Training Manual for Health Care Providers on Women Centred Counselling in a Gynaecology Clinic

Item

Title: Training Manual for Health
Care Providers on Women
Centred Counselling in a
Gynaecology Clinic
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Training Manual for Health

Care Providers on Women
Centred Counselling in a
Gynaecology Clinic

Women Centred Health Project

Public Health Department
Municipal Corporation of Greater Mumbai
Society for Health Alternatives (SAHAJ)

Royal Tropical Institute

liioOS
Other Publications of WCHP:

Paving the Way: Tools for Quality and Gender
Mainstreaming

Counselling Services in the Gynaecology Clinic

of a Municipal Hospital in Mumbai
increasing Men’s Involvement in Reproductive

Health: Experiences of WCHP, Mumbai
Training Manual on Women’s Health for Clinicians.

Stepping Stones Workshops in a Public Health
Department

Mainstreaming Quality Assurance in the Public
Health Department, Mumbai, India

Women-Centred Health Project 1996-2002: Report
of the End Evaluation

Mainstreaming Gender and Rights in Reproductive
Health Care within a Public Health System: A

Review of Women-Centred Health Project, Mumbai

Reproductive and Sexual Health in a Public
Health System: Policy Briefs

Working with Men - Gender, Rights. Sexuality.
Health: Trainer’s Manual

Published by

Society for Health Alternatives (SAHAJ)
1, Tejas Apartments
53 Haribhakti Colony
Old Padra Road
Vadodara - 390 007
Gujarat. India.

E-mail

sahajbrc@icenet.co.in

Date of Publication

May 2005

Supported by

Ford Foundation

Edited by

Rima Kashyap

Design and Layout by :

Usha Pcx"‘

Cover Design by :

Amol Th

Printed by .

Innovate

Community Health Cel!
Library and Information Centre
# 359, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Ph: 2553 15 18/2552 5372
e-mail: chc@sochara.org

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Training Manual for Health
Care Providers on Women
Centred Counselling in a
Gynaecology Clinic

Swati Pongurlekar

Renu Khanna
Asha Rilkar

Bharati Ghule

Women Centred Health Project
Public Health Department
Municipal Corporation of Greater Mumbai
Society for Health Alternatives (SAHAJ)
Royal Tropical Institute

(
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CONTRIBUTIONS
Renu Khanna

Women Centred Counselling

I

MeewLiriiaye
/

■

'i,

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Gender and Health

Renu Khanna

Principles and Skills of Communication and Counselling

Meera Limaye

Usha Ubale
Swati Pongurlekar

Renu Khanna

Counselling on Sexuality Issues

■

Swati Pongurlekar

Counselling in Gynaecological Health Issues

Korrie De Konning

Adolescent Health

AmitaAbichandani

Yamini Venkatachalam

Gender Based Violence

Renu Khanna

Recording and Documentation

Anagha Pradhan

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Swati Pongurlekar

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_____ _ _____________ ________________ —---___________

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PREFACE

I

This manual is the result of a unique effort to start counselling services within a Gynaecology Clinic

in a municipal hospital in Mumbai. The counselling centre, an intervention of the Women Centred
•1

Health Project, is an attempt to bring gender issues into the forefront, and concepts of quality assurance

I

within a public health system. The project, begun in 1996 is a collaboration between the Public

1

Health Department of the Brihanmumbai Municipal Corporation, SAHAJ, a non-government organization
based in Vadodara (Gujarat) and the Royal Tropical Institute, Amsterdam (Netherlands).

I

The counselling centre emerged in response to the need to improve client-provider communication
within the outpatient clinic.
I

Communication with health care providers is an important aspect of “quality of care" from the perspective

I

of poor, marginalized women seeking health services, within the urban or the rural context.

I

The training needs of counsellors were determined through a task analysis which forms the basis of this

I

manual. The manual has been pre-tested with three batches of health care providers that included
Auxiliary Nurse Midwives (ANMs), Male Multipurpose Workers (MPWs), Community Development

Officers (CDOs) and also health care providers from NGOs. In addition to ANMs, MPWs and CDOs, this
manual could also be used to train doctors and nurses in basic counselling skills and to sensitise them

to women’s reproductive health issues.

Several individuals contributed to the writing of this manual. Their specific contributions are separately
acknowledged.

ACKNOWLEDGEMENTS

1
We thank all the resource persons— Ms. Kalindi Mazumdar, Ms. Helen Joseph, Dr. Rani Raote, Ms.
Jyotsna Karkare, Ms. Sangeeta Rege, Dr. Surinder Jaiswal, Ms. Deepa Venkatraman, Ms. Fiona
Dias, Ms. Amita Abichandani, Ms. Rohini Gorey, Dr. Sreekala, Dr. Kamakshi Bhate, Ms. Medha

Prabhudesai, Ms. Vrushali, Ms. Ila Pathak, Dr. Brahamabhatt, Dr. Lalita Mayadeo, Dr. Uma Pocha

and Chitra Joshi for giving their valuable feedback on the first draft of the manual and helping us to

refine the contents.
We acknowledge all the resource persons for their commitment in conducting the training sessions:
Dr. Uma Pocha, Ms. Vidya Lad, Dr. Prabhu, Dr. Chitra Ramnathan, Dr. Lalita Mayadeo, Ms. Bilquees

Shaikh, Ms. Sangita Punekarand Ms. Padma Deosthali

We thank the Medical Superintendent of V.N.Desai General Hospital for her support in initiating the
training for health care providers in the hospital, and also for the training arrangements done by the

staff of the Matron’s office.
We extend our gratitude to the Medical Officers (Health) of all the participating wards for relieving staff

for the training, and the Community Development Officers for making the necessary modifications in
I

their work schedules, so that the work at the health centre did not suffer during the training.
Our special thanks to Ms. Meera Limaye for organising the feedback and training workshops.
We thank the WCHP team for support in organising the training.

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LIST OF ABBREVIATIONS USED
AHO

Assistant Health Officer

MCH

Maternal and Child Health

AIDS

Acquired Immuno-Deficiency Syndrome

MDACS

Mumbai District AIDS Control

AMO

Administrative Medical Officer

ANC

Ante Natal Care

MO

Medical Officer

ANM

Auxiliary Nurse Midwife

MOH

Medical Officer of Health

BP

Blood Pressure

MIC

Men’s Involvement Committee

CDO

Community Development Officer

MPC

Module Preparation Committee

CHVs

Community Health Volunteers

MPW

Multipurpose Worker — Male

CME

Continuing Medical Education

MTP

Medical Termination of Pregnancy

I

D&C

Dilation and Curettage

NGO

Non-Governmental Organisation

DEHO

Deputy Executive Health Officer

I

OPD

Out-Patient Department

FGD

Focus Group Discussion

PHD

Public Health Department

FHAC

Family Health Awareness Campaign

PHN

Public Health Nurse

FP

Family Planning

PID~

Pelvic Inflammatory Diseases

FPAI

Family Planning Association of India

PNC

Post Natal Care

I

FTMO

Full Time Medical Officer

QA

Quality Assurance

I

FW&MCH

Family Welfare and Mother-Child Health

RCH

Reproductive and Child Health

I

FWCW

Fourth World Conference on Women

RNTCP

Revised National Tuberculosis

G/N

I

G/North (One of the 24 administrative

wards of Mumbai)

Society
I

I

I
I

Control Programme
RMO

Resident Medical Officer

H/East (One of the 24 administrative

RTI

Reproductive Tract Infection

wards of Mumbai)

SAHAJ

Society for Health Alternatives

HIV

Human Immuno-deficiency Virus

SS

Stepping Stones

ICPD

International Conference on Population

STD

Sexually Transmitted Disease

I

and Development

STI

Sexually Transmitted Infection

I

IEC

Information Education Communications

VCTC

Voluntary Counseling and Testing

ISDT

I

Integrated Skill Development Training

IUD

Intera-uterine Device

KIT

Royal Tropical Institute

LSTM

Liverpool School of Tropical Medicine

MCGM

Municipal Corporation of Greater Mumbai

H/E

Centre

VNDH

V. N. Desai Municipal General

I

I

I
1

Hospital

WCC

Woman Centred Counsellor

WCHP

Women Centred Health Project

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CONTENTS
PREFACE

1
LIST OF ABBREVIATIONS

SECTION I: INTRODUCTION AND CONTEXT

1

Chapter

1

Women Centred Health Project (WCHP)

3

Chapter

2

Counselling Centre in the Gynaecology Out Patient Department

5

Chapter

3

Development of the Counselling Manual

9

SECTION II: PERSPECTIVE BUILDING

13

Chapter

4

Gender

15

Chapter

5

Women Centred Counselling

17

i

SECTION III: TRAINING SESSIONS

23

Chapter

6

Principles and Skills of Communication and Counselling

25

Chapter

7

Communication and Counselling around Sexuality Issues

109

Chapter

8

Counselling around Gynaecological Health Issues

135

Chapter

9

Communication and Counselling Around Adolescent Girls’ Health Issues

197

Chapter

10 Counselling for Gender Based Violence

Chapter

11

Training for Documentation and Recording

211
229

ANNEXURES

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!

Annexure

I

Task Analysis of Staff at Gynaecology OPD

237

Annexure

II

Design of the 4-day Counselling Workshop

247

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SECTION I
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INTRODUCTION AND CONTEXT

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1

Chapter 1
Women Centred Health Project (WCHP)

The Women Centred Health Project came about as a result of a research study commonly referred to
as the PID study (Pelvic Inflammatory Diseases). The PID project was carried out in collaboration
with the Brihanmumbai Municipal Corporation and the Liverpool School of Tropical Medicine (UK),

and was funded by the Overseas Development Assistance (ODA) of UK. This study was carried out
in 1993-96 in three locations in Mumbai to find out the social and clinical factors predisposing women
to PID in the slums of Mumbai.

During the participatory research project on PID, women from the community expressed a need for

services for reproductive health problems at the peripheral health care facilities, i.e. the health post
and dispensaries. A group of thirty Auxiliary Nurse Midwives (ANMs) from the Public Health Department

were then trained in communication and counselling skills that helped them to build rapport with the
women in the community and to understand their problems. This brought out the need and importance
of counselling for women for their medical and associated problems.

One of the outcomes of the PID project was learning about the actual health needs of women and

their expectations from the health system:
1.

Women want information on the diseases they suffer from — their causes, treatment options

and ways of prevention.

2.

All women’s health services should be under one roof - Post Partum Centres (PPC) should

also have treatment and counselling for sexually transmitted infections.
3.

Women want facilities for infertility investigations, treatment and support services like adoption.

4.

Women want counselling and support for associated problems like alcoholic husband and
family pressures related to family planning decisions.

Based on the expressed needs of women, a proposal for the Women Centred Health Project was
developed to evolve a model for

•

the provision of women centred health care with an emphasis on sexual and reproductive
health and

•
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integration of need-based services into the existing healthcare delivery system.

Concept of Women Centred Health Care
"Women Centred” means that needs, values, information, experiences and issues from the point of

4*

view of women are considered and incorporated in the planning, implementation and evaluation

processes of policies and programmes which affect women’s lives.

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Translating this concept means

•

Healthcare for women through all stages of their lives beginning from adolescence to the
post-menopause stage.

•

Healthcare for women for whatever health problems they identify i.e. childlessness, prolapse,
and symptoms of reproductive tract infections (RTIs) as opposed to only addressing the

childbearing aspect of women’s health.

•

Addressing gender issues which may affect women’s health, i his means involving male

partners and addressing the sexual health of couples (together).

The plan was to implement this concept through different interventions and research activities at all

levels of the existing system i.e. starting from the community to the next link of Health Posts, Post
Partum Centres, peripheral hospitals and finally the teaching hospitals.

The purpose of this research-cum-intervention project entitled ‘Women Centred Health Project’ (WCHP)
was to improve the quality of healthcare services in the MCGM health units.

The objectives of the project were:

1.

To improve, strengthen and increase the quality and range of health care services for women
at health posts, dispensaries as well as at secondary levels.

2.

To enable women to have access to gender- sensitive and user- friendly health services.

3.

To raise awareness and sensitivity on women’s health and reproductive rights, gender issues,
and to increase knowledge of women's health amongst men and women in the community,
health workers and service providers of the MCGM.

4.

To develop and build the capacity of staff in two wards of the MCGM in training, action
research, monitoring and evaluation on issues related to women’s health and reproductive
rights.

5.

To develop indicators for monitoring and evaluating quality and range of services provided.

-

4

Chapter 2

Counselling Centre in the Gynaecology Out Patient Department

As part of its objectives of enabling women to access reproductive health services and empowering

them with the necessary information, knowledge and confidence, an Information and Counselling
Centre was initiated at the Gynaecology Out Patient Department (ORD) at V. N. Desai General
Hospital. The rationale for the Counselling Centre emerged from the RID Study. As mentioned earlier,

women in the study stated that lack of appropriate and accessible information, counselling and
support services, as well as limited decision-making power within the family limited their control over
their reproductive health

Rationale
Apart from the findings in the RID study, WCHP conducted baseline studies and a series of Quality

Assurance (QA) workshops with health care providers. Three hundred and sixty-seven exit interviews
conducted as part of baseline studies revealed that those who expressed dissatisfaction, though
small in number, mentioned “disrespect shown by health care providers” as one of the reasons for

dissatisfaction. The clients in the same study were asked why they did not question doctors when
they had doubts. Responses indicated poor communication between providers and clients.

In the first Quality Assurance Workshop, health care providers identified issues related to provider
client communication styles, and health education as one of the important factors affecting the

quality of services. Lack of time to talk to the patients, no counselling services, inadequate information

services and sometimes language barriers were among the problems hindering provider-client
communication. The participants recommended better patient information and counselling services
as a part of providing good quality health care.

A pilot study to monitor provider-client communication at Kherwadi Maternity Home through Focus
Group Discussions with the women attending Gynaecology and ANC ORD, revealed their perception
of respectful behaviour and their expectations from health care providers. In their own words women

detailed their requirements of simple and effective communication.

It was decided to undertake a similar study at the general hospital level as the dynamics in the ORD
at the general hospital are different. Observations of provider-client communication patterns were

started in the Gynaecology ORD of the V. N. Desai Hospital. The observation studies in the ORD
showed that the quality of communication varied from person to person and even for the same person
at different times, depending on other background factors such as work load, non- availability of staff,

communication between the doctor and the other staff at the ORD, and socio-cultural gap between
the patients and providers. Language, terminology and mannerisms used by the doctors are not
i

understood by patients and vice-versa, adversely affecting the quality of care in terms of misdiagnosis,

compliance and informed decision-making.
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Box 1 : Women’s perceptions about respectful behaviour and effective
communication from health care providers

■

•

They feel respected and less inhibited if the provider maintains eye contact while taking

their medical history.
i

•

Provide' should listen patiently and encourage them to share their symptoms and other
problems that they feel are associated with their condition.

•

Providers should not shout at them if they sometimes are not quick at responding or
understanding the information provided.

•

They find it disrespectful if the provider tells them to stand or sit away from them.

•

Communication would be effective if the providers use simple language and local

terminology.

•

Their questions should be answered patiently and instructions repeated if not understood.

•

They appreciate it if they are told what is wrong with them by the provider.

•

Internal examination staff needs to be more patient, as they (patients) need time to
loosen their clothing and to climb on and off the examination table.

Lack of privacy and a heavy load of patients makes it difficult for the doctors to spend enough time
with patients requiring counselling - women seeking services for contraception are worst affected by

this. Hospital policy denies entry of men into the Gynaecology OPD to ensure privacy as involvement

of husbands is seen to be unnecessary when their wives seek treatment. This, however, proves to be
a negative factor for women with reproductive tract infections and sexually transmitted infections.

Lack of sensitivity towards the anxiety experienced by women undergoing internal examination,
especially unmarried women and adolescent girls, can prevent women from coming for early treatment.

The observations also highlighted information and counselling needs of clients. Women needed
emotional support. There was also a need to discuss sexual problems with those couples presenting

with infertility. Privacy for such a consultation is not ensured in the OPD. This can discourage the
couples from sharing sensitive information on their condition, leading to delayed treatment.

Women coming for termination of pregnancy (MTP) are at most times lactating mothers and they find

it difficult to make decisions whether to continue the pregnancy or opt for MTP. The doctors emphasise

on inserting an intrauterine device (IUD) after the MTP to prevent further unwanted pregnancies and to

meet their targets. This leads to arguments between doctors and patients.

6

Many women come up with misconceptions, or social and family problems, that influence their

contraception decisions. Providers fail to understand the real reasons and label them as 'ganwar" or
‘morons'. The couples who come for MTP after the sex determination test require counselling.

Sometimes the woman herself is not willing for the MTP but is being forced by her accompanying
husband or mother-in-law. They wait outside the OPD while the woman seeks consultation. There is
a need to talk to the decision makers and discourage them from opting for abortion.

In the absence of any information being given on gynaecological examination, .aany women do not

follow the instructions given by the doctors. This results in them being scolded by the providers.
Some women are scared of, and not prepared for internal examination and refuse to undergo the

examination. Adolescent girls who come with menstrual disorders or with reports of white discharge
find it difficult to give consent for internal examination. They find the OPD atmosphere inhibiting and

scary. This again leads to doctors yelling at them and the girls further resist the examination. Some
girls avoid the consultation.

