: “Do not smoke” “Immunise your child.” This kind of message does not offer an opportunity for the receiver to understand the reasons underlying the message. A better message would be something like "An immunised baby is healthy and strong. Ensure that your child is fully immunised against the six childhood diseases.”
• The Channel:

A channel is the medium of way in which messages are delivered to the intended receiver. In some parts of the country, it may seem modern to telecast health messages on television, but if the intended audience has no access to television sets, your efforts are in vain. If many of the targeted receivers cannot read, then posters with clear pictures will work better than posters with information in printed words.

Activity
 7 There are several channels that can be used to disseminate health education messages. When selecting a channel, consider the characteristics of the target audience. List five channels of communication commonly used in your area: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

The choice of a channel may depend on the message being passed on. For instance, if the message involves teaching a skill, then you should use the channel that gives you a chance to demonstrate the skill. In nutrition education, for example, showing food items rich in different nutrients and how to prepare these foods to minimise the loss of nutrients and maintain food hygiene would be appropriate.

It is important to note that you can use more than one channel to communicate a single message. The same message can be channelled through health talks in outpatient departments, one-on-one communication with patients, posters, by radio, and through influential people – all at the same time. In other words, the message can be received by any of the five senses such as hearing, seeing, touching, smelling and tasting.

The traditional method of health education was mainly through talks, but the current trend has changed. Now it is best if the receiver can participate as illustrated in Fig.6.3 and Fig. 6.4 below.

Key points
 You must know your audience before you can communicate effectively.

The chosen venue may be a problem. Many of us prefer to talk to patients in the outpatient unit, but there may be too many distractions from children crying, other very ill patients, and so forth. Sometimes it is best to find a venue free from distractions.

The time of year can also present problems to effective communication. For example, during the rainy season many people are planting. They may feel impatient if they are required to sit and listen to a long health education seminar. They minds might be in thei shambas instead of listening to you. Try to choose a time when people will be most disposed to listen.

Always pre-test your message and the channel you have chosen to communicate your message. Pre-testing means trying out the message on a sample of intended audience to see if it is communicating the intended message effectively. There are several ways you can pre-test your message. For example, if you have decided to present your message in a pamphlet, give a sample to members of the community to examine, to read and to point out areas not well understood. Ask those reading your sample to interpret what they think is the message, and to suggest ways it can be improved. An illustration, such as a poster, can be pre-tested by asking someone to tell you what he or she understands as the poster’s message, and to make suggestions for improvement.

Fig. 6.3: “One-Way” Health Education. The communicator talks “at” the receivers. No interactive communication

The receiver, also referred to as the target audience, is the person or group of people to whom you intend to send your health education message. Receivers can be classified as a primary target audience or a secondary target audience.

The primary target is the person you want to change. For example, your primary target audience may be schoolchildren whom you want to educate on how to brush their teeth every day, comb their hair, and bathe, because basic hygiene promotes good health. The secondary target audience is the person or persons you want to assist in influencing the primary target. In this case, the secondary targets are the parents, guardians, and teachers. These are the people you can influence to act positively in helping the primary target.

As another example, a child who is not immunised is not responsible for that action but will suffer severely if attacked by any of the diseases that are preventable through immunisation. In this case, the children are not the primary target, as they cannot act on behalf of their own immunisation. Instead, the parents and guardians are the primary targets for your health education intervention. It is very important to analyse the target audiences before designing your intervention.

Fig. 3.4: “Two-Ways” Health Education.

Know your target audiences by learning about the major causes of illness in the community. If malaria is the major cause of illness in your community, then clinic based health education interventions and input by the community outside the health unit should be encouraged. Otherwise, people will continue to feel that it is not their responsibility to promote health and to control the disease.

Key points
 Study the situation described in the case study below.