Sometimes the language barrier affects the history taking process and the doctors fail to understand

what the woman is trying to communicate and vice-versa. Insufficient information on the timings and

procedures required to avail referral services for investigations and treatment, leads to delayed treatment

and adversely affects the compliance.

Providers’ Viewpoint

In the course of informal discussions, the providers and the administrators of the V.N. Desai Hospital

felt that an information booth staffed by qualified personnel, offering patients guidance and counselling

for commonly encountered situations, would help ease the situation and improve the quality of care at
the OPD. Following this, an exercise (of providing information, guidance and counselling to those in
need) was carried out on a pilot basis. Doctors wanted this activity to be continued on a permanent

basis in the hospital as it would save them the time spent on explanations. The experience of the pilot
study showed that establishing such a booth would be beneficial and ease the stress on all levels of

providers as well as patients.

Establishing the Counselling Centre
The goals and objectives identified for the setting up of the Counselling Centre were as follows.

Goals

•

Providing information and support to enable informed decision-making

•

Providing counselling services to men partners and key family members

•

Providing a safe and open environment in the formal set up of the OPD

7

Objectives
•

To meet information and counselling needs of the clients (men and women) seeking care at
the Gynaecology OPD of the secondary hospital.

•

To assess feasibility, in terms of availability of space at the hospital, privacy, support from the
clinicians at the OPD and from the hospital administration. This requires motivation of staff,

willingness of clients to seek counselling in such a setting, and establishing a client guidance
and counselling centre at the Gynaecology OPD of a secondary hospital.

•

To assess the effect on client - provider communications.

Features of the Centre

The information and counselling centre would focus mainly on meeting the needs of those
using services at the obstetric and gynaecology department in the hospital

•

The centre would be open for the duration of the OPD hours only. (9.00 am to 4 00 pm)

Counselling would be restricted to medical and social issues associated with gynaecological

/reproductive conditions only.

•

For conditions / situations requiring special counselling skills, the cases would be referred to
centres (NGOs/government) providing these. Such cases would include HIV positive

individuals, alcoholic husband, domestic violence, marital conflicts and psychiatric problems

Staffing

Auxiliary Nurse Midwives (ANMs) and Multi-Purpose Workers, mostly males (MPWs) from surrounding

Health Posts would be trained in counselling and placed as counsellors on a rotational basis to staff

the Centre. The ANMs have two to three years training in nursing and are trained in conducting
deliveries. (The MPWs have completed a one-year course as Sanitary Inspectors). The reason for
training these ANMs and MPWs was that they would then be able to counsel clients when they go

back to their health posts and also refer patients to the Gynaecology OPD after the basic counselling
done at their level.

Rotes of ANMs and MPWs at the Centre would be as follows.

8

a.

Information-giving

b.

Counselling

c.

Link between client and doctor

Chapter 3
Development of the Counselling Manual

Task Analysis and Training Needs Assessment

The previous chapter outlined the staffing plan for the Information and Counselling Centre. Adetailed
task analysis was dore of all those who would be associated in any way with the Counselling Centre,
e g. the doctors who would refer women to the Centre, the ANMs and MPWs who would provide

counselling to the women and their partners respectively, and the nurse in the OPD who is responsible
for looking after the logistics, assisting in internal examination of the patient, removing sutures,

helping patients in confirming pregnancy by urine examination etc. The nurse has a very important
information-giving role in the OPD. Patients often seek guidance from the nurse for locating various
departments in the hospital and also regarding the prescribed procedures and investigations. Patients

also consult the nurse to confirm doctor’s advice, prescriptions of medicines etc.

The task analysis (see Annexure I) revealed that the persons staffing the Information and Counselling
Centre would require training in the following aspects:

1. Knowledge or Cognitive input

•

organisation of the out patients’ department: clinical specialities, doctors, timings,
procedures, diagnostic services, costs and charges

•

referral services : specialised services and support groups for a variety of needs such as
violence counselling, child sexual abuse, sexuality counselling and so on; information regarding

location of health posts and staff available at the health post
•

technical gynaecological input— till a certain level— on various conditions, so that they can
guide patients appropriately

•

concepts like gender-based violence, sexuality and their linkages to health

2. Skills related to

•

communication: giving clear information, active listening, probing, observation of non - verbal
and body language, using audio visual material to explain things

•

counselling

•

performing a link role between the doctors and nurses in the OPD, the Community Health

Volunteers(CHVs) and health post staff at the peripheral level

•

training of CHVs, health post staff: participatory, experiential training

•

documentation, analysis and interpretation of simple data

9

3. Perspective building

•

to see the inter-linkages of a woman’s health with her social, economic and gender background,

sexuality issues and possibility of gender-based violence.

•

to develop respect, acceptance, non-judgmental attitude towards all patients

Once the training needs were identified a draft manual was developed

Preparation of a Training Manual
Women coming to the Counselling Centre not only require information to enable them to make

informed decisions about their reproductive health problems, but also need to be counselled from a

gender and reproductive rights’ perspective. Many of their problems like contraception decisions,
treatment for infertility, multiple abortions indicating sex selective abortions, and sexual health problems

were related to gender issues. Societal expectations of women to be tolerant, obey decisions taken
by family members or husband, affected her ability to assert her reproductive and sexual health
rights, and in turn affected her body and health.

Therefore the project team prepared a training manual on women centred counselling. The manual

would assist counsellors in developing counselling skills, and also enable them to look at women’s
gynaecological health problems from a gender and reproductive rights perspective, and counsel them

accordingly.

The draft of the Training Manual on Women Centered Counselling was reviewed by eminent practitio
ners, academics, activists and clinicians from the field of Gynaecology, Preventive and Social Medicine,

Sexuality, Counselling and Social Work. A two-day consultation resulted in valuable feedback in

terms of content, methodologies, feasibility, possible trainers and so on. The revised manual was
then field tested in three four-day training workshops for all ANMs and MPWs in one of the two project

wards in 2001. For the training design of the 4-day training workshop see Annexure II. A total
number of 50 health workers were trained (30 ANMs and 20 MPWs). This manual is an outcome

of this long process.

About this manual
This manual contains a section outlining the perspective on which the counselling content is
based. The first chapter in the Perspective section explains the gender perspective and the

second chapter tries to clarify the concept of Women Centred Counselling. Section III contains

session outlines which form the bulk of the manual with detailed notes on methodology for the
facilitators. Handouts and exercises for the participants and contents of the overhead
transparencies are included at the end of each chapter. Annexures at the end of chapters

10

include exercises and role plays.The annexures at the end of the manual provide background

material like the Task Analysis, contents and schedules of workshops with ANMs and MPWs.

How to use this manual

The manual can be used to train health professionals and para professionals in the basics of
communication and counselling related to reproductive health conditions. This manual is not for

advanced counselling for complicated issues like child sexual abuse and rape, mental health problems,

domestic violence etc. It is hoped that the contents of this manual will enable the trainees to recognise
the limits of their role and capacity, and appropriately refer clients who need more skilled counselling.

11

SECTION II
PERSPECTIVE BUILDING

13

Chapter 4
Gender

What is Gender?
‘Gender’ as a concept is different from ‘sex’. While ‘sex’ refers to the biological and physical aspects
of being male and female, ‘gender’ refers to those characteristics of men and women that are socially

determined. Most of the differences in men’s and women’s roles and responsibilities, norms and

values that guide their behaviour and access to, and control over, resources have little to do with the
fact that they are born male or female or that women can bear children. It has more to do with what

society expects of them.

Gender actually works like a system. At the base are social beliefs about men and women (e g. ‘men

are strong and women are weak’ or ‘men are rational and women are emotional’) that are naturalized.
These beliefs then form the basis of gender norms for behaviour and differential expectations from men

and women. This in turn leads to gender roles and sexual division of labour. Access to resources and

control over them is determined by gender roles. And this in turn is reflected in who makes the
decisions, and who has the power to influence social beliefs and gender norms. The cycle continues.

Health conditions and health needs are determined by the interaction between biology and the

gender factors described above (PAHO 1997). Thus while certain health conditions are purely
sex specific, e.g. pregnancy, childbirth in women or prostate cancer in men, others are more
prevalent in one sex than the other. An example of this would be anaemia due to iron deficiency

linked to women’s loss of iron during menstruation, pregnancy and lactation, (and exacerbated

by cultural practices that privilege men in household distribution of iron rich food) or osteoporosis
in women (eight times higher in women than men); and cirrhosis associated with alcohol abuse,

lung cancer associated with tobacco consumption, excessive mortality from violence, homicide
and accidents, in men. Yet another result of the biology and gender interaction is diseases that

have different characteristics in men and women. For example, Sexually Transmitted Diseases

(STDs) are ‘asymptomatic’ for longer periods in women, genito urinary TB in men is relatively
rare, while one in eight women with pulmonary TB may also have genital TB. (Genital TB is an

important cause of infertility in women in developing countries).
Finally, diseases produce different consequences and responses for men and women. For

example, STDs in women can lead to sterility, nutritional deficiencies can cause maternal
deaths in childbirth, malaria during pregnancy is an important cause of maternal mortality,

spontaneous abortion and stillbirths. Particularly during pregnancy, malaria contributes
significantly to development of chronic anaemia.
•

Cardiovascular problems are considered “typical” men’s diseases; as a result, these symptoms are
not recognised in women. Data indicate that cardiovascular diseases are one of the main causes of
death, (in some population groups the major cause of death), among women older than 49 years.

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Disfigurement due to leprosy generates greater rejection by society if the sufferer is female, given

•

the connection between physical beauty and women's worth.

•

Very few male sterilisations are done compared to female sterilisations (despite the fact that vasectomy
is a simpler, more economical and less invasive procedure than sterilisation for women).

•

Domestic violence towards women is judged differently from public violence against strangers

and there is a greater degree of social tolerance for violence towards women from their male

partners than there is for other types of social violence. This tolerance is reflected in legislation

on family violence in almost every country.

•

Focus of family planning services on women have excluded men, with the result that men have
limited access to such services. In addition, given the gender relations within a family, decisions
about contraception need to include men, otherwise women can be prevented from using them by

their partners/husbands.

Gender Perspective of Health
A gendered perspective of health thus looks at the difference in health needs of men and women,

differences in risk factors and determinants, severity and duration, in perceptions of illness, in access
to and utilisation of health services and in health outcomes. A gender approach in health, besides

looking at biological factors considers the critical roles that social and cultural factors, and power
relations between women and men, play in promoting and protecting or impeding health (WHO 1998).

Frameworks for analysing women’s health have typically focused on their childbearing functions,
pregnancy and childbirth related issues. In addition to these special health needs, women are also
exposed to all the health problems that affect men e g. malaria, tuberculosis, leprosy etc. In fact,

malaria and hepatitis become life-threatening conditions for women during pregnancy.

Gender Perspective in Counselling
A gender perspective in counselling will guide the counsellor to analyse the gender factors and the
power relations in a client’s situation. The counsellor’s line of treatment will attempt to

•

reduce the power differentials between any two individuals, the counsellor and the client, or

the woman who comes for counselling and the ‘powerful’ others (husband, mother-in-law)
who knowingly or unknowingly control her health-seeking decisions.

•

address the social, cultural and gender factors as presented in individual clients situation.

References
1.

Ravindran, TK. Sundari. (2002). Engendering Health, Seminar

2.

World Health Organization. (1998). Gender and Health: Technical Paper.
WHO/FRH/WHD/98.16

(ii) Pan - American Health Organization. (1997). Facilitator’s Guide: Workshop on Gender,
Health and Development. Washington. D C. PAHO.

16

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Chapter 5

Woman Centred Counselling

What is Woman Centred Counselling?

Woman Centred Counselling (WCC) is an integrated and empowering approach which enables women
to regain control over their lives, helps them to make choices, set goals and also encourages them to

believe in, and nurture, themselves. Woman Centred Counselling does not exclude men, but addresses
men in their relationship to women and their influence on women’s situations.

Basis of Woman Centred Counselling

WCC is based on feminist principles. Feminist ideology defines two long term goals: Freedom from

oppression (this involves freedom of choice and power to control their own lives within and outside

their homes) and, Removal of all forms of inequality and oppression through creation of a more just,
social and economic order with the equal participation of women in all decision-making processes.

Feminism advocates equality against oppressive systems manifested in diverse forms over time.
It also stands for economic survival, physical safety and security, reproductive and sexual self-

determination, and equality of status in all spheres of activities. Feminists conceptualise power
in two ways - power over, i.e. domination, and power to/for, i.e. personal empowerment, which
has to do with the control of one’s own feelings, thoughts and behaviour. It is the latter that is
promoted by the feminists.

WCC reflects the conviction that personal change and socio-political changes are inextricably linked

and problems are viewed in a socio-political and cultural context. WCC is a political activity; it is

concerned with changing society’s attitude towards the problems of women. It believes that women’s

problems are not a result of their personal inadequacies, but are created by unjust and oppressive

social structures. It does not encourage women to adjust to their situation; rather women are challenged
to actively change it by making them more aware of their rights.

Another aspect of Woman Centred Counselling is the idea that the personal is political. The idea

behind this is that the person is an integral part of the larger environment. For this reason, feminist

(woman-centred) counselling should help clients place their personal experiences in a wider social
context and especially explore the gender issues relating to a particular situation. This is also an
argument for conducting group sessions where women share their experiences (taking away the idea

>

that their problems are strictly individual), and to acknowledge the fact that a group can change a
social environment, an individual cannot.

a

9

17

WCC advocates changes in society’s institutions and structures so that they will allow equal treatment

and opportunity for both men and women. This counselling makes women more aware of their rights,
and this awareness facilitates women, or enables them to change their own situations. By involving
the community, the feminist vision helps women to create an environment wherein a woman can lead

a life devoid of fear and violence. To reach this stage the change has to take place in all the units of

society. Involving the community is an important aspect of preventive work.

WCC counselling emphasises consciousness-raising (CR). Critical consciousness-raising and
empowerment finds its roots in the black women’s liberation movement where social and community

raising (mostly focused on men) is combined with improving self-esteem, challenging personal
internalised values and gender identities towards a process of self-realisation and self-discovery in
addition to social and political action.

The goal of WCC is to encourage women’s liberation from oppression by the patriarchal system,

promote individual change and harness it towards social change. Both the counsellor and the client

are involved in the process of social change.

Many women experience low self-esteem and/or dependency through their relations with men at
home and at the work places. Women’s strengths, courage, intelligence and know-how very rarely

get valued in systematic ways. WCC gives value to the woman’s own self (her way of thinking and
analysis, feelings) which reveals the inner resources that she possesses. These resources will help

her to empower herself. According to WCC, self-esteem is a necessary condition for effectively
dealing with life’s stresses. Self-esteem includes self-respect, self-authority, dignity, pride, awareness,
calmness, a sense of achievement. The priority of WCC is to support other women on their road

back to reclaiming their lives from a nightmare of abuse.

The work of counselling also assumes women’s right to self-determination and control over their own
lives. The WCC approach asserts every women’s right to be an active participant in her own healing,
where she makes her own decisions. The primary commitment is to validate a woman’s right to her

feelings, decisions and intelligence - and also to validate her experiences. The world is seen from the
survivor s point of view, the client is believed and her feelings are validated.

WCC upholds the woman s dignity as equal to a man’s within the family and challenges the subordinate
status of the woman in her family, thus inspiring confidence. Usually women have the experience of

being silenced by their families. The process of counselling will help such women to overcome these
pressures and encourage them to speak out.

WCC challenges male expectations which are based on traditional role models and stereotypes of
women by introducing counterculture and different ways of looking at these stereotypes. The counse

lling process helps women to identify negative responses and gives practical suggestions to improve

their communication. If required, significant others are also involved in the intervention process.

18

How does Woman Centred Counselling differ from conventional counselling?

WCC differs from traditional counselling intervention models, because feminist understanding of women's
oppression and their rights is intrinsic to any assistance provided under WCC. Instead of being

neutral, woman centred counsellors are pro-women. They operate on the premise that women are
oppressed, exploited and are often rendered powerless in comparison to men in the present patriarchal

society. Helping women takes predominance — women, due to discrimination and their "low" status,

are considered more needy than men in family and society.

In WCC the major concern is the woman and her perception of the problem. She is asked to think of

alternative solutions that she can accept, and then is helped to achieve what is best for herself. The
conventional counselling process, on the other hand, would encourage compromise to save the
institution of the family. In WCC, the woman is assured that she can reject the compromise, if she
feels ill-treated. She need not adjust to the world around, but can exercise her own rights and choices.

What happens in Woman Centred Counselling?

During the process of woman centred counselling, traditional stereotypes of women as passive,

dependent, submissive and silent are challenged. WCC is not only limited to helping the individual

woman but is also extended to questioning oppressive family structures and community pressures.

The counsellor is a facilitator in the process and mainly practices two kinds of counselling methods,
crisis counselling and facilitative counselling.