Case Study
 1 A newly qualified health worker has been posted to health unit X. Prior to the posting, he spent a few months at the KMTC on a short health education course. While he was there he acquired two English tapes on the control of leprosy. Although he had been equipped with new communication skills, he thought that playing tapes was the most modern way of educating communities in rural areas. After spending one month in the unit, the health worker decided to initiate health education in the patient waiting room. He decided to use his cassette player and play the health message tapes he had acquired. Each day, when he saw that more than ten patients had collected in the waiting room, he played the tapes for about 30 minutes. This became a routine in the unit, and he would not see any patients for treatment until the tape was finished. After this exercise he would see the patients one by one to address their specific ailments. He was very happy that he was carrying out health education.

Self Assessment

 1. What do you think about this approach? 2. Was this health worker communicating effectively? 3. If no, in your own words explain where the problem could be. 4. How best could this health education approach be improved?

Now read the analysis and compare it with what you discussed.

The health worker had been equipped with some communication skills. However, he chose to use a radio cassette to play tapes on leprosy control for an audience of patients in the outpatient waiting room.

It is obvious that in the time he had spent in this community he had not carried out a community diagnosis. If he had, he would have discovered that leprosy was not the primary health issue in the community. Therefore, the priority health issues were not being addressed. He opted to play tapes and did not even use his skills to discuss the issue of leprosy with the group after presentation. Thus, the patients were forced to sit through a taped program about an issue that had little effect on them, and were not given the opportunity to discuss the topic.

The choice of venue was poor. Remember that in an outpatient waiting room there are all sorts of patients. Some are children in pain, crying and in need of urgent attention. Others are adults with a variety of health complaints. Leprosy is not a health problem for most of these patients. Additionally, when people are sick, they are not able to concentrate well on an educational tape. A patient waiting room may not be the best venue for group health education, as there are too many distractions. To improve the health education intervention, he should have chosen another venue and time.

Since the tape came from KMTC, it is safe to assume that the sender of the message, the person who recorded the tape, was communicating in English or Kiswahili. It is possible that there were some people in this group who did not know either of the two languages. If he wished to use a tape, he should have found one that was recorded in the local language of the people who lived in his target area.

Finally, he should have begun by briefly addressing the group himself. He should have introduced the topic, played the relevant tape (on a subject relevant to the patients, not leprosy) and followed up the discussion involving them. This would have resulted in interactive communication and a more effective health education intervention.

Some Tips For Good Communication:

In your day to day work you are required to communicate with your clients right from the time you meet. One of the problems identified among clinic based health workers is inadequate interaction with patients. This is associated with the time limitations due to the great number of patients who come for medical attention. As a result, patients go back home with little information about their disease, or the side effects of the drug or treatment given to them. In such cases patients tend either to take drugs incorrectly or change medication too early.

In this section we will discuss good communication skills, and how you can apply them in various situations, including counselling.

Activity
 8 Think about the various reasons why people communicate. Write down some of these reasons _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

There are many reasons why people communicate. The following are the main reasons.

• To inform others;
• To get work done;
• To get feed back from others;
• To make change in others;
• To get others to think or act as we want;
• To mobilise others;
• To express feelings/opinions;
• To clarify information;
• To elicit action.

It is important to know how to communicate effectively if we are to achieve the desired goal.

Here are some useful skills to use when communicating

• Present your message clearly and simply. This involves using words that are familiar to your audience. Find local names for common diseases. It is important to keep your presentations short, since long sessions bore listeners. Ensure that all words used to educate people about health, whether they are written or spoken, are clear and simple. The time chosen for the presentation should be listener friendly. When doing a demonstration, explain steps clearly or use objects the audience can understand.
• Listen effectively. Listening is a way of showing respect to your health audience. Listening is important because it allows the communicator to learn how the receiver feels about a problem and the reasons for the actions being taken. When listening, give the other person your attention so you understand what you are being told. Do not make yourself busy with work or something else while the other person is talking to you. This will hinder communication.
• Ask questions. Asking questions makes communication between people more accurate. It can help to clarify what someone has said. After listening, restate what was said in your own words. Then confirm that you heard correctly by asking the other person. This kind of interaction leads to good communication. You can also use questions to check whether your receiver has understood your message.
• Use interactive discussion. In a discussion both the sender and the receiver participate in the communication. By applying good listening skills and asking questions the health worker encourages the receiver to participate actively in the communication process.
• Use pictures and illustrations that are familiar to the receiver. Sometimes images are enlarged to make them clearer for the receiver. A poster of an enlarged mosquito can be easy for a student but difficult for the local community to understand and identify with. Similarly, cartoons may be suitable for the youth and younger age group but may not be accepted as serious by an elderly community.