Crisis counselling
When the crisis reaches a stage when it immobilises the woman and prevents her from consciously

controlling herself, the counsellor gives her psychological help and gives her a feeling of security,

gives her some breathing time and space. The counsellor gives her practical help like how to file an
FIR (First Information Report) at the police station, or information on a suitable shelter/short stay

home. The counsellor helps the woman to reduce her anxiety, and give her hope in the situation. The

psychological help is so extended that it enables the woman to review her own situation and make
informed decisions based on options offered by the counsellor.

Facilitative counselling

It is the process of helping the woman clarify a problem/concern and through self- understanding and

modifications in the environment, decide a plan of action and carry out that plan of action. The
counsellor carefully studies and weighs the woman’s situation, and offers the options available to her.
»

Here the counsellor’s focus is on helping her to know, understand and accept.

19

Role/Skill of a Woman Centred Counsellor
The understanding of woman’s status at the macro level enables the counsellor to understand women's
oppression at the micro level. The counsellor intervenes when any woman in distress approaches

her-regardless of her race, ethnic origin, ability, class, etc. She is also concerned with the health
status and nutritional intake of the counselled woman.

The counselling process is not done in isolation but is aligned with the social environment of the

client. During this process the pro-woman counsellor challenges the client woman's individual
exploitation/violation in family/community. All this is assessed by making home visits. So the

home visit becomes the most important tool of assessing the social environment of the woman.

Social assistance is required and necessary at all the stages, and is offered by the counsellor in
various ways, such as accompanying the woman to places like the police station, courts, government
offices, medical establishments etc. In some cases the counsellor also helps the woman by providing

her shelter. To empower the woman financially the counsellor arranges for training, so that she can
support herself. This entire process including exposure to situations where she deals with the persons

in authority, helps the woman to raise her self confidence.

Counsellor - Counsellee Relationship
In WCC, the counselling relationship, or the power relation between the counsellor and client, is egalitarian,

unlike in traditional psychotherapy and counselling techniques where the powerful position of the counsellor
was critiqued. From a feminist point (women-centred) of view, the counsellor was always in a more

powerful position because they did not share their own experiences and weaknesses. On that basis
mutual counselling or client-centred counselling was introduced. This meant that the counsellor and the

client changed roles. For professional counselling situations this is not very practical but the issue of power

still needs to be addressed. The ways counsellor go about this is through: creating an enabling environ-ment,
and enabling a person to gain self-esteem and self-confidence so that they become more and more able to
contradict or question suggestions/ideas put forward by the counsellor. Also the counsellor makes the contract
outlining the roles of each, and agreeing to what a client can expect and demand of the counsellor.

Feminist counsellors also acknowledge that women are oppressed in different ways. Women can, and

do, oppress other women. Feminist counsellors need to be aware of their own personal privileges and
place in society so as not to hurt their clients.

Results of Woman Centred Counselling
r

WCC attempts conscientisation of women to oppose oppression in their daily lives, and to talk about
their own issues. Women, whose perception of their individuality is raised, start asking questions

20

about being battered and realise that they need not have suffered so. Information regarding support
systems is also shared here. These activities make women active participants, they form groups and

act as pressure groups and help other women in the community. This facilitates women to overcome
isolation and also to relocate themselves in different relationships, besides the family and community

relationships.

WCC increases women’s vocabulary to define their own experiences and provides them objectivity

about their own lives. Women are empowered with knowledge, skills, and are also helped in changing

their attitudes.

References

1.

Berennan, Teresa, (1997) edited, Between Feminism and Psychoanalysis.

2.

Davies, Miranda, (1994) compiled, Women and Violence, Zed Book Ltd. London, N. Jersey.

3.

Eberhardt, Louise,Y., Working with Women’s Group, Vol. I, and Vol.II.

4.

Goleman, Daniel, (1997), Healing Emotions, Shambhala, Boston and London.

5.

Krzowski, Sui and Land, Pat, (1988), In Our Experience, Workshops at Women’s Therapy
Centre, The Women’s Press Ltd. London.

6.

Miller, Jean, B.M.D.(1973), edited, Psychoanalysis and Woman (Accelerating Paradigmatic

Shifts), Penguin Books Ltd. England.

7.

Pathak, Ila,(1997), Getting Our Own Spaces, Ahmedabad Women’s Action Group, AWAG,
ROWS Gender Series, SNDT, Mumbai.

8.

Pathak, Ila,(1997), Guide-Lines for Counsellors of Family Counselling Centres,
Ahmedabad Women’s Action Group, AWAG, ROWS Gender Series, SNDT, Mumbai.

9.

Special Cell for Women and Children,(1984-1994), Because Personal Is Political, edited
by Tata Institute of Social Sciences, Mumbai.

References from Internet Sites

10. http://www.amazon.co.uk

11. http://www.google.com
12. http://www.rapecrisis.org.za/about/feminist.htm
13. http://www.saxonet.co.uk

■

21
-

SECTION III
TRAINING SESSIONS

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Chapter 6

Principles and skills of communication and counselling

PART 1 : COMMUNICATION

Communication is a process through which people exchange ideas, facts, feelings or impressions in
ways that create a common understanding of a message. Health workers need to communicate

more effectively than other workers, because they deal with health problems, as they need to give

and get information, and establish rapport with the community to reach decisions and solve problems.
Effective Inter Personal Communication (IRC) between health care providers and clients/patients is
an important factor in improving patient satisfaction, treatment compliance and outcomes. It helps to

develop a rapport with the patient ensuring that diagnosis is accurate, compliance with treatment is
better and follow-up is more regular. If the patient is given information about her illness, the investigations

that are to be carried out, and the treatment options, and when concern is shown to her, there is
bound to be greater patient satisfaction and better treatment compliance. Thus, the long term outcome

would be reduction in morbidity/mortality, leading to a positive health status. While there is evidence
of better treatment outcomes with effective communication skills, it is also evident that poor provider

client communication can affect the quality of health care. Unfortunately, inadequate emphasis is
given to communication skills during basic Medical and Nursing training.

Effective communication may not come naturally or easily. Even though the health care provider and

client may belong to the same geographical area, there may be differences in their social status,
educational backgrounds and cultural background. Due to this, messages may not be interpreted

correctly. Factors such as lack of privacy and time constraint also affect inter- personal communication.

It is important to understand that communication styles of men and women are different. Women

communicate more through non-verbal, body language. They also tend to communicate more through
metaphors or symbolic forms of expression, especially when they want to speak about their bodies.

Women are not comfortable talking about sexual and reproductive issues. Health care providers, too,

are not comfortable talking about these issues in day-to-day language, which is why it is important for
health care providers to develop communication skills to tackle this.

Communication styles also indicate the respect one has for others. The objective of communication
should be sharing of information in a way which is understood by the woman, respecting and valuing
1
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her, and helping her to gain control of the situation i.e. empowering her. Listening to the woman and

then explaining the medical facts to her in language understood by her is most important Health care

providers, by virtue of their training, tend to subconsciously use jargon while communicating with
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patients, which increases the feeling of inequality between the health care provider and the patient.

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Health care providers have to be constantly aware that they wield considerable power in their relationship
with patients. They have the power of their class, education and status, as well as the power of being

perceived as healers by vulnerable, sick people. Effective communication, listening to people, empathizing
with them, sharing information and enabling them to come to decisions related to their health helps in

bridging the gap. It is important to remember that health behaviour varies from person to person, one

household to another and one cultural/social group to another. Thus interpersonal communication is an

important function of health care personr ol at all levels - more so in a counselling session.

Inter - Personal Communication (IPC)
Inter-Personal Communication means sharing of words, feelings and communication between two or

more people. Establishing a common interest or common meaning of words between two persons is

the key to successful inter-personal communication. This communication must take place in close
proximity i.e., face to face with each other and must always be two-way.

Figure 1: Two Way Communication

Receiver

Sender

Information
Views
Emotions

Channel and Medium of Information

Information \
Views
|
Emotions
/
\

Interpersonal communication is face to face, verbal and non-verbal exchange of information, feelings,
between two or more people.

In one-way communication, only the sender sends the message. The receiver, or the audience, does
not interact. An example of one-way communication is a lecture. There is no feedback about whether
the receiver of the message has understood the message.

In two-way communication, the sender sends the message. The receiver comprehends and understands
what is being said in the message and then sends feedback to the sender. Two-way communication

is always better than one-way communication because there is interaction between the sender and

receiver as it allows for an opportunity to ensure that the message has been interpreted correctly.

The Communication Process
Inter-personal communication can be made effective by reviewing each component of the communica

tion process. Components of the two-way communication process are:

26

Communicators
For two-way communication, there is a sender and a receiver. The sender is the originator of the

message. To be effective, the sender must be clear about (i) the objective of the communication
(ii) needs, interests and abilities of the receiver (iii) the content or usefulness of the message and
(iv) the channel to be used. It is important that the message is sent in a language that is

understood by the receiver of the message. The receiver listens to the message, has to understand
its content and then respond to it.

Message

Message is the idea, feeling or information that is to be sent to the receiver. It may be verbal or non
verbal. For effective communication, the message should be clear and free from ambiguity.

Channel

Channel is the medium of communication, and can be audio, visual or both. Communication should
be adjusted to local cultural patterns and cultural media, for example, use of folk lore through folk

theatre, folk music etc. to communicate effectively with village folk.

Effect or outcome
These are changes that occur in the receiver as a result of receiving the message: e.g. at the end of

a health education session there may be
•

Changes in a receiver’s knowledge - for example, when a man is provided health education

on different contraceptive methods, he may have greater awareness of different family
planning methods,

•

Changes in the receiver’s attitude - the man cited above now begins to appreciate the small

family norm and the need to be involved in making responsible choices,
•

Changes in action - the husband is now willing to undergo vasectomy instead of insisting on

tubectomy for his wife.

Barriers in Communication
These are beliefs/attitudes of sender/receiver and other distracting features like noise, over crowding,
heat or cold in the room. The other barriers which affect communication are socio-cultural gaps

leading to differences in language, terminology and mannerisms, and structural factors like lack of

I
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privacy, workload, and lack of sensitivity by some providers to the anxiety expressed by women
undergoing examination, or, during the consultation. The barriers could be external or internal.

External Barriers
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•

Noise/disturbance

•.

Ambience or atmosphere

•

Time constraints for sender and receiver

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27

Internal Barriers

For sender
Inadequate knowledge
Inadequate skills

Self image
Frame of mind

Attitudes, mind set

Biases/ prejudices

No listening skills
Inappropriate verbal or non-verbal language

Inappropriate use of audio-visuals

For receiver
• Frame of mind e.g. disturbed or distracted mind when in pain or suffering

o

Attitudes, mind set

•

Biases / prejudices

•

Closed to learning

•

Content is irrelevant to the receivers’ experiences, so he / she cannot relate to it

•

Does not feel respected

Communication for Behaviour Change and Process of Behavioural Change
In a health care setting one objective of communication with clients is to bring about desirable changes

in their attitudes and behaviour so that they can prevent or control the “unhealthy condition/situation”.
E.g. abstinence from sex or use of condoms for prevention of STDs, avoiding getting treatment from

quacks, or including iron rich food in the diet of pregnant women. Often, mass awareness strategies

are employed to reach messages related to preventive measures for the community. Some healthrelated messages are given to people through group meetings and one-to-one interpersonal

communication. Health-care providers often get frustrated that in spite of their efforts to spread

awareness, people and society do not change and do not behave in a desired manner to prevent
diseases. It is important to understand that public awareness about health problems and issues

alone does not bring about behavioural change. Therefore it is necessary to understand the process
of behavioural change.

1

5

According to a study done by Tata Institute of Social Sciences (TISS, 1992), even if 10% of the truck
drivers knew about Nirodh (a brand of condom) and use of condoms, only 1% of them were actual

users. It is clear that knowledge does not always influence behaviour.

Similarly, it is a known fact that smoking causes cancer but how many actually resist smoking is a

big question. The process of behavioural change is presented in the following diagram.

28

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Figure 2: Process of Behavioural Change

Unaware

Aware

si
Motivated

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Concerned
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Change

Sustain Change

E g. Initially, it was difficult for surgeons to adjust to wearing gloves during surgery. But gradually they
adjusted to this for their own, and patient’s safety. Similarly, it is only when people realise the advantage
of condoms and the dangers of diseases like AIDS, that they will use condoms. But to apply knowledge

to any practice and make it a regular habit will take some time. Thus, it is not advisable to criticise

people for certain habits they cannot change. Many health workers think that specific groups of
people resist family planning. The health worker’s attitudes get reflected through verbal and non

verbal communication. This in turn creates a block in the receivers’ minds against health care providers
and the health care system. Thus it is important for health workers to reflect on their attitudes and
use their communication skills to understand the sources of notions and beliefs of the people, and

clarify them by giving information.

Health care providers need to learn some essential communication skills and techniques for effective
communication to build a rapport with the client.

29

Non-Verbal and Verbal Communication Skills
Communication can be verbal or non-verbal. All that we communicate has 70% of non-verbal and 30%
of verbal communication.

Non-verbal communication skills
1.

Eye contact: Maintaining eye contact helps to put the client at ease and helps the client to talk
openly about her/ his problems. One should balance the intensity of eye contact by not staring

Remember
•

Look at the client when the client is talking
It is okay to look elsewhere occasionally, but one should not let the eyes wander aimlessly,

away from the client, for long stretches.
2.

Facial Expression: Appropriate facial expressions assure the client that you are listening and

responding to her talk/sharing. Sometimes clients judge whether the counsellor is accepting

them based on the facial expressions of the counsellor
3.

Body language: Be relaxed. However, if the counsellor sits in a too relaxed position (with his/her
. feet on a stool/table), the client may feel that the counsellor is casual and disinterested in her/him. If
your body language indicates excessive tension, the client may feel that either you are not confident

about addressing her issue, or that you are impatient and find it difficult to discuss her issue. Body

tension can however be used positively by leaning forward towards the client to show attentiveness.
4.

s

Physical distance between the counsellor and the client: The client finds it easier to talk
openly, rf the distance between the client and the counsellor is 3 to 4 feet. The client may

g

experience pressure, fear or tension, if the distance is less than 2 feet or more than 4 feet.

5.

Active listening and observation: Listening is of two types, active and passive, and it has great
impact m the process of counselling. Sometimes unconsciously, when the client comes for

*

counselling, the counsellor may attend to the client while continuing to do her own work. The

►

counsellor may hear what the client says, but may not be listening to what the client is saying

Active listening understands what the client is communicating, including the feelings and thoughts
behind the spoken words. One cannot depend on client's verbal expression alone to understand
the real problem. The counsellor needs to observe the expressions and feelings reflected on the
chent s face, her body language, body movements, tone of voice and the silences and pauses

Unexpressed thoughts and feelings can only be picked up through non-verbal communication.

6. Appropriate use of smiles: Clients feel encouraged to talk, if the counsellor smiles and nods

whUe respondmg to the client. But smiling continuously or inappropriately could be interpreted as
a negative response and can discourage the client from sharing

30

Verbal communication skills
1. Allowing the client to complete the sentence without interrupting: If the counsellor

interrupts the client while talking, the client may feel that the counsellor is trying to use his/her
power to correct the client’s shortcomings. However, if the client is wandering away from the

subject it is necessary to intervene politely and direct the conversation back to the topic.

2.

Use of encouragers: The client is assured that the counsellor is listening if the counsellor makes

use of verbal encouragers like “ uh. uh", “okay, then..." during the conversation at appropriate points.

4. Appropriate use of voice: The tone of voice is important for effective communication.

Counsellors should leam the skills of voice modulation, the speed of speech etc.

5. Quality of information given to the client: Using language familiar to the client is an
important aspect of verbal communication. It is necessary to consciously avoid using technical

words. To simplify technical information for clients is the most challenging task of a counsellor
working in a health setting.
Remember

Essentials for Verbal skills

•

Welcome - make the patient
comfortable

•

Friendly tone and voice

•

Give complete information

•

Invite clarifications

Essentials for Non-verbal skills
•

Be relaxed

•

Have an open and approachable
facial expression

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•

Lean towards client

•

Maintain eye contact

•

Touch patient appropriately to

communicate concern

(Source: Khanna R, Ponguriekar S, de Koning K, Training Manual for Auxiliary Nurse Midwives in

Communication and Research into Women’s Sexual Health Issues)

31

SESSION OUTLINES
Module Objectives

At the end of this module, the participants will

•

Describe the process, components and essentials of two-way
communication
S‘ate barriers to effective communication and identify their own attitudes

ano biases that affect their communication

Demonstrate basic verba! and non-verbal communication skills
Describe different audio-visual aids and media used for effective communication

Session 1

Components and Essentials of Effective Communication

Learning Objectives

At the end of the session the participants will be able to

•

list the qualities required for effective communication

•

enumerate the importance of two way communication

•

describe the process and the components of two way communication

•

state the importance and use of verbal and non-verbal “communication skills" in

a counselling situation

Time

1 hour

Exercise 1:

Qualities required for effective communication— Process of two-way

Communication

Time

20 minutes

Resources

Black board, chalk

Methodology

1.

Facilitator tells the participants to recall an individual who is a good

communicator

2.

Ask participants to share the recalled person’s abilities or qualities as a good

communicator

3.

r-

Facilitator writes their responses on the black board

>

32

Possible Responses

•

Clear speech

Open and broad-minded, frank

•

Easily understood language

Good listener

and terminology

Sensitive to the person

Ability to express ideas and

Knowledgeable

feelings clearly

Friendly

•

Respect for the other person

Showed interest

•

Positive attitude

Initiative

Non-judgmental

Self-confidence

•

Facilitator’s Note
The facilitator uses this exercise to explain that a good communicator has a number

of good qualities. One quality common to all good communicators is their ability to
reach their message effectively across to the receiver. Qualities like sincerity and
empathy are always associated with effective communication.

Exercise 2:

Importance and Process of Two-Way Communication (10 minutes)

Time

10 minutes

Resources

Few packets of condoms, OHT 6.1 showing process of Two-way Communication

Methodology

1.

The facilitator distributes the packets of condoms to all the participants without

communicating anything, waits for some time and observes their response.
2.

Facilitator then asks the group to share their thoughts, feelings. Generally the
response is that they didn’t know what they were supposed to do with the

condoms.

3.

Facilitator explains the need to communicate effectively with clients who receive
such packets. Clients should not be looked upon as targets— their information

I

needs need to be satisfied. Hence any health education or promotion activity

I

should provide people with an opportunity to clarify their doubts and ask

questions through the two-way communication process.
4.

Facilitator asks participants to define one-way and two-way communication

and lists down their responses in two columns on the board.

5.

The facilitator summarises the process and components of two-way
communication with the help of OHT 6.1 (Two-way Communication)

33

Exercise 3:

Non-verbal and Verbal Communication Skills

Time

30 minutes.

Resources

Role-play, two facilitators to enact the role play, Transparencies of verbal and non
verbal communication skills (OHT 6.2)

Methodology
4

Facilitator briefly talks about each of the following verbal and non-verbal skills,
followed by a short role-play demonstrating appropriate and inappropriate ways

of counsellor’s behaviour. (See Annexure 6.1 for role play situations) Facilitator
explains the do’s and dont’s of each skill being enacted.

Non-verbal

•

Eye contact

•

Facial Expression

•

Body language

•

Physical distance between the counsellor and the client

•

Active Listening and observation

•

Appropriate use of smile

Verbal

2.

•

Allowing the client to complete the sentence without interrupting

•

Use of encouragers

•

Use of voice

•

Quality of information given to the client:

Facilitator asks the group to then summarise the skills covered in that session

and ends the session by showing transparency (OHT 6.2)

Remember
Skills that need to be developed for effective IPC

•

Effective listening - leaning forward, eye contact, head nod, responses like -

“I see", “uh-huh”

•

Encourage dialogue - ask open-ended questions

•

Avoid interruption

•

Avoid premature diagnosis - do not jump to conclusion before hearing the person fully

•

Probe for more information by asking open-ended questions

•

Ask the person what seems to have caused the problem, what are the difficulties,

any other worries?

34

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Listening pairs

Exercise 1:

Learning Objectives
At the end of the session participants will be able to

•

differentiate between active and passive listening.

•

describe the importance of active listening in counselling

Time

30 minutes

Resources

Room for forming pairs

Methodology
1. Divide participants into two groups ‘Group A’ & ‘ Group B’

2. Each member of Group A will pair with a member of Group B

3. The facilitator announces that each Group A member has to narrate a happy
event in his/her life to the Group B partner.

4. Facilitator takes Group B out of hearing of Group A and instructs Group B members
that while the Group A partner is narrating the incident - for the first five minutes -

"do not pay attention to what she/he is saying, interrupt her or be pre-occupied.
For the next five minutes, listen with attention”. Group B return to their partners.

5. The facilitator announces the commencement of the exercise and lets it proceed
for 10 minutes.

6.

Facilitator then asks members of Group A to share how they felt during the first
five minutes, and then the next five minutes. Enable participants to reflect on

how they felt when they were not being listened to, and how they felt when they

were being listened to with attention. Group A members will generally express
feeling hurt, angry and helpless when the Group B members did not listen to
them carefully. These feelings are accentuated because they were talking about

something personal in their lives.

7

i

The facilitator lists out the action or behaviours that indicate active listening e g.

i

eye contact, saying “uh-hun”, “l-see”, leaning towards the person who is talking

i

to you, nodding of head, not interrupting, allowing the person to finish and then

checking out whether what the person is saying is understood.

I

Facilitator draws attention to the fact that listening to the person with attention,

i

encourages him/her to share information, promotes warm and close relationships.
I

8.

i

Facilitator also asks Group A members how they felt about the non-verbal

communication or body language of their Group B partner, like looking
disinterested, lack of eye contact. The facilitator relates this to the health care
setting, the situation with the patient.

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35

OR
Exercise 2:

Active listening

Learning Objectives
At the end of the session participants will be able to

•

describe the importc nee of listening

•

describe the difference between hearing and active listening

Time

20 minutes

Resources

None

Methodology
Facilitator tells participants “close your eyes and recollect three people you met

1

yesterday and write down what they said to you."
2.

After five minutes, facilitator asks participants to read out what they have written.

3.

Generally, it happens that they write and remember more of what they said than
what they heard.

Facilitator’s Note
You generally tend to remember what you said to people. Often, you do not remember

what others said because although the messages are transmitted, they are not
listened to.

Remember

To be a good listener,

•

Be attentive - look at the speaker, take down notes for later reference.

•

Comprehend what the person is trying to communicate to you.

•

Absorb. If you listen carefully, you will understand what the person is saying and

then you will be able to take it in. This will enable decision-making and taking
action.

•

Listening to the underlying feelings in any message is important.

►

36

Being Congruent: Expression of EmotiuJC through Body

Session 3

Language and Voice

Learning Objectives
>

At the end of the exercise, participants will
•

state the different levels at which communication takes place.

•

describe the need to be congruent in words and body language

(i.e. bclh should match).

Time

30 minutes

Resource

Volunteers to participate in short role-plays

Methodology

1. The facilitator enacts a few situations on incongruent communication with a

volunteer from the group. The volunteer is informed of his/her role in each situation
and asked to become conscious of his/her feelings in each situation.

Example 1: While saying ‘welcome, welcome’ to guests on opening the front
door, the host does not move from the door and does not let the guests into the
house.
Example 2: While saying, ‘what a lovely gift’, the receiver puts aside the gift

without examining it.
i

Example 3: While saying ‘I am sorry to hear that you got into trouble with your

boss’, the person who is saying this, is smiling.

i

2.

After enacting these situations, the facilitator asks the participants:

•

What they observed about the levels of communication.

•

Was there a difference between the words and the body language?

•

The volunteer is asked to share how he/she felt at the end of each message
and why.

I
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3.

when they felt they were receiving double messages (superficial and hidden.)

I
1
1

The facilitator asks the participants to give examples of moments in their lives

4.

The participants are asked to get into groups of 3-5 members and create

situations of, incongruent communication, and then, in the same situations,
using congruent communication.

Session 4

Internal Barriers to Communication

Learning Objectives
At the end of the session participants will be able to

describe how attitudes, perceptions and prejudices affect one’s behaviour and

•

communication.

•

describe the process of effective communication and behavioural change.

Totai Time

50 minutes

Exercise 1:

Effect of Perceptions and Prejudices on one’s Communication and

Behaviour-1

Time

15 minutes

Resources

Newsprint, marker pens

Methodology
1.

Ask participants to write down the first thought or word that comes to their

minds associated with each of the following words. Read each word one by one
allowing time for participants to write their thoughts.

•

Man

Woman
Prostitute/Commercial Sex Worker

Unwed mother

2.

•

HIV positive person

•

Person not willing to use any contraceptive

•

Repeated MTP

Stick newsprint on the wall with the above words written on them in big and bold
letters. Use separate newsprint for each word.

3.

Ask the participants to share their thoughts, and write on separate newsprints

as they share the associated words.
4.

Discuss the connotations associated with various words and how these words

reflect attitudes towards groups of persons. Ask participants to state what the

consequences of such attitudes will be on communication with that particular
person.

38

OR

>

Exercise 2:

Effect of Values and Attitudes on Communication

Time

20 minutes

Resource

Copies of sheets with statements (Handout 6.1)

Methodology
4

Facilitator gives each participant a sheet with the following statements and
asks them to mark whether they agree, disagree or are ‘not sure’ with the

statements.

Statements
1.

Unmarried people should not have access to contraception methods.

2.

HIV positive people have sex with multiple partners.

3.

It is all right to insist that poor families adopt family planning as they cannot

afford large families.

4.

Daughters should not be given freedom.

5.

It is all right for boys to have sex before marriage.

6.

Clients do not comply with treatment because they do not value doctor's advice.

7.

Homosexuality is wrong.

8.

Girls do not masturbate.

9.

Sex workers are responsible for spreading HIV.

10. Girls should choose caring professions like teaching and nursing.

11. Public health system should make special provision for caring for unwed

I

mothers.

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Following the exercise facilitator initiates a discussion around the above-mentioned

I

statements.

Facilitator’s Note

There is no right or wrong answer to the statements. Each of us responds the
way we do because we attach a value to each statement, which is governed by

an attitude. These attitudes can be a barrier to effective communication.

rb® rb®

39

Effect of Perceptions and Prejudices on one’s Communication and

Exercise 3:

Behaviour-ll
Time

15 minutes

Resources

A large enough room to conduct the exercise, two sets of stickers:

Set 1: Stickers in set 1 contain names of paternal and maternal relationships like
grandfather, grandmother (father’s parents), grandfather, grandmother (mother's parents),

mother, father, kaka, kaki, aatya and her husband (paternal uncle and aunty), mama,
mami, mavshiand her husband (maternal uncle and aunty) and so on.

Set 2: Stickers in set 2 contain names of various occupations/professions like teacher,
doctor, clerk, air-hostess, sweeper, nurse, engineer, cook, ayah/ba/, domestic servant,

scientist, commercial sex worker and so on

Methodology

1.

Divide participants into two groups.

2.

Distribute one set of stickers to each group and ask each participant to stick
one label on their forehead and assume that role for the exercise.

3.

Each group is asked to discuss the rank order (who will stand first in the queue

till the last person) and form a single line.
4.

Once the lines are formed, discuss the reasons of arrangement of a particular order.

Generally paternal relatives and men in the family are placed before the maternal

i
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relatives and women. Also commercial sex worker is generally placed last in the line.

5.

Discuss the issue of discrimination based on gender, class, education, kind of

occupation, patriarchy etc. and ask the participants whether the attitudes towards
a particular person’s occupation or familial/social status affects the perceptions
and behaviour of health workers towards that person. Point out that we tend to
associate status, and hence respect, based cn our attitudes towards people or

professions, (e.g. placing sweeper at the end of the rank order) which also

determines our behaviour towards that person. Therefore we tend to respect
people in “respected” professions and do not respect others. E g. in the hospital

well dressed, English-speaking patients are respected and treated differently

from non-literate patients. This kind of discrimination leads to hesitation and
loss of confidence in poor and needy patients.
6.

Discuss the need for changing the order. Facilitator points out that such

perceptions and attitudes are in-built in our minds. In spite of being trained

health workers we still could not do away with our biases and prejudices. Such
changes take a long time to reflect in practice. Similarly at the community level,
changes in people’s perceptions and attitudes will take long to change, but we

have to keep working towards it.

40

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Points to Emphasise
• Our perceptions and attitudes reflect in our practice.

•

We tend to discriminate based on the status associated with a particular profession
or people from particular socio-economic background. Thus attitudes influence

behaviour.

•

Changing perceptions and attitudes is not easy and is a long process.

•

One has to keep working towards it by discussing the issues and making people
reflect about their behaviour.

I
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Exercise 4:

Understanding Behavioural Change Process

Time

20 minutes

Resources

Pen and paper

I
i

OHT 6.3 showing data regarding use of Nirodh among Truck Drivers and steps in
behavioural change process

Methodology

i

1.

Ask participants whether they are right or left-handed.

2.

Ask right-handed persons to write their names with left hand and vice- versa.

3.

Discuss their experiences and learning

4.

Explain that it is not easy to give up old habits .i.e. the change that we wish to

bring about in client’s behaviour, will not happen over-night.
5.

Ask the participants how many children would they prefer, the unanimous answer

generally is 1 or 2. Explain that, as against this, the earlier generation believed

in having at least 4 to 5 children in each family. It is clear that it sometimes

takes a generation to realise and bring about change.
6.

Present the transparency (OHT 6.3) with the truck drivers’ data on use of condoms
and process of behavioural change to the participants.

7.

Conduct the discussion about the importance of behaviour change. Explain with
the help of examples, that some of the behaviour, attitudes, and perceptions are

l

culture and religion-based and existing since generations.

Points to Emphasise
Counsellors/health educators need to have patience with clients, and avoid a bias

towards people who find it difficult to change their behaviour.

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41

Skills in Information Giving

Session 5

Learning Objectives

At the end of the session participants will be able to

•

state ways to make a health message effective and interesting.

•

describe the different media for effective communication and state when to use

each.

Total Time

1 hour

Exercise 1:

Use of organised, logical way of providing information

Time

15 minutes

Resources
Chit (1) with a message written in a jumbled manner, e.g. daddy wants to make

pulao (vegetable rice) so go to the market and get kothimbir (coriander), jeera (cumin
seeds), rice, kanda (onions), mirchi (green chilly), dhana (coriander seeds), garam
masala (spices), potato, aalae (ginger).

Chit (2) with the same message written in an orderly fashion, items that form one

group for ease of buying are mentioned together, e g. daddy wants to make pulao

(vegetable rice) so go to the market and get rice, kanda-batata (onions, potato),
aalae, mirchi, kothimbir(ginger, green chilly, coriander), dhana-jeera (coriander seeds,
cumin seeds), garam masala ( spices).

Methodology

1. Ask the participants to sit in a circle.
2. Pass chit (1) through the participants within 2 minutes.
3.

Ask one or more participants to recall the message.

4.

Pass chit (2) and ask them to do the same. It is generally observed that
participants can recall the second message better than the first one.

I

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5. Ask the participants for their impressions about the two different messages.
6. Brief them about how a message should be i.e. simple, crisp and logical.
Point to Emphasise

It is important to present technical knowledge in an organised and logical manner for
better recall from clients.

42

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Exercise 2:

Effect of Tone, and Emphasis on Words in Communication

Time

10 minutes

t

I
Resources

OHT 6.4 with following statements written on it

I

"Maro, mat chhodo!" And "Maro Mat, Chhodol"

1

(“Kill, do not let him go !” And

“Don’t kill, let it be!")

“ Woman without her man is nothing" and “Woman: without her, man is nothing".

"Kam se kam chot lagel"
Transparency showing principles of effective communication (OHT 6.5)

Methodology
1.

Show transparencies with statements. Ask different participants to read each,

discuss the change in the meaning of the statements with punctuation and

emphasis on certain words.

Facilitator’s Note
The facilitator summarises the important principles of effective communication with

the help of a transparency. (OHT 6.5)

Points to Emphasise
•

Emphasis on certain words in communication changes the meaning of that
communication.

•

It is important to pause and emphasise certain words to convey the right
meaning.

43

Exercise 3:

Using Appropriate Media

Time

30 minutes

Resource

OHT 6.6, pen,

Methodology
1.

Facilitator puts up a transparency showing the following

i You remember 20% i You remember 40% i You remember 80% of

I

You remember 90% of

; of what you hear

of what you see

what you hear and see

what you hear, see and do

j 1.

Conversations

1.

Posters

1.

Video

1.

Demonstration

2.

Dialogues

2.

Leaflets

2.

Cinema

2.

Role Play

3.

Lectures

3.

Pamphlets

3.

Flash cards

3.

Games and exercises

4.

Debates/

4

Books

4.

Stories based on

Discussions

5.

Exhibitions

: 5.

Story telling

*!*

Flanellogram

5.

Puppet shows

6.

Street plays

(Source: Dr. Pocha’s training session on effective IEC conducted for WCHP)

2.

Facilitator should lead the discussion by giving examples of each medium of
communication and advantages and disadvantages of each.

i

l

OR

2.

Participants are divided into four groups. Each group discusses advantages and

disadvantages of one medium of communication.

3.

Questions for the group discussion could be
•

What are the different media aids that you know?

•

List 3 or more advantages and disadvantages of each.

•

Which media are you comfortable with?

•

Which is the least effective medium?

•

Which is the most effective medium?

•

What are the factors that would influence you to use a particular medium?

Points to Emphasise

•

To make the health education session interesting and effective one needs to use

appropriate media. Participatory two-way methods like storytelling, demonstration
and group discussion help clients remember information better.

•

Choice of media will also depend on the content, audience and the purpose of

the session

•

One could make use of visuals and discussion to give information on a health
issue to the client during counseling, rather than just verbal information.

44

1

Demonstration and Practice of Effective Use Of IEC Material

Session 6

Learning Objectives

At the end of the session participants will

•

demonstrate effective use of IEC material like flip chart, flash cards and models
of reproductive organs

Time

1 hour

Resources

A set of IEC material like flip chart, models of reproductive organs, and pamphlets,
copies of checklist for monitoring information session with the client. (Handout 6.2)

Methodology

1.