Activity
 9 Think about what you have learned about effective communication. List the five useful skills of effective communication. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

6.4: COUNSELLING

Counselling is something that you have already been involved in knowingly or unknowingly in your work as a health worker. To be an effective counsellor, you need to be equipped with the proper information and skills. In this section we will explore what counselling is, who needs it, who does it, where, when and how it is done.

Counselling can be described as the process of helping a person to identify the main difficulties he/she is facing and assisting the person in finding out a way of understanding, coping or overcoming them. For example, good counselling can help someone to cope and live positively irrespective of the gravity of the diagnosis. Counselling is defined as an interpersonal communication through which a person is assisted in a constructive change of attitude.

In counselling, the focus of attention is the individual and not the problem. The aim is not to solve the particular problem. The aim is to assist the individual to become independent and able to cope with the present problem and later problems without external aid such as counselling or guidance.

Counselling has many functions. It can be used for the prevention of a problem through providing information and answering questions. Counselling can be used to offer support to someone already affected by a problem and who needs a little help to adjust. This kind of counselling can be most important and necessary when a client is at a loss or knows the truth but is debating the solution.

Another type of counselling is ongoing, as in the case of many chronic and often disabling diseases. Here, counselling can help an individual adopt a positive attitude towards the situation and live longer with it.

Let us now briefly look at important points to consider in conducting a successful counselling session. Here is an example to help you identify these points more clearly.

Key points
 Study the situation described in the following case study.

Case Study
 2 Grace is a 30 year old lady, who has a swelling on her abdomen. She occasionally has pain and has gone to a trained health worker she trusted for treatment. Each time she has gone to the health worker she was given painkillers and sometimes antibiotics. The health worker knew that Grace had a hernia that needed surgical treatment, but never revealed this to the patient. One day Grace came for treatment as usual and this time the health worker told her to go to the main hospital for surgery. Grace went back home crying and not knowing what to do next.

Activity
 10 In this case it is obvious that the health worker did not prepare or help the patient to cope with the situation. The patient was undergoing symptomatic treatment in the hope that she would recover. The health worker knew that this patient needed surgical treatment in the long run. Think about how this health worker could have helped this patient and write your answers. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Important Points to Consider In Counselling:

• Relationship: A counsellor should build a relationship with a patient by showing concern and a caring attitude. This should be applied right from the beginning. In this case the health worker should have started counselling the patient as early as possible to introduce the possibility of surgery. This relationship between the health worker and the client is very important.
• Identify Needs: This means that the counsellor should help the patients to identify his/her own needs. The use of open-ended questions is useful here.
• Confidentiality: A patient or client in need may tell you very personal information and potentially embarrassing problems. This indicates that this person has trust or confidence in you.

All patient information must be kept as a secret unless the patient grants specific permission. If you are in a place where you are likely to be over heard, then the patient may not feel free to express his/her deep secrets, so be sure the venue is one that promotes trust. The re-assurance you as a counsellor give at the beginning will also promote trust. Remember that people are more likely to talk about their problems with someone they trust.

• Empathy: A good counsellor should develop empathy for the person's feelings. This means that the counsellor should be able to place him or herself in the other person's position and try to understand what the other person feels. It does not mean that the counsellor should have pity or sorrow, but does mean that the counsellor should show understanding.

It is natural for a person to have worries and fears about problems. But it is important that the counsellor help the patient or client to become aware of these feelings and to cope with them. Feelings can include fear, anxiety, shame, regret/bitterness, excitement, anger, and so forth.