The check list for evaluating “health education session" (Handout 6.2) is read
and discussed.

2.

Facilitator then demonstrates a session of giving information to the patient on

any topic, either in the group, or one-to-one.
3.

Participants observe the session and fill the observation checklist.

4.

Points on the checklist are discussed and do's and don’ts in the health education

sessions are written on the board.

5.

Two participants are then invited to give a demonstration on condom use. Others

observe, use the checklist, and give feedback.

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45

1
PART 2: COUNSELLING
*
Counselling is creating new perspectives and change within the person to enable the person to

think differently about his/her own situation, or to change an aspect of his/her behaviour in order to
cope with the problem that he/she is facing, or to change the conditions in the immediate environment.

I
Counselling is a process of communication, involving two or more persons who meet to solve a

problem, resolve a crisis or make decisions involving personal intimate matters and behaviour. It
encourages an exchange of information as a means of clarifying and resolving problems. Counselling

is a process of building a relationship through which the client experiences confidence in the

counsellor. Counselling is an interactive and continuous process. Counselling is not about meeting
the client only once - the counsellor encourages the client to make regular visits if required. •

X
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Counselling is a facilitating process which enables the client to make decisions that result in a plan
of action to solve the problem. Only the client can make good decisions about the situation, as only

he/she knows more than anyone else about his/her own life, needs and feelings. The counsellor

empowers the client to make decisions by providing clear, accurate and appropriate information. The

counsellor also enables the client to apply this information to his/her life situation. This makes the
relationship a vital partnership.

The counsellor explores along with the client, what is bothering her, and what are the stumbling

blocks that prevent her from taking a decision. The purpose of the counselling session is primarily

xr

concerned with exploring facts, providing relevant need-based information to the client and thinking
together about the consequences. Information should be tailored, personalised and specific in order

to enable the client to make an informed, accurate and good decision. The counselling process does
not end here, it further supports the client to handle his/her feelings if he/she suffers from the

*

consequences of wrong decisions.

Counselling has both process and content components, and both are dependent on each other.

Principles of Counselling
•

Uniqueness / Individuality of the client
The person who seeks help shares some characteristics of the society he/she represents, but is

also unique in terms of family background and coping mechanisms. The client should be made
aware that he/she is a unique human being. This uniqueness must be respected at all times.

46

rb®

►

Unconditional acceptance
In order to respect this uniqueness, the client must be unconditionally accepted with all his/her

positive and negative behaviour, attitudes and views. The counsellor accepts the client without
bringing in his/her own values, cultural background, ideologies, biases and prejudices while

counselling. The client can feel this acceptance from the counsellor through body language and
non-verbal communication. When the client experiences the counsellor’s unconditional positive
regard, the process of change gets initiated.

Non- judgmental attitude
Both the client and the counsellor come from different social, cultural and economic backgrounds
and different value systems. Thus a non-judgmental attitude is crucial. The counsellor may not

agree with the values of the client but he/she has to allow clients the right to hold their own value
system. Before exploring the background and the problem situation, the counsellor should not
label or judge the clients’ motivation, capacity to develop and change according to the situation.

Non-judgmental attitude need not be one-way — if the client is being adamant, refuses to see

other view points, the counsellor has to be forthright, but not coercive or pressurising.

Self - Determination
This is an important principle of counselling. The client must always take responsibility for decision
making. The counsellor encourages the client to think of possible consequences, through self-

determination and by providing accurate, appropriate information and also by providing available
options. Through the counselling process the client develops the capacity of self-searching and
empowerment, reflecting on any positive actions she has taken in the past and derives strength

I

out of these.

•

Confidentiality

I

This is the most important principle in counselling. Assurance for maintaining confidentiality

I

encourages the client to verbalise his/her problem, and share medical and personal information
with the counsellor, because he knows that this information will not be revealed to any other

I

person without his prior permission.

I

B
B

Qualities of a Counsellor

I

All health care providers need to use counselling techniques as part of their work. Counselling is not

I

giving advice or just using skills, but having certain characteristics like

►

•

Warmth, honesty and genuine interest in the well-being of others

•

Caring, positive regard

•

Enthusiasm and a sense of humour

•

Sensitivity and good listening skills

•

Acceptance and recognition of others’ qualities and capacities

47

•

Self-awareness: Understanding his/her own limitations and biases and positive self -esteem

•

Openness to learning

•

Knowledge of the task and subject.

•

Awareness of different cultures and practices among different people.

■

Self- awareness, relaxation and development

It is important to develop the desired qualities necessary to be an effective counsellor. Being conscious

of one's behaviour and responses while interacting with others, and being aware of one’s feelings and
thoughts can develop these qualities. It is also necessary to review one's values and attitudes,
I

discuss and obtain feedback from others, practice self-disclosure and use psychological tests and
self-administered questionnaires to find out more about one’s self. Realising one’s strengths and

weaknesses is the first step to developing the good qualities mentioned above. (Some of the self
administered questionnaires are included in the session plan).

The counsellor’s own state of mind, ability to concentrate, listen patiently, and be empathetic affects

the process of counselling. Unless one takes care of one’s own mental and emotional state, counselling

can result in burn-out. Counsellors need to be aware when they are experiencing a burn-out state and
take necessary remedial and preventive action.

What is burn-out and how to prevent it
Burn-out can be defined as a condition of psychological exhaustion and diminished efficiency resulting

from overwork or prolonged exposure to stress. Stress can cause a variety of illnesses, both

f

psychological and physical.

..
Symptoms of stress burn-out

Symptoms of burn-out can be noticed at three levels, “The physical level (characterised by
exhaustion); the character level (irritability, lack of concentration, reactive attitude, feelings of
helplessness); and the utility level (loss of productivity, lack of innovative decisions or actions).’’

Chronic fatigue and irritability are the starting symptoms of burn-out. Eating and sleeping patterns

change^and one engages in escapist behaviour such as sex, drinking, drugs, partying, or shopping

binges. You become indecisive, productivity drops; your work deteriorates.

Early warning signs

48

1.

Chronic fatigue - exhaustion, tiredness, a sense of being physically run down

2.

Anger at those making demands

3.

Self-criticism for putting up with the demands

4.

Cynicism, negativity, and irritability

5.

A sense of being besieged from all sides

6

Exploding easily at seemingly inconsequential things

7.

Frequent headaches and gastrointestinal disturbances

8.

Weight loss or gain

9.

Sleeplessness and depression

10. Shortness of breath
11. Suspiciousness

12. Feelings of helplessness
13. Increased degree of risk-taking

Gender and stress

It is not known if stress affects men and women differently. Generally, as the two sexes often
operate in different social contexts, both tend to develop different emotional dispositions and

personality traits. Accordingly, their responses and coping mechanisms to stress situations vary.

Women : Women have a lot of balancing to do between home and workplace, and between social
and personal requirements. Issues of maternity, menopause, parenthood, and gender roles, familial
and social support, often complicate women’s lives.
I
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Social and Work Stress . Sociological researches assert that family demands and family attitudes
were found to influence employee attendance at the workplace. The re is a strong relationship between

I

social support and mental stress and trauma in women. Experiencing a high level of burn-out was

I

associated with increased absenteeism if employees had children under six living at home or reported

having difficulty with their child care arrangements.

Gender Roles: Quantity and quality of leisure time distribution between the genders is an interesting

index of how women get burdened with either natural or social obligations. Women today bear a “dual
burden as both family providers and family carers. Although men and women have similar quantities
of free time, when the character of leisure is considered the gap between genders re-emerges. Mothers

handle the bulk of parental responsibility such as educational and emotional care of children. This
can be both physically and psychologically draining.

49

9

Men : Most of the causes of male depression and stress arise from their self-nurtured identities,
especially related to their professional status. “If you ask a man who he is, the first thing he says is

his work—I’m an executive, I’m a doctor, I'm a house builder," says Glenn E. Good, an associate

professor of educational and counselling psychology at the University of Missouri, Columbia.
“Suppressing feelings and internalising stress are acquired male traits", says Good, “On some inner

level, it comes down to: If I can’t tough it out, then I’m not much of a man."

Work Stress : For men workplace stress can have extreme consequences. In Japan, the work

stress related suicide rate among men has risen over the last 15 years. According to the Government’s
Statistics Bureau, the highest suicide rate occurs in men from 35 to 44 years old, making it the 13th

most common cause of death for men.
Uncertainty in the workplace can cause high levels of stress. Causes of uncertainty can be:

•

Not having a clear idea of what the future holds

•

Not knowing where your organisation will be going

•

Not having any career development plans

•

Not knowing what will be wanted from you in the future

•

Not knowing what your boss or colleagues think of your abilities

•

Receiving vague or inconsistent instructions

What is stressful for one person may not be a problem for someone else. This viewpoint leads to

prevention strategies that focus on ways to help them cope.

Tips for surviving Burn-out
These tips are a way to help yourself get back on track when your stress levels are out of control.

•

Re-evaluate your goals, re-set them as needed. Look closely at what you are doing and why you

are doing it How does it enrich your life? If it doesn’t, change it.

•

Develop a mission (purpose) for your life. Having a purpose that is value-driven helps you to put

your life in perspective and set realistic goals.
•

Work in a well-lit and comfortable area. Consistent exposure to poorly-lit or uncomfortable work

areas leads to stress, loss of interest and excitement with your work, and ultimately burn-out.

•

Take a work break every 2 hours - away from your work area. Take vacations regularly. Breaks
and vacations refresh, re-energise, and re-focus us. Reward yourself for all your accomplishments
big or small. No need to wait forthat “big event” to happen before you reward yourself. Acknowledge
the small strides and allow yourself a small reward like fresh flowers for your desk, or dinner at a

favorite restaurant. If you feel overwhelmed with a project, put it aside for a while and shift to less

demanding work. Pounding on the same project causes frustration and blocks creativity. Let it go
for a while.

50

t

•

Set realistic and do-able goals for your professional and personal life. Making your goals too

difficult creates stress if you don’t accomplish them; making them too easy doesn’t stretch you
enough and will cause you stress as well. Finding a middle ground and adjusting your goals

periodically is less stressful and encouraging.

•

Develop a hobby or interest in something totally unrelated to your work to create more balance.

Your circle of friends will expand into other realms and give you a respite from the same, old
grind.

Six ways of coping with stress

I
•

Keep a perspective: it's only a job — not your life

•

Don’t be a perfectionist: you can’t get things perfect every time

•

Learn to say ‘No’: don’t agree to take on too much

•

Delegate: don’t try to do everything yourself

•

Express: don’t bottle up feelings and emotions

•

Separate work from home: learn to switch off

i
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Another component of self-awareness is giving positive strokes to one’s self. Instead of being

unnecessarily harsh with ourselves, we can remind ourselves of those happy moments when we
really felt proud of ourselves.

There are various techniques for relaxation, de-stressing and unwinding that a counsellor should

learn and practice, to cope with stress and avoid burn-out. Some of the techniques are:

•

Deep breathing and focusing on one’s breathing

•

Meditation

•

Sports and games

•

Fun activities like listening to music, reading

•

Physical exercises and activities, like walking, jogging, swimming

•

Relaxation exercises, like shavasana, yoganidra

•

Sharing feelings with close friends and colleagues

Skills and Techniques used in Counselling
Every counselling situation is a unique experience, because every client is unique, has different

problems which need different solutions. To make counselling effective, there are certain skills and
techniques, which need to be adopted by the counsellor. Some of these skills and techniques are

presented below.

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Macro skills

1. Clarification
Use questions such as “Did you say--------------- ?" “According to you------------ ?", " Was it —’, to
ensure that the counsellor has understood the client’s message correctly. It is important to ask for
such feedback from the client frequently during communication with him/her.

2. Asking open-ended and probing questions
Ask questions which will encourage the client to speak at some length and not give monosyllabic
answers like ‘yes' or ’no’. Questions like ‘‘Could you tell me in detail what happened?"," Could you
elaborate? “ encourage clients to share more information. As far as possible avoid questions beginning

with ‘why’ and ‘where’. Also avoid asking leading and directive questions.

It may be necessary to ask probing questions to get relevant information about the problem situation.
It also helps to clarify certain concepts, beliefs, concerns that otherwise may not be openly shared

by the client. See examples in Handout 8.2.

3. Empathy
Empathetic understanding involves accurately sensing the client's feelings and being able to see
things the way he/she does. It is the ability to see and feel the world from the perspective of another

person while remaining objective.

4. Reassurance
The client could be agitated, depressed or anxious so the counsellor needs to reassure the client
through verbal and non-verbal communication and encourage her/him to cope by saying ‘‘Don’t lose
hope" or “Don’t worry, things will change for the better”.

5. Summarising
Clients who are disturbed and experiencing mental or emotional shock tend to talk faster, and about

many things at the same time. They are also searching for answers, which may lead to a confused
state of mind at the end of the counselling session. The counsellor should summarise the issues and

clarify things with the client to ensure that the counsellor has understood correctly. As the last step

in counselling, the counsellor lists out all the important and main points of the discussion.
6. Recapitulating
Asking the client to recapitulate the information given is usually done in a concluding session, after

information about an investigation or treatment procedure is given to the client. This serves a dual
purpose. One, it gives the counsellor a chance to find out if the information has been understood by
the client. Two, it helps to gauge if the client is listening to the information being imparted or is pre

occupied with his/her own thoughts.

52

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Micro skills

1. Paraphrasing of content

To paraphrase is to say the client’s words and thoughts in your own words.

Client

I know I shouldn’t be so hard on myself. But I can’t seem to stop

blaming myself

Counsellor

You are aware that being critical of yourself isn’t helpful, even
though you haven’t found a way to stop doing it.

2. Reflection of feeling

Counsellor reflects the client's feelings, in her own words, to reassure the client that the counsellor

has understood her/his feelings accurately. It also helps the client to recognise her feelings.

Client

I feel very agitated about how my husband is treating me and I

really don’t know how to change him.

Counsellor

You seem to be very angry with your husband because of his
behaviour towards you. You also seem to be worried about how
you can help him change this behaviour.

3. Appropriate use of silence

Silence in a counselling session gives the client an opportunity to reflect, integrate feelings, think

I

through an idea, or absorb new information. It is not always comfortable to allow the silence to

F

continue, but the counsellor should not interrupt prematurely because of his/her own discomfort.

Client

How could this happen to me? What have I done to deserve
this? (begins to cry, looking down)

Counsellor

(softly after 10 to 15 seconds) Would you like to talk about this?

4. Focussing

Counsellor should help the client to focus his/her thoughts on the most important issue on hand. The

i

aim of focusing is to prioritise what needs immediate attention.

Client

My daughter is not well.. .You know, I went to my native place and my
uncle died. He was very fond of my daughter. He left the land in my
daughter s name. So I was busy with getting the paperwork done. I am

going back next month. We have a big house in the gaon.

Counsellor

Okay, now, shall we come back to your daughter’s health? I think
you want to discuss that.

53
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5. Confrontation

Confrontation is honest feedback to the client about inconsistencies in her behaviour, action or

communication, and this needs to be completely non-judgmental.

Client

No one in my office likes me, there’s no one I can talk to

Counsellor

Now that’s an exaggeration, surely

What is good counselling?
Good counselling consists of two elements
1.

Establishing a trusting and caring relationship with clients.

2.

Giving and receiving relevant, accurate information to help client make decisions.

What counselling is not

Counselling is not telling a client what to do. A counselling session is not a question and answer

period. It is not a forum for the presentation of the counsellor’s values.

Errors In Counselling

i

•

Directing

•

Labelling

•

Moralising, preaching

•

Giving false reassurance

•

Denying client’s feelings

•

Encouraging dependence

•

Breaking confidentiality

•

Interrogating

Now let’s look at different models of counselling relevant to counselling situations in the health set-up.

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54

Models of Counselling

Model 1: GATHER

Elements/Steps of Counselling

Counselling has six elements or steps, encapsulated in the word GATHER. Each letter is meaningful
and helps in progressing the process of counselling.

G : Greet the client - It is the first step towards comforting and respecting the client, enables rapport

building and expresses friendliness towards the client.

A : Ask - Enable the client to put into words the problem he/she is facing. Asking open-ended

questions helps the counsellor in gathering the facts of the problem and exploring details. It
encourages the client to express his/her feelings which in turn will enable him/her to identify the

problem.

/ : Talk - List the different options or enable the client to list these options. Give the client accurate,
tailored and personalised information about options available to him/her. The information given to
the client will enable informed decision-making and will also enable the client to review the

situation in different dimensions.

H ■ Help - Help the client to think about the positive and negative aspects of each option and to
assess the results of choosing each option. Enable the client to take the right and appropriate

decision which suits his/her situation by making use of available resources and support systems.

Also support the client to handle his/her feelings, if he/she suffers from the consequences of
wrong decisions.

E. Explain - Explain how to carry out the decision: to ‘fragment’ the problem in various stages, then
prioritise the problem, and then plan action to solve the problem. Also enable the client to adopt

new behaviours.

R : Return - Return for follow-up. Arrange for referrals in case the required help is not within the

purview of the counsellor.