• Participation: Earlier, we examined the importance of participation of the community in health education interventions. In counselling, a client should participate actively in thinking about all the factors involved in a problem and make a choice about the solutions or options to solve it.

NEVER try to persuade a patient to accept your advice. This can be detrimental, because if it turns out that the advice is wrong, you as the counsellor will be blamed for the choice. Alternatively, if the advice works well, then the patient may become overly dependent on you for more advice to solutions of his/her problems.

• Information and Resources: A counsellor can be tempted to give advice, but it is preferable to share facts during the discussion and help the person have a clearer view of the problem. Help your patient or client to explore for him or herself what the various options are, and include as many options as possible. This way the patient can make an informed choice. But you as the counsellor must always remember that the choice must remain with the patient or client.

Key points
 Counselling means giving choices, not force, and not advice

Your advice as a health worker may seem reasonable to you, but it may not be appropriate to the situation in which your client lives. So be realistic in choosing choices to offer. Talk about those that are reasonable and that are acceptable to your client/patient.

Now in light of what you have just learned about counselling procedures, think about the following questions and write your answers in the space provided.

Activity
 11 Think again about Grace and the health worker. How could the health worker have handled the situation? How could the health worker involve Grace in coping with the treatment option? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Different Counselling Situations:

1. Individual counselling: A counsellor is expected to have one to one or interpersonal communication with a client. In this situation a person with a need (the client) and the person who provides support and encouragement (the counsellor) meet and discuss in such a way that the client gains confidence in his/her ability to find solutions to the problems. Such opportunities arise wherever we work with individuals at health units or during home visits.
2. Counselling with families: A client with a need or problem may need help with other family members to solve a problem. When working with a family, we are dealing with more than one person. In this case there may be more than one problem, which surely means more than one solution.

Key points
 Sometimes it is necessary to involve the whole family in solving a health problem. Remember that each member of the family has a different responsibility in the home and can help in different ways to find solutions.

A father for example, may have the major say on how money is spent by the family. The mother may be the main person to decide on the types of food eaten. Grandparents influence the degree to which families follow traditional customs. Therefore, the choice of which family members to involve in solving a family problem will depend on the nature of problem being solved. The head of the household must always be given all due respect.

3) Child counselling: Children have both physical and emotional needs. Counselling can be provided for children above age of 4 years. Children in this age group are able to understand a simple conversation. When counselling a child it is better to talk to him/her alone because the presence of a parent can sometimes be a barrier to the child's expression of feelings, or the parent may prefer to answer all the questions.

Key points
 Remember that children are often fearful when they are sick. Ensure that the child can trust and feel comfortable with you.

When counselling a child, create a friendly atmosphere. This can be achieved through initially talking about happy things, like his/her favourite games. After the child has relaxed, introduce the problem by asking relevant questions. Assure the child of confidentiality and follow the counselling principles, just as you would do with an adult. Children would cooperate better if they understand what is wrong with them. They have their fears and as a good counsellor you should dispel them. Children also need counselling when they have a sick parent.

Activity
 12 Think about the different kinds of counselling situations you may encounter in your work as a health worker and write them down. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Now that you know the different situations where counselling can be applied, let us look at the counselling process. This will help you review the approach you have been using and improving it if necessary.

Stages in The Counselling Process:

There are three stages in a counselling session. Each stage is important if you are to achieve successful results. Let’s look at each stage in turn:

*The beginning stage: This is a crucial stage because it makes a big impression on the client. Welcome the client warmly, introduce yourself and tell the client what you do. Explain the importance of confidentiality in your work. Give the client time to introduce him or herself.

In this stage, try and identify the feelings of the client. Is the client angry, worried, or anxious? Is the client emotionally stable? Ask open-ended questions that are relevant to the situation.

*The middle stage: In this stage you should help the client to explore all the possible implications of the problem/need. Explore all the options for a solution. It is important to support the client towards behaviour change and to assist the client gain control by making informed decisions. During this stage the client may express emotions which you should monitor. Always provide support.