55

Model 2: Woman Centred Counselling
Instead of being neutral, woman centred counsellors are pro-woman. They operate on the premise
that women are oppressed, exploited and are often rendered powerless in comparison to men in the

present patriarchal society

Values and Ethics in Woman Centred Counselling
Woman centred counseling:

•

believes that women’s problems are not a result of personal inadequacies, but created
by unjust and oppressive social structures.

•

does not encourage women to adjust to their situation ... women are challenged to become

aware of their rights.

•

advocates changes in society’s institutions and structures to allow equal treatment and
opportunity for both men and women. Change has to take place in all the units of society
and involving the community is an important aspect.

•

leads to improving self-esteem, challenging personal internalised values, and gender
identities, towards a process of self-realisation and self-discovery

•

challenges male expectations which are based on traditional role models and stereotypes
of women by introducing different ways of looking at these stereotypes.

•

gives value to the woman’s own self (her way of thinking and analysis, feelings)

•

assumes women’s right to self-determination and control over their own lives.

•

asserts every woman’s right to be an active participant in her own healing, where she
makes her own decisions.

•

validates a woman’s right to her feelings, decisions and intelligence - and her experiences.

The process of woman centred counselling

•

challenges the subordinate status of the woman in her family and inspires confidence in her.

(Usually women have the experience of being silenced by their families).

1

I

•

helps the woman to break her oppressive support system in life- threatening situations.

•

helps women to identify negative responses that break communication and gives practical

suggestions to improve communication.

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Counsellor- counsellee relationship
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•

In WCC, the counselling relationship or the power relation between the counsellor and client is

I

egalitarian. Counsellors share power with their clients to make the relationship more equal by

1

discarding the notion of “us” (counsellor) and “them".

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Feminist counsellors also acknowledge that women are oppressed in different ways. Women

can and do oppress other women. Feminist counsellors need to be aware of their own personal
privileges and place in society so as not to hurt their clients.

Model 3: First Aid Counselling

First aid counselling is giving immediate help, emotional support, providing guidance and referring the
client to the appropriate agency. This is important in a clinical setting because at times client comes
with physical/sexual abuse or after a traumatic situation like miscarriage, or loss of child. In such a

situation it is necessary to use some additional skills apart from the skills presented earlier.

Emotional support - giving the client a feeling of genuine concern through verbal and non-verbal
responses.

Receiving information - trying to find out as much as possible about the problem without any
prejudice or bias.

Reality orientation - Taking a practical view of the problem, clarifying fantasies.

Anticipatory guidance - Mentally visualising and taking stock of foreseeable consequences and

what to do about them.

Role-playing - is linked to anticipatory guidance and means enacting the anticipated event. The

foreseen events may be acted out so as to try out different roles. For example, if a girl knows that
when she becomes 16, her parents will insist that she gets married, she can enact how she will
respond, how she will try to convince them to delay her marriage.

I
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Motivation - Motivating the client to take action to solve the problem.

I

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Reflective discussion - This is discussion between the counsellor and the client based upon the

I

client’s reflection on different areas of his/her life that may have some bearing upon his/her problem.

Reflective discussion promotes analytical thinking on the problem.

I
Correcting perceptions - Clarification can lead to a change in the understanding of particular
situations.

Modeling - Modeling means setting an example through one’s own conduct.Clients do learn from
what the counsellor says/does. Since the counsellor converses purposefully and responsibly, some
clients learn helpful and constructive ways of communication from their interaction with the counsellor.

57

Removing guilt feelings - Removing guilt feelings is essential so that the client can participate in
the problem-solving process.

Using guilt feelings constructively - Guilt feelings are warranted and realistic when they result

from behaviour which causes harm to oneself or others, and is socially unacceptable. In such
circumstances the client can be enabled to use his/her guilt feelings constructively for changing his/

her behaviour. For example, Farah who went to see a film without informing her mother and bunking

her tailoring class, may feel guilty aoout her behaviour. This guilt can be used to make her realise her
mistake and generate insight and awareness so that she will not repeat the same act

Partialisation - means dealing with the most immediate problem first and reserving the rest for
discussion later. Sometimes the client may prioritise the problematic aspects wrongly, in which case
the counsellor has to enable him/her to think over and correct his/her perception.

Interpretation - is the explanation of the client’s behaviour in terms of its psychological meaning.
For example, Shashi is a 14-year-old girl. Suddenly she started wetting her bed. When the case
history was taken it showed that this phenomenon started after tension between her parents escalated

and they started discussing separation. This may indicate onset of insecurity in the girl, and due

measures can be taken by the parents.

Universalisation - means making the client aware that others too have similar problems. Some
times the client may think that he/she is the only one who has a particular problem and hence

t

experiences excessive anxiety, self-pity. Universalisation enables one to overcome such anxieties
and self-pity. For example, if an adolescent girl feels that the anxiety or fear about growing up is

unique to her, we can assure her by saying that all of us go through a similar phase. This will help to
reduce her anxieties and face the changes more confidently.

Setting limits - The concept of acceptance does not mean that every kind of behaviour has to be
accepted or condoned. The client as an individual has to be accepted unconditionally, but his/her behaviour
may be approved conditionally and hence setting limits to certain types of behaviour is important. For

example, if a girl has a habit of using abusive language, limits can be set on the use of language. This

setting of limits becomes essential when working with adolescents with behavioural problems.

The above skills and techniques can be used in combination as required in a counselling situation.
The counsellors, should be careful however, that they do not encourage dependency, but instead,

empower women to take control of their lives. Counsellors also need to be conscious of‘transference’
ie. getting emotionally involved with the client and fighting the problem as her (the counsellor’s)

own, or losing rational thinking and feeling extremely upset when she cannot do much in a difficult
<■

situation. In all such situations it is advisable to refer the client to another counsellor or institution.

58

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SESSION OUTLINES
Module Objectives

Learning about Counselling Principles, Skills and Techniques, and Values is not very easy. The aim

is.to encourage people to get involved in the counselling activity, to encourage them to think about
their own behaviour and also to understand behaviour of clients.

It is important that each activity or session should be worked through slowly and should be aimed at

encouraging the participants to observe minutely what happens in the session and reflect and react
on the process freely. The participants should be able to apply and transfer these skills and principles

in real life situations.

It is also important to work on one's own self as a counsellor. Thus the first session in this section is

about knowing one’s self, to increase self-awareness and to understand one’s biases.
At the end of these sessions, the participants will be able to

i

•

Describe the Principles of Counselling, and Ethics and Values in Counselling.

•

Analyse what is not counselling and reflect on errors in counselling

•

List their strengths and areas for improvement as a good communicator and counsellor

•

Demonstrate basic skills and techniques used in counselling

Session 1:

Sensitivity in counselling and qualities of a counsellor

j

Learning Objectives
At the end of the session, participants will

•

experience feelings related to talking about their personal experience to others,
and be able to relate the experience to the counselling process

•

list the qualities of a counsellor.

Time

1 hour

Resources

u,

'Sensitivity exercise"for participants, black board and chalks.

Methodology

1. The participants are told to find a partner who is not known to them, with whom
they would have to share a personal experience.
2.

After the participants choose their partners they are told that the women would

have to share experiences about their “first menstrual experience," and the men

about their “first ejaculatory experience”, with their partners.
3.

The participants are given 10 minutes to do this.
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59

4.

Each pair then, talks about how they felt, sharing this very personal experience

with their partner in the larger group. (Facilitator emphasises that they are not
required to talk about the content of the experience).

5

The feelings that they experienced are listed on the blackboard and this then
leads to an open discussion on how clients feel when they go to a counsellor

who is a stranger. The barriers that the client could experience are discussed
(like talking to a person of opposite sex, to a stranger, to a known person).

6.

The facilitator then asks the participants what qualities they would look for in a

person to share such a personal sensitive experience.

7.

The facilitator writes participants' responses on the board in 3 columns without

naming them. The columns could be for qualities, skills and principles. Facilitator
helps participants to distinguish between the three aspects. The participants

are then asked for their inputs, so that each of these three categories is
conceptually clear to the participants.

Session 2: Self-Awareness, relaxation and development
Learning Objectives

•

to enhance self-awareness as a counsellor.
to identify strengths and weaknesses
to enable self to become stronger

Time

70 minutes

Exercise 1:

Relaxation technique-Sufcftasana

Learning Objectives

At the end of the session participants will be able to

•

state the importance and advantages of the relaxation techniques

•

practice techniques of relaxation

•

list barriers to concentration and relaxation

Time

10 minutes

Resources

Mats or Durries

I

Methodology
1.

Facilitator explains that self-awareness is a very subjective process; hence it

requires effort from the individual's side. One can give of one’s best only when
one is relaxed, tension-free. To achieve this, we can start with Sukhasana.

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2.

Ask the participants to sit on a mat cross-legged.

3.

“Close your eyes and concentrate on the tip of your nose. Try not to think about

anything".

4.

Try this asana for 5 minutes.

5.

Facilitator explains that initially this asana can be done for 5 minutes but then

can go up to 30 minutes every day.

6.

Facilitator also shares advantages of regular practice of yogasana.

OR

1.

Ask the participants to sit relaxed in a chair and close their eyes.

2.

Give instructions to concentrate on the toes first. Move the attention gradually

through each part of the body, till you reach the crown of the head. Then give

instructions for concentration on their breathing for 5 minutes.
3.

Gradually ask the participants to open their eyes.

4.

Ask them to share how they felt, whether they could concentrate, or what

prevented them from concentrating.

Facilitator’s Note
1.

Through regular practice of this exercise one can improve endurance and

tolerance levels - these qualities are very useful for counselling, as counselling
requires patience.
2.

Counselling also requires attention and active listening. With the help of
sukhasana, we can increase concentration.

3.

It also helps in understanding barriers in our thinking process.

4.

It helps in becoming aware about physical discomfort - physical discomfort and

talking are closely related. When one is in great physical discomfort, one cannot
communicate properly.

5.

Sukhasana is the first step of making one's self comfortable, and in tune with

the self - to alleviate physical discomfort, one can also practice vajrasana and

shavasana
Exercise 2:

SWOT Analysis

Learning Objectives
At the end of the session participants will be able to

•

identify their own strengths and areas for improvement

•

distinguish between threats and opportunities and relate these to self-realisation
and enhancing one’s strengths

►

Time

10 minutes

61

Photocopies of questionnaire (Handout 6.3)

Resources

Methodology
1.

Facilitator gives the questionnaire to each participant to fill up.

2.

Facilitator tells them that they don’t have to share the results if they don’t want
to. It is for their personal use.
Ask them to write the first thought that comes to their mind and to be as truthful

3.

as possible.
1)

lam good at

________________

2)

Because I am a girl/boy

_____________

3)

The best thing that I like about myself

4)

The thing that I hate about myself

5)

I feel that I can not

6)

I feel that I can not do it, but I could do it if

7)

I feel very insecure when

8)

I feel very secure when

9)

I can talk freely about

10) I feel shy about

11) I could have achieved something if
Key-

1,2,3,8 denotes your Strength
2,4,5,10 denotes your Weakness

6,9,11 denotes your Opportunity

7 denotes your Threat
4.

The facilitator emphasises
•

That strength, weakness, opportunity and threat are subjective issues.

•

They change over time - what is a threat today, can be an opportunity

tomorrow. The same is true with strength and weakness.

•

Remember that strength, weakness, opportunity and threat depend on our
viewpoint. If we consider something as a threat, then it will never be looked
upon as an opportunity but continue to be a threat. E.g. A person who is
afraid of public speaking is given a chance to speak in public , but if she
considers it to be a threat, she’ll never overcome that fear. However, if she
considers it to be an opportunity, her whole perspective will change

5.

I

Facilitator asks the participants to take the questionnaire home and keep adding
responses, weekly or monthly, to become more aware of themselves and see

their threats changing into opportunities.

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Self-awareness questionnaire

Exercise 3:

Learning Objectives
At the end of the session participants will be able to
•

learn how to be aware of self-image

•

identify the areas for improvement to develop positive self-image

Time

20 minutes

Resources

Photocopies of questionnaire (Handout 6.4)

Methodology

1.

Facilitator gives the following list of qualities to each of the participants

2.

Facilitator asks them to mark themselves out of 100 for each of the sentences

1.

Self-acceptance. (I like myself)

2.

Ability and presence of mind to speak the right thing

3.

Ability to express myself

4.

Competence on the job

5.

Enjoying meeting people

6.

Competence in managing my time

7.

Enjoying doing the work

8.

Engaged in continual self-development

9.

Knowing what is good for me and can assert myself

10. Remaining always cheerful

11. Enjoying being close to nature
12. Ability to create trust in others
13. Capacity to earn
14. Capacity to imagine new possibilities and alternatives
15. Courage to change and form new habits
16. Self-reliance
17. Maintaining a healthy family relationship
18. Controlling my behaviour
19. Being in touch with my feelings

20. Self-confidence
21. Capacity to relax

3.

Ask them to add their scores and divide the sum by 21, which will give them their

self-image score

4.

Ask the participants to reflect on their weak areas and to develop action plans to

improve what bothers them the most.
5.

To sum up the session, the facilitator reinforces that self reflection can help us
overcome our weaknesses and enhance our self-image.

63

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Exercise 4:

Personal Effectiveness

Learning Objectives
At the end of the session participants will
• know their personal effectiveness in the area of openness and getting feedback.

30 minutes

Time
Resources

Copies of Questionnaire on persona! effectiveness (Handout 6.5 ), OHT 6.7 on Johari

window
Handout 6.6 on Johari window

Methodology
•

All participants are given the questionnaire (Handout 6.5.)

•

The scoring process is explained

•

Each participant calculates and reflects on their scores

•

Discussion is held on improving personal effectiveness with the conceptual

framework of Johari window (OHT 6.7)

Session 3: Errors in Counselling
Learning Objectives

At the end of the session participants will be able to
•

list the don’ts in counselling in terms of principles and values

20 minutes

Time

Resources

Role-play (Annexure 6.2),

OHT, Transparencies (OHT 6.8),
Black board and chalk.

Methodology
1. The facilitators do a five-minute role play showing the errors involved in counselling

(participants are not told what they will see in the role play). Participants are
told to record their observations.

2. After the role play participants are asked to share their observations.
3. Facilitator lists their observations.

4. The facilitator will then put up the transparency, which lists the errors and co
relates each error with the role-play. (OHT 6.8)
5. A summarisation of all the errors is done at the end of the session.

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Choice—the client’s right

Session 4:

Learning Objectives
At the end of the session participants will

•

be able to describe client's ‘right to make a choice' in a counselling situation

•

understand the important and basic principle-that clients should not be forced or
coerced (unless he/she is in a death and life situation)

Exercise 1:

Who can eat faster

Time

20 minutes

Resources

Packets with a mix of eatables (spicy potato chips, caramel centred chocolate, hard
boiled sweets, soup stick, peas(chana), biscuits
Methodology

Divide the participants into pairs and form two groups — group A and group B.

1.

Some pairs should be same sex; others have a man and a woman.
Part 1
a. Instructions for group A. Youjhave to feed the contents of this packet to

your partner. You are to ensure that your partner eats every thing in the

packet in two minutes. If she/he refuses, force her/him to eat. You (the pair)

will be the winner if you consume all items in the shortest period.

Part 2: To be conducted after first part is over
b. Instructions for group B: Now group B will feed their partners from group
A. You will hold the box in front of her/him and ask her/him to eat anything

s/he likes from the packet.

I
I

2.

Ask members of both groupsto stand facing each other to form random pairs.

3.

Distribute packets with eatables to each participant.

4.

Conduct the exercise in two parts

5.

Ask each group to share their experiences

6.

Ask specific questions about experiences related to

•

Being fed by a person of opposite sex.

•

Feeding a person of opposite sex

•

Being forced to eat

(generally it is observed that participants who are forced to eat do not like the

I

experience and do not complete the exercise within the given time. (2 minutes)

65

Ask the participants what they learnt from this exercise and whether they can

7.

relate this situation, to the information given to clients who approach them for

advise in the community or health centre.
Facilitator summarises by emphasising importance of giving choice to people in

8.

a counselling situation

Facilitator’s Note
1. Generally health care providers want to give information/advise about all possible

diseases and programmes at one time. Often, the information does not match
peoples’ needs so people avoid taking help, or asking for advise from health care

providers. The health education campaigns and programmes too, are general

and not streamlined for each individuals problems.
2.

As we saw in part 2 of the exercise, people were much happier and could finish
in time because they had a choice about what to eat first and at their own pace,
rather than being forced to eat everything by someone else.

3.

Analysis is also done about feelings of female clients when they are expected to
take advise from male workers and vice-versa (many participants do not attempt

the exercise because they feel shy about feeding a person or being fed by a
person of the opposite sex).

4.

Also in the second situation all the items were kept open in front of the partner

for him / her to plan how to begin eating.

Points to Emphasise

•

The clients should be clearly shown all the alternatives available

•

The role of the counsellor is to suggest alternatives and enable/let the client

choose.

Exercise 2:

Giving direction

Time

10 minutes

Resources

A situation where participants can offer some advice
Methodology

1.

Read out the situation: “I need some help. I have just received a message that

tomorrow at 9.30 a.m. I have to attend a training programme at municipal school
at Chembur. I stay at Bhandup and am not familiar with Chembur. Can anyone

please tell me how to reach there?” (Change the places to suit the city)

66

I

People tell different routes to reach the place, including different modes of travel,

2.
f

costs and time involved in reaching the place

i

Facilitator then chooses a route that is more economical or faster or easy to

3.

access.

I

Facilitator asks participants to relate the situation to a counselling session where

4.

L

the client is seeking advise from the counsellor and counsellor gives more than
two options to deal w'th the problem The client will choose what suits her best.
Summarise — that all ways suggested by the counsellor might be correct and

5.

might help the client solve the problem, but the choice is the clients.

Facilitator’s Note
If possible probe for more than 3 answers

Points to Emphasise
The client should be given alternatives to choose from

The role of the counsellor is to suggest alternatives and enable/let the client choose.
Based on information given, client will choose what best suits him/her

Session 5: Macro and Micro skills in Counselling
Learning Objectives

At the end of this session participants would be able to

•

identify the “macro” and “micro” skills in counselling.

•

demonstrate the skills in role play situations

I

I

Time

1 hour, 15 minutes

Resources

Transparencies of macro and micro skills (OHT 6 9)

Methodology

1.

Facilitator briefly talks about each of the following macro and micro skills giving
examples of each skill with the help of a transparency.

Micro Skills
Clarification

•

Asking open-ended and probing questions

•

Empathy

•

Re-assurance

Summarising
Recapitulating
rb®

rb>°

67

Macro Skills

Paraphrasing of content
Reflection of feeling
Appropriate use of silence

Focussing
Confrontation

A few volunteers are invited to form a pair and demonstrate use of the micro and

2.

macro skills in the form of a short conversation between any two people (like

friends, parents, spouses etc.)
Facilitator asks the group to then summarise the skills covered in that session

3.

and end the session by showing transparency (OHT- 6.9)

Demonstration of counselling skills

Session 6

Learning Objectives

At the end of this session the participants will

•

state how various skills of counselling are to be used.

Time

60 minutes

Resources

Role-play, Annexure 6.3, black - board, chalks.

I

Methodology

1. A twenty-minute role play is enacted by two facilitators, which covers the non
verbal, verbal, macro and micro skills, (see annexure 6.3 for role play).

2.

Participants are divided into 4 groups and each group is asked to observe non
verbal, verbal, macro and micro skills respectively.

3.

Session 7

Facilitator makes 4 columns on the black board - non-verbal, verbal, macro
skills, micro skills - and asks each group for their inputs coupled with an open

i

discussion.

i

Practicing Counselling Skills

Learning Objectives
At the end of the session participants will

68

•

be able to demonstrate use of counselling skills

•

learn to evaluate a counselling session

JI
j

F

2 hours

Time

f
i

Resources
Situations for role plays, checklist for observing quality of counselling session (Handout
6.7) protocol for contraception counselling (Handout 6.8)

I

i

Methodology

I

1.

Participants are divided into 3 groups

2.

Each group is asked to perform a role-play on the following situations

1

J

•

A man wanting his wife to get sterilised after two children

•

Unmarried girl coming for an MTP

•

Women wanting to change the method of contraception from oral pills to

Copper-T

I
3.

I

The groups are given protocols on contraception counselling so that they cover
all the relevant aspects in the role-play

V

4.

The groups perform the role-play demonstrating use of various counselling skills.

5.

Feedback is obtained from the larger group on the skills and content of the role
play using Handout 6.7

6.

Facilitator summarises

Session 8:

Woman Centred Counselling

Objectives

•

rI

Participants will be able to describe characteristics, process and outcome of

WCC

Resources

OHTs showing characteristics, process and outcome of WCC (OHT 6.10)

Time

1 hour

Methodology
Brainstorming, Presentation through OHTs

•

Facilitator asks participants to brainstorm on what they think is meant by WCC
and notes down their responses in three columns on the black board, (the columns

are not given headings although the facilitator categorises responses according

to characteristics, process and outcome. Facilitator relates his/her
OHT presentation to the responses listed on the blackboard.

•

Facilitator ends the session by emphasising that in subsequent modules on
counselling for Gynaecological Problems, Sexuality, Gender-based Violence

and Adolescent Health issues, the participants should be conscious of principles

of WCC.

69

I

Session 9:

Conducive Counselling Environment

The counsellor should make the environment such that privacy and confidentiality during the sessions

can be maintained, so that the client can talk freely without being interrupted and overheard by
anyone.

Learning Objectives

At the end of the session the participants will be able to
•

describe a good counselling environment, to maintain privacy and confidentiality
during counselling session.

Time

45 minutes to 1 hour

Resource
Flip Chart, Pens and pads to note down various settings in which counselling takes

place.

Methodology

1.

Divide the participants into 3-4 small groups.

2.

Let them discuss various locations and settings where counselling can take

place.

3.

Let the groups note down elements, which can be obstacles for counselling.

4.

Let the group reconvene again.

5.

Allow them to share the various locations and settings for counselling.

6.

Let participants focus on the negative elements in the counselling environment.

7.

After sharing and discussion let participants learn the importance of maintaining

privacy and confidentiality in a counselling session.
I

Points to Emphasise

•

i

It may not be possible to have an ideal counselling environment in an OPD

i

situation

i

One can talk softly to create verbal privacy in a crowded OPD

i

In a small room or where separate room is not available, visual privacy can be

l

created by putting a curtain

i

In a home visit situation, client could be taken away nearby if possible, or could

H

be asked to come to health centre

H

II

70

rb®

/b®

References for Communication

' COr™'*,“ °'

beh„i0„ : , men

. .
J Roler o Kal2rl. 1988.

MMIcacare 26.

2 lLr*",lngMan“,""A">™»-yNure.MiOwi„,

.
’ '"‘"Nation and Research into
- Wished by the Pub|lc Hea|th

partment of BMC, 1995
4.

KA8 Practices related to HIV/AIDS in four It>.

.

DasS., 1992, TISS)

arashtra, Chitale V and

References for CounseHing

1.
2.

3.

Train^nq M9 Sk'"S

Burnard Ph'Hp. Vivt

anual of Auxiliary Nurse Midwives io

ra,n,n9ReS°UrCe^^

;

• New Delhi

-^^■unication and Research
■ England.

Reference from Internet Sites

http7Zwww.google.com

I

I

-----------------------

71

HANDOUTS
Handout 6.1
Statements
1.

Unmarried people should not have access to contraception methods

2.

HIV positive people have sex with multiple partners.

2

It is all right to insist that poor families adopt family planning as they cannot afford large
families.

4.

Daughters should not be given freedom

5.

It is all right for boys to have sex before marriage.

6.

Clients do not comply with treatment because they do not value doctor's advice.

7.

Homosexuality is wrong

8.

Girls do not masturbate.

9.

Sex workers are responsible for spreading HIV

10. Girls should choose caring professions like teaching and nursing

11. Public health system should make special provision for caring for unwed mothers.

72

/b®

/b®

<b®

<b®

/b® c*d> <b®

<b®

Handout 6.2

Observation Checklist for

Monitoring One

Health Ed
1

-TO-ONE

ucation Session

Introduction

■ 2 D,d »>ecouns.«m„,rMdMherse,Wmse|r?
ePUWe«esess,on?

2

G..h.rt„gre,eva„t,acl8,|n(ormMOT

share her perceptions, ideas, concepts?
“d,'’“oo„sel,or,,tou„ers,and,hec|.i!i
-‘nt's concepts/ideas/perceptions?
'd the counsellor listen to the client’s
'deas, concepts, perceptions patiently?
2 4 D,d th® counsellor ndicule the client about
wrong’’ beliefs?

3

Giving information
3 2 Was X000"86"0'USS 'EC material t0 9,ve information?
Was the material used suitable?

-b,e aec,s,on.makmg g_?
4

Quality of information
41 Wasa"

information given?

4 2 lfnOt’What information was left out?
4 3 W^th® '^formation accurate?

4-4 h not, what was wrong?
5

Answering queries

sfle/tl® is no, s„re „ jn aoaM?

6

I™ »>. cones, e„STOr

She

ca„

Language

- o“

u ~—

“ « "»

„„ flfcl, wo,ds,

",4

““o.edicewecheiea,

■= O«tdecou„se„oruseEng(shws?

,e™’,e™s?
words?

73

6.6 If medical or English words were used, did the counsellor try to find out whether the client

understood the words?
6.7 Was the information organised and in logical order?

7

Ensuring that client understood the information
7.1 Did the counsellor ensure that the client understood the information given to her/him?

7.2 At the end of the session, did the counsellor summarise the issues discussed?

8

Time to absorb the information
8.1 Was the information given hurriedly?

8.2 Did the counsellor allow the client some time to think about her decision?

9

74

Was the interaction two-way ?

f

Handout 6.3
SWOT ANALYSIS
1)

I am good at

2)

Because I am a girl/boy

3)

The best thing that I like about myself

4)

The thing that I hate about myself

5)

I feel that I can not

6)

I feel that I can

7)

I feel very insecure when

8)

I feel very secure when

9)

1 can talk freely about

not do it, but I could do it if

10) I feel shy about

11) I could have achieved something if

Key-

1.2,3,8 denotes your Strength
2.4,5,10 denotes your Weakness

6,9.11 denotes your Opportunity

' denotes your Threat

75

Handout 6.4

Self-Awareness Questionnaire
Mark yourself on 100 for each question e.g. 50/100

Marks out of 100

1.

Self-acceptance (I like myself)

2.

Ability and presence of mind to speak the right thing

3.

Ability to express myself

4.

Competence on the job

5.

Enjoying meeting people

6.

Competence in managing my time

7.

Enjoying doing the work

8.

Engaged in continual self-development

9.

Knowing what is good for me and can assert myself

10. Remaining always cheerful

11. Enjoying being close to nature
12. Ability to create trust in others
13. Capacity to earn money
14. Capacity to imagine new possibilities and alternatives

15. Courage to change and form new habits
16. Self-reliance

17. Maintaining a healthy family relationship
18. Controlling my behaviour
19. Being in touch with my feelings

20. Self-confidence

21. Capacity to relax

76

rb®

Handout 6.5
QueST.ONNA.RE ON PERSONAL EfEECT.VENESS
Instructions

™^«’««eme„1,steo,y„

‘,e'“ aM
4:

3.

Mo« eharaae„s„c „ yo„ „
«1 r>» e( you.

you seem to be do.og lh.s qute ote„

2.

Somewhat characteristic of you

1:

N«Charaete.i„,oo,you.oryo„ao,o,sonlysome„mes

0.

,

a. o« oharaotensso of you. o, you seldom do this

Statements
1.

2.
3.

m

express my feelings to others
and s^ m exp.essmgmyop,nionsm

3 aarson even if Ibis may be unaoceplable to Idem

a group or

4.

5.
6.

7.
—yb8h_.

8.

9.

'fake steps to find how my behave ha
IS been perceived by the person
With whom I have been interacting

toyXoeu:“:Sm'',b“'h™’*-«™a«o 00.00.0.

"'^'“’'^b’ve.osayapou.mys.yto.bebavloureto
>.nd.osayth.„g8tha,turr,ou,tobeoutofp(aM

" “SWI regret say,„g some.h.ng tocdessiy., like ,o cheok

ootomuZZXZ "

“ '"a’ a"d

'\“X;rr“eSab“'"m-'e-»S.ndreadt,o„s.
eo vtoen, m „ote()

bored

’“'b^ “iS“- <- oe .oto) ,oat pe0p,9

put o„or

annoyed, atoen, .bougp. .be, ,ere

77

SCORING SHEET

QUESTIONS

YOURSCORE

REVERSAL

No. 1

YES

No. 2

YES

No. 3

NO

No. 4

YES

No. 5

NO

TOTAL SCORE FOR SELF DISCLOSURE (NO.s 1 TO 5)
No. 6

NO

No. 7

YES

No. 8

NO

No. 9

YES

No. 10

NO

TOTAL SCORE FOR FEEDBACK (NO.s 6 TO 10)

No. 11

YES

No. 12

YES

No. 13

NO

No. 14

NO

TOTAL SCORE FOR SENSITIVITY (NO.s 11 TO 15)

78

rb® /b®

/b®

f'b10

ACTUAL SCORE

Handout 6.6
The Johari Window

F'gure 1
Known to self
Not known to self

Quadrant 1

Known to others

Quadrant 2

Area of Free Activity

Blind area

(on top of table)
Not known to others
Quadrants

Quadrant 4

Avoided or hidden

Area of unknown

area (under the table)

activity

way of understanding the re|aBorah(p
«a<W.lp

8“TO 10

repre“""te^-»,nrela^
QUADRANT 1 _• is t^e beh

^anoneeos,,.

’

“ "’e

«ntea Jlh re

QUADRANT 2 The Blind

™5'S °I“'° "» self but hidden from
F°r example, a man

other people,

may want to

79

■Hill I III II

get a particular assignment from the boss in order to make himself look good as a result of carrying

out that assignment, but does not tell the boss what he wants nor does he go about getting the

assignment in an obvious way.
Another example is the person who knows well that he resents a remark made by an individual in a
meeting, but he keeps the resentment to himself. Or in a committee meeting a member may focus

attention on a particular project which he knows is embarrassing to one of the other members.

A convenient way of differentiation between Quadrant 1 and 3 is to think of Quadrant 1 as those things

which are on TOP OF THE TABLE and Quadrant 3 as those behaviours which are motivated by
issues UNDER THE TABLE.

<

QUADRANT 4: is the area of activity where behaviour and motivation are unknown to the individual or
to others. We know this quadrant exists because both the individual and persons with whom he is

associated discover from time to time new behaviour or new motives which were really there all along.
An individual may surprise himself and others, for example, by taking over the group’s direction during
a critical period; or another person may discover that he has great ability to bring two warring factions

together He never saw himself as the peacemaker before, nor did anyone else, but the fact is that
the potential for this sort of activity and the actual behaviour was there all the time.

Figure 2
Known to

Not known

self

to self

Known to others

I Free Activity

II Blind area

Not known to others

III Hidden

IV

I
I

Figure 2. Illustrates how a person looks when he is in a completely new situation or when he meets
a person for the first time. The area of open shared activity represented in Quadrant 1 is very small.

i

I

People tend to behave in a relatively superficial manner. Social convention provides a pattern of
i

getting acquainted and it is considered bad form to act too friendly too soon or to reveal too much.
l

This same constricted picture may by typical of some persons who have difficulty in relating to other
i

persons. An overly shy person may, for example, have difficulty in developing a large Quadrant 1 even
after much time with a group, or another individual, has elapsed. Sometimes an individual may hide

i

behind a flurry of words, but very little of him becomes known or available to others.
1

I

80

1

!

Figure 3

Known to self

I

Known to others

Not known to self

OPEN

BLIND

Not known to others

HIDDEN

UNKNOWN

•« quadrap, lte aoser „ se„
»““ and ,„„rests al lbe
"”'dtea“S,’te ^euow„kofa,arg

S“Sb*

2. 3 and 4 Th. larger ,he

J* ;

m ,te s’™« « he Is
bi8 „eMs
6»
-hem avaiaMe te omers „

lhe emphasis ,s on persona’,"."

qregarlonsnessand

Whether the relationship is between that of
°'
« fepartmenis. ,h. reiafesZ" 7“"

“a1'"'’' "'^work ompa, as we|| as
fi’-2p,»er„areenamaeasedhysuspiZ

.

M al’°

““'‘""‘“h "'«««»>««

demons,rated to resu!,

'"'—rxoa.pmand^slne,JZ77

mere

—suite

7-“-^^masma,QZ7 XZ
°u.rda„,, Ho^er. ,he enterg.men, e, Quad,an

—iship. This can he ,„USMM by ,he

™\ ’ a“s

“^>h« Under grea, tension a„d s.mss " teZ

akpenenclng tee same stress and tens,on

« te-'"»a»y te emerge
» heder and more produe.iue

X 'W’°

TO’S » »»sa »ho are

I

81

i
Handout 6.7
Checklist for Assessing Quality of Counselling
1.

Did the counsellor ask the client to take a seat? Was
the client seated?

2.

4. Do not

applicable

Did the counsellor explain what the client should
expect from the session?

3

1. Yes 2. No 3. Not

1. Yes 2. No 3. Not

4. Do not

applicable

Did the counsellor assure the client that the
discussion would be kept confidential and not shared

know

1 Yes 2 No 3 Not

know
4 Do not

applicable

know

with anyone else?

4.

Was the accompanying person politely asked to wait
outside if privacy was required?

5.

applicable

Did the counsellor enquire about client’s past
illnesses/treatment/investigations?

6.

1. Yes 2. No 3. Not
applicable

Did the counsellor listen to the client without
interrupting her/him?

7.

1. Yes 2. No 3. Not

1. Yes 2. No 3. Not
applicable

Did the counsellor listen attentively to the client?

1 Yes 2. No 3. Not
applicable

8.

Did the counsellor ensure that s/he understood

correctly what the client had to say?

9.

1. Yes 2. No 3. Not
applicable

Did the counsellor paraphrase what client had said?