*The end stage: This is the stage where a client makes a plan of action. Work closely with the client to create a plan of action by looking at the various options available and selecting the most realistic and appropriate ones. By this stage the client has developed some degree of confidence in the service provided. A follow-up appointment should be made at a date and time convenient to both the client and the counsellor.

Activity
 13 What are the three stages of the counselling process? Why is each stage important to the outcome of counselling? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

In conclusion, it is important to empathise with your client. That is, always try to place yourself in the client’s position and understand why he/she is behaving that way. People are not always aware of their motivations or why there is a problem. Your role as a counsellor is to understand the problem and then help the person to understand it, too. Your next role is to assist the client in finding the appropriate and best solution/options.

Sometimes you may come across a person who is reluctant to take the necessary action to solve his/her problem. This person may feel that it is not worth the time and effort to act. Encourage such a person to re-examine his/her values and to make a decision based on the importance placed on his/her health and welfare.

Fig. 6.5: A health worker counselling a client

Another way to help people decide to act is the use of self-reward. Clients can decide on a reward/benefit that they will give themselves if they complete the necessary action. However, rewards or benefits should be used with caution. The client should choose healthy behaviours and rewards. Otherwise a problem like in the situation described in the next case study may result.

Self Assessment

 Study the following case study.

Case Study
 3 Steven has a dental problem. He is supposed to come for treatment but he sees no point in wasting time. He believes that he should only come for help when the situation is beyond control, and then have an extraction. The health workers knows that Steven dental problem can be controlled and that he can avoid unnecessary extractions if he comes for treatment. Thus he gives Steven free mouthwash and a nice toothbrush and promises that he would give him free treatment on subsequent visits. Steven is very happy and promises to come back. After the second visit the health worker is offered a scholarship to train abroad, and is replaced by a new health worker. The next time Steven comes for treatment, the health worker on duty is not ready to offer free treatment or a free toothbrush and mouthwash. Steven decides not to come again and his dental situation deteriorates.

Why did the health worker fail to help Steven? The obvious answer is that the health worker made all the choices. The situation may have gone differently if Steven had been counselled to link treatment with good health, thus placing value on the treatment, rather than the rewards he was getting in order to come for treatment

A common way of encouraging children to adopt healthy behaviour is by offering an unhealthy reward: "If you comb your hair daily, I will buy you sweets or biscuits."

This may sound a good motivation but the child is being bribed and not counselled. The child will certainly comb the hair and demand the sweets. Can you imagine what would happen if sweets or biscuits are not given? What would happen to his/her teeth if the sweets are given everyday? Offering another reward is not the answer even if the alternative is not harmful. Help the child to find a workable alternative.

Can you think of other situations in which bad options have been chosen or unhealthy rewards offered?

Key points
 Always remember that counselling calls for a personal approach and for skills in listening, providing information and helping other people determine what is best for them

Like any skill, counselling improves with practice. Remember the simple counselling steps. Be creative. Think of what educational tools you can use. Can you demonstrate a skill that needs to be learned by the mother? Can you use posters or pictures? Can you make up a story to guide the counselling session?

Do not rush counselling. It is natural for the sessions to go slowly at first. After you have had much real practice, you will be able to understand problems more quickly and select educational tools more easily.

Whatever the situation may be, remember that counselling involves the four following steps:

1. Identify the problem.
2. Determine why it is a problem.
3. Look for all possible solutions to the problem.
4. Encourage the client to choose the MOST APPROPRIATE SOLUTION.

Counselling is not advising a person on what to do or suggesting to a person what to do. Counselling takes time, needs devotion and practice. And it is a procedure that requires absolute and total confidentiality.

Remember: The type of counselling you use will depend on the client's needs and circumstances, including their psychological state, type of problem and the stage of the problem when counselling begins. Depending on the client's needs and the counsellor’s skills, a counsellor can always refer the client to others for better or more convenient services.

As we said at the beginning of this unit, counselling has many functions. It can be used for the prevention of a problem through providing information and answering questions. Counselling can also be used to offer support to someone already affected by a problem and who needs a little help to adjust. This kind of counselling is most important and necessary when a client is at a loss or knows the truth but is debating the solution. Another type of counselling is ongoing, as in the case of HIV infection. Here, counselling can help an individual adopt a positive attitude towards the situation and live longer with it.

6.5. THE ROLES OF THE HEALTH WORKER AND THE COMMUNITY IN HEALTH EDUCATION AND COUNSELLING

Throughout this unit we have been focussing on helping an individual or a community to influence positive behaviour change to promote health. The major emphasis has been on communication skills both in health education and counselling. Up to now you may be thinking that you are the only key player in this strategy. As you will learn later, different actors have to play their roles if the desired change is to occur. It is now time to define these different roles.

For example, people in an upcountry community have been visiting your health unit complaining mainly of diarrhoea. This has worried you, and as a health worker you have taken the necessary action to help these people. Besides the treatment you are offering, you want this community to improve their sanitary situation, especially the coverage and proper use of latrines. This has come up during your counselling and home visits. You have given all the necessary information but no action has been taken. It will therefore require the involvement of the local community leaders.

Health education has been defined, but it is important to know that health education is an important component of health promotion. Health promotion is a broader concept in that it is the process of enabling people to increase control over and to improve their health. Health is a positive concept emphasising social and personal resources as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond a healthy lifestyle to total well being.

The health worker is responsible for identifying the causes and possible remedies to the prevailing health problems in your area. It is your responsibility to identify the priority problems and plan an IEC intervention. If one of the factors to the poor health situation in your area is lack of knowledge, then you must attempt to create awareness using all the possible channels, including the involvement of other key actors such as the community and the community leaders.

The role of the health worker in community health education can be summarised as follows:

1. Carry out a community diagnosis;
2. Identify the priority health problems and their causes;
3. Identify possible solutions/strategies;
4. Carry out home visits to follow up cases;
5. Carry out counselling with individuals and families;
6. Design health messages and materials to address health problems in the area;
7. Involve other members of the community in health education and counselling.

The community has a vital role to play in identifying their own health problems and feasible solutions. The role of the community (including community leaders) can be summarised as follows:

• Identify the health problems in the community;
• Identify the possible remedies to the health problem;.
• Participate in solving the health problem.

Community leaders have special roles too:

• Mobilise the community for a health action;
• Advocate for the available health services;
• Create awareness of the health problems and prevention measures;
• Clarify issues, especially unanswered questions or misconceptions;
• Participate actively in health education, health promotion and counselling.

Key points
 Remember: What I hear, I forget What I discover, I utilise

6.6. MAKING HEALTH FACILITIES USER FRIENDLY

Often people do not want to go to a certain health facility because of the way the facility works. This may be because as a health care provider, clients look to you as unapproachable, rude, rough, etc. The facility itself may lack equipment and drugs; it may be dirty. A certain age group may be afraid to come – this group is usually the adolescent with reproductive issues, or drug problems. For this group having a separate clinic may be an answer as this will provide privacy. Avoiding blame is another important lessona that health workers need to learn

Reflect on your facility and suggest how you can overcome or remove obstacles that may be preventing people from using your facility.

We have now come to the end of this unit. You should now be able to explain the difference between health education, IEC and counselling and apply them in your daily work. If you have no difficulty with any of the material in this unit, please do the last activity before moving to the assignment but should you have any problem with any part of this unit, re-read the section. If you are still having any problem write to your tutor for further clarification.

Activity
 14 Think about the followings and discuss them in depth with a colleague or a supervisor. 1. Think how you would apply the principles of health education and the steps involved in planning a health education intervention: 2. Outline your role in health education and counselling the youth 3. Outline how you would monitor and evaluate your health education and communication Before moving on to the Tutor Marked Assignment, make sure you have conducted at least one successful counselling session with an individual, family or child. Plan and carry out a health education to a group of people on a common problem in your area.

Keep up the good work!!