1. Yes 2. No 3. Not
applicable

10. In case of discrepancies in the client’s narrative, did
the counsellor clarify them with the client?

1. Yes 2. No 3. Not
applicable

11. Did the counsellor answer the questions asked by
the client?

1. Yes 2. No 3. Not

applicable

12. Did the counsellor ask the client if s/he had any
questions?

1. Yes 2. No 3. Not
applicable

13. Did the client ask any questions?

1. Yes 2. No 3. Not

applicable

14. Did the client ask any questions related to sexual
relations?

1. Yes 2. No 3. Not
applicable

15. Did the counsellor answer questions asked by the
client regarding sexual relations?

1. Yes 2. No 3. Not
applicable

16. Did the counsellor give information regarding investiga 1. Yes 2. No 3. Not
tions prescribed, reason for doing the investigations,
where to get them done, and the costs involved?

82

rb® /b® /b®

/b®

/b®

applicable

4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know

1 Yes 2 No

3. Not

Do not

applicable
1 Yes 2. No

Mwwor the suw<t>ocea

Yes.

I9
I

3. Not

110 the client?

I 4. Do not

applicable I

'©si 2. No

I

know

3. Not

know

i' 4. Do not

applicable
1. Yes 2. No

----- to her/hfm?
21

3. Not

3. Not

22 “

125

know
j 1 4. Do not

applicable

tte si,Mon/coMj(ion

1 Yes 2 No

know

3. Not

I giving information?

4. Do not

applicable
the

---- T^nsellorprobe where required?

I

4. Do not

3. Not

23"

I

know

applicable

1. Yes 2 No

ougWRne„

4. Do not I

applicable
1. Yesl 2. No

1 Yes 2. No

3. Not

know

4 Do not

know

speaking to the client?

I 4. Do not

applicable
1. Yes 2 No

llemMons expressed by tbe chent?

'

y

(TN°

3. Not

3. Not

|28-

__ lthe cour|selling session?

appropriate times during

29

3. Not

c(jent?

3. Not

30. Did the cou^ltoT^^

client focus on the

[___ lmPortent issues at hand?

applicable

i. Yes> 2. No

3. Not

1- Yes 2. No

3. Not

1- Yes 2. No

3. Not

applicable
;

know j

know

I

know I
i 4. Do not I

_____ I
applica ble
know I
counsellor H. yesi 2 No 3 N~^t
i
I 4. Do not I
- ---------------------- -I
know I
,OI|O»-"P |t Yesfj No
applicable I
3. Not

|trie session?

know I
i 4. Do not!

I1 4. Do not I

applicable

'34. Did the counsellor tell the riior^
IgWterrequired, when, etc ?

I

I 4. Do not I

applicable
critical or judgmental?

know

4. Do not ]

applicable
1. Yes 2. No

know

4. Do not

applicable
1- Yes 2. No

know
i 4. Do not

applicable

1 Yes 2. No
—--------—I----------1|

3. Not
applicable

I

know
I

|' 4. Do not I
know I
| 4. Do not I
know

83

I

Handout 6.8
Protocol for MTP and Contraception Counselling

Name of the observer:

Client number:

Date:

Time:

For each question, please circle the appropriate option

1

2

4. Do not
Did the counsellor ask the date of the last menstrual 1. Yes 2. No 3. Not
know
applicable
period?
_____________
Did the counsellor take the history of number of children, 1. Yes 2. No 3. Not

pregnancies, abortions/MTPs?
3

___________

Did the counsellor discuss in detail the reasons for 1. Yes 2. No 3. Not
aborting present pregnancy?

4

____

applicable

Did the counsellor ask the client if she would like to 1. Yes 2. No 3. Not
invite the husband inside?

4.2

applicable

If the client knew about the methods of MTP, did the 1. Yes 2. No 3. Not
counsellor ask her to share the information?

5.2

applicable

Did the counsellor allow the client some time to think 1. Yes 2. No 3. Not
applicable

about her decision?

8.1

Did the counsellor ask the client if she wanted to go 1. Yes 2. No 3. Not
out of the centre to think and make a decision?

9

applicable

Did the counsellor then explain the risks associated 1. Yes 2. No 3. Not
with MTP?

8

applicable

After she gave this information, did the counsellor ask 1. Yes 2. No 3. Not

the client if she wanted an MTP?
7

applicable

If client did not have complete information, did the 1. Yes 2. No 3. Not
counsellor explain how MTP is done?

6

applicable

Did the counsellor ask the client if she knew how MTP 1. Yes 2. No 3. Not
was done?

5.1

applicable

Did the counsellor ask the husband to come inside if 1. Yes 2. No 3. Not
the client so wished ?

5

applicable

Did the counsellor ask if client’s husband has 1. Yes 2. No 3. Not

accompanied her?
4.1

applicable

applicable

Did the counsellor ask the client if she still wanted to 1. Yes 2. No 3. Not
have an MTP after she had reviewed all the information

applicable

4. Do not

know
4. Do not
know

4. Do not
know

4. Do not

i

know

l

4. Do not

I

know

4. Do not

i

know

I

4. Do not

I

know
4. Do not

know
4. Do not
know

4. Do not
know

4. Do not

know
4. Do not
know

4. Do not

know

given to her? ;
10.

Did the counsellor inform the client that at times MTP 1. Yes 2. No 3. Not

results in incofnplete evacuation of the contents of the

applicable

4. Do not
know

I

I

uterus?
rb® <5®

i
i

11.

Pregnancy immediately after the MTP? Dld th , 1 Ves 2. No

3. Not

4. Do notl

applicable,

12.

P ocess of conception?
12.1

1 Yes 2. No

3. Not

—-——L—.

4. Do not;

applicable,
r,
'd d he c°unseiiZZZzzPr^~
[ her the relevant information?
I1 ^2. No I 3? Not
j
13.

know

know ]
4 Do not]

Did the cou.

I applicable] know ]
used ar>y 1. Yes 2. No
I contraceptive/r-3. Not
^Pg£!n_g method in the past?
|4. Do not]
13.1
If the client had used
applicable,I know ]
eth°d' didtheC0unseii°Z Yes]
b2£2^9ehertodi'scu^Z
;
2. No 3. Not
j 4 Do notl
14.
] If the client didr—
applicable] know ]

1 Yes 2. No

15.

more children?
lfclient^nted more children, di^(

3. Not

i

(4 Do not]

applicable,

^COunseiio7gK^p~Y^

2 n° i

'Hformation about reversible/temp,
'orary contraceptives
below?

4. Do not]
applicable

]

about 1. Ye, 2. No
I 3. Not

3. Not

3. Not

applicable,
1- Yes 2. No

15'5 D“

]

I

1516F^°d^°^
] cannot?

—
---- 1

Se OCPs and who

se 0CPs, at least]

briefly?

rs-2 [Condom

3. Not

know j

Do not!
Do not]

applicable,

know I

1 Yes 2. No

3. Not

applicable;
1- Yes 2. No

know I

4. Do notl

3. Not

know /

4- Do notl

applicable]

counsellor addi

know I
Do notl

applicable]
1 Yes 2. No I 3. Not

[

LJ^^s or what she ha h
what she h.

know j
4. Do notl

applicable)
1. Yes 2. No

know I

4 Do notl

applicable,

L
1. Yes 2. No

know ]

know I

W ab°^- Ye,
2. No 13. Not
I

ess misconceptions if any?
1 Yes 2. No
use the condom 1- Yed 2. No

applicable]

3. Not
applicable;

4 Do not]
know I
4. Do not]

know I

3. Not

4. Do notl
^Pj^blelH^ I
1 Ye$ 2J^T3~n^
t
p. Do notl
----------------------------- 1_____ L applicable |i
know I

85

15.2.5

Did the counsellor explain the advantages of using 1 Yes 2. No 3. Not

applicable

condom?

15.2.6

Did the counsellor explain the disadvantages of 1. Yes 2. No 3. Not

condom use?
15.2.7

4. Do not

4. Do not

applicable

Did the counsellor explain how to use a condom?

(If 1. Yes 2. No 3. Not

male partner had accompanied the client, was he

know

know

4. Do not

applicable

know

called inside and explained about condom use?)

15.2.8 Did the counsellor demonstrate how to use condom? 1. Yes 2. No 3. Not

4. Do r.ot

applicable
15.3

Copper! (CuT)

15.3.1

D^id the counsellor ask the client what she knew or 1. Yes 2. No 3. Not

had heard about CuT?

15.3.2

4. Do not

applicable

Did the counsellor address misconceptions if any?

1. Yes 2. No 3. Not

Did the counsellor explain how the CuT functions as a 1. Yes 2. No 3. Not

contraceptive?
15.3.4

15.3.5

Did the counsellor tell the client when the CuT should 1. Yes 2. No 3. Not

1. Yes 2. No 3. Not

applicable
15.3.6

Did the counsellor discuss the disadvantages of CuT? 1. Yes 2. No 3. Not

applicable
15.3.7

Did the counsellor discuss which women should, and 1. Yes 2. No 3. Not
which women should not, use CuT?

15.3.8

applicable

Did the counsellor ask if the client had any symptoms 1. Yes 2. No 3. Not
of RTI?

15.3.9

applicable

If the client reported symptoms of RTI, did the 1. Yes 2. No 3. Not

counsellor advise her not to insert CuT immediately

applicable

know
4. Do not

applicable

Did the counsellor explain the advantages of CuT?

know
4. Do not

applicable

be inserted?

know
4. Do not

applicable

15.3.3

know

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know

and discuss about intercourse?
15.3.10 Did the counsellor demonstrate how the CuT is 1. Yes 2. No 3. Not

inserted?

16.

applicable

If the client did not want more children after MTP, did the 1. Yes 2. No 3. Not

counsellor give her information on permanent methods of

applicable

4. Do not
know

4. Do not
know

contraception as per the checklist given below?

16.1

Female Sterilisation

16.1.1

Did the counsellor ask the client if she knew or had 1. Yes 2. No 3. Not

heard anything about female sterilisation?

4. Do not

applicable know

16.1.2 Did the counsellor address misconceptions if any?

1. Yes 2. No 3. Not

4. Do not

applicable know

86

Zb®

rb0

/b0

16.1.3

Did the counsellor tell the client that this is a permanent 1. Yes 2. No 3. Not
method and the woman will not be able to conceive

applicable know

after this?
16.1.4

4 Do not

i

Did the counsellor explain reasons for inability to 1. Yes|2. Nd) 3. Not

4. Do not

conceive after sterilisation ?

applicable know
16.1.5 Did the counsellor tell the client when this surgery 1. Yes 2. Nd
3. Not
4. Do not

should be performed?

applicable know
16.1.6 Did the counsellor discuss the advantages of female 1 Yes
2. No 3. Not
4. Do not
sterilisation?
applicable know
16.1.7 Did the counsellor discuss the disadvantages of such
1. Yes 2. No 3. Not
4. Do not
sterilisation?
applicable know
16.1.8 Did the counsellor inform the woman about the 1. Yesl 2. No
3. Not
4. Do not
required length of stay at the hospital following
|
applicable know
surgery?

16.1.9 Did the counsellor tell the client about the duration of 1. Yes) 2. No

rest required to be taken after sterilisation surgery?

3. Not

4. Do not

applicable know

16.1.10 Did the counsellor explain the surgical procedure?

1 Yes 2. No 3. Not

4. Do not

applicable know
16.1.11 Did the counsellor tell the client where to go for the 1. Yes 2. No

3. Not

4. Do not

I surgery?

applicable know

16.1.1

Did the counsellor discuss the possibility of failure of 1

• Yes 2. No 3. Not

the surgery?

applicable know

16.2

Male sterilisation

16.2.1

Did the counsellor ask the client if she knew or had 1. Yes| 2. No

heard anything about male sterilisation?

yes 2. No

after this?

Did the counsellor explain the reasons for inability to

. Yes 2. No

conceive after the operation?

3. Not

. Ybs 2. No 3. Not

sterilisation?

applicable

16.2.6 Did the counsellor discuss disadvantages of male 1. Yes

2. No 3. Not

sterilisation?

applicable

16.2.7 Did the counsellor tell the client about the required

1. Yes 2. No

I ten9th of stay in the hospital after the surgery?

3. Not

applicable
16.2.8 Did the counsellor say anything about the number of days 7

I

I

4. Do not

know
4. Do not

applicable

16.2.5 I D’d the counsellor discuss the advantages of male 1

^Z1

know

applicable
3. Not
~

applicable

that the man will be required to rest after sterilisation?

4. Do not

1. Yes 2. No 3. Not

16.2.3 I Did the counsellor explain that this is a p------------permanent
method and the woman will not be able to conceive

I

3. Not

applicable

16.2.2 Did the counsellor address misconceptions if any?

16.2.4

4. Do not

. Yes 2. No 3. Not
applicable

know

4. Do not
know

4. Do not
know

4. Do not

know
4. Do not
know

4. Do not

know

87

(

I
16.2.9

Did the counsellor explain about when this surgery 1. Yes 2. No 3. Not
should be perforjned?

16.2.10 Did the counsellor explain surgical procedure?

applicable

1. Yes 2. No 3. Not

applicable
16.2.11 Did the counsellor discuss the possibility of failure of 1. Yes 2. No 3. Not

applicable

the surgery?

17.

Did the counsellor ask the client which of the 1. Yes 2. No 3. Not

aforementioned methods she wanted to adopt?
18.

applicable

If the client made a decision, did the counsellor explain 1. Yes 2. No 3. Not •
that it was important to inform the client’s husband

applicable

4. Do not

know
4. Do not

know
4. Do not

know
4. Do not
know

4. Do not
know

of this decision?
18.1

If the client agreed, did the counsellor give all the 1. Yes 2. No 3. Not
information to the client’s husband?

18.2

Did the counsellor start the discussion with male 1. Yes 2. No 3. Not
applicable

sterilisation?
18.3

Did the counsellor inform the client and her husband 1. Yes 2. No 3. Not

about temporary methods?
18.4

applicable

If no decision was taken, did the counsellor fix another 1. Yes 2. No 3. Not

appointment?
23.

applicable

Did the counsellor give the client/husband the date 1. Yes 2. No 3. Not
and tirrfe for admission?

22.

applicable

If required, did the counsellor give detailed information 1. Yes 2. No 3. Not

about the method selected by the couple?
21.2

applicable

Did the counsellor repeat the information for the 1. Yes 2. No 3. Not
method selected by the couple?

21.1

applicable

I Did the counsellor allow them time to think before 1. Yes 2. No 3. Not

making a decision?
21.

applicable

Did the counsellor ask the husband’s opinion on the 1. Yes 2. No 3. Not
method preferred by the client?

20.

applicable

Did the counsellor ask the husband which method 1. Yes 2. No 3. Not
they (the couple) would prefer?

19.1

applicable

Did the counsellor inform the client and her husband 1. Yes 2. No 3. Not
about permanent methods?

19.

applicable

applicable

Did the counsellor tell the client that she could refer 1. Yes 2. No 3. Not
other women to the counselling centre for information

applicable

4. Do not

know
4. Do not

know
4. Do not
know

4. Do not
know

4. Do not
know

4. Do not
know

4. Do not
know

4. Do not

know
4. Do not

know
4. Do not
know

4. Do not
know

4. Do not

know

on contraception and other reproductive conditions?
24.

Did the counsellor smile at the end of the session? 1. Yes 2. No 3. Not
applicable

t
88

rb®

4. Do not

know

I
I

OVER-HEAD TRANSPERENCIES

OHT 6.1

OHT 6.3

Two Way Communication

Process of
Behavioural Change

Channel
Sender

!

Receiver

and

drivers knew about use of condoms.

Medium
Information

Information

Views

i

Views

*

Emotions

i

“A study revealed that 10% of the truck

However only 1% of them actually

used condoms."
Source: T/6S Study

Emotions

i

Unaware

i

Interpersonal communication is face to face, verbal and
non verbal exchange of information, feelings, between two

Aware

or more people.

Motivation

I

OHT 6.2

I

Non-verbal and Verbal

I

Communication skills

I

Non-verbal Communication Skills

•

Eye contact

•

Facial Expression

•

Body language

•

Physical distance between the counsellor

I
I

i

Concerned

Change

I
Sustain Change

The process of behavioural
change

and the client
•

Active listening and observation

•

Appropriate use of smile

OHT 6.4
Effect of Tone and
Emphasis on Words

Verbal Communication Skills
Allowing the client to complete the sentence without

"Maro, mat chhodor

interrupting

(“Kill, do not forgive’”)

•

Use of encouragers

uMaro mat, chhodo?

•

Use of voice

(“Kill not, forgive’”)

•

Quality of information given to the client

“Woman without her man is nothing"

•

f

“Woman: without her, man is nothing”.
uKam se kam chot lager

________________________________ I
89

OHT 6.5

Principles of Communication for Behavioural Change
•

Mere information and awareness does not lead to behavioural change

•

Prejudices and biases about a person or group of people affects our behaviour
with them. It could be a barrier to change

•

It is difficult to change people overnight. Changing perceptions and attitudes is

not easy and is a long process

•

It is important to present technical knowledge in an organized and logical manner
for better recall from the clients

•

Emphasis on certain words in communication changes their meaning. It is
important to pause and emphasise certain words to convey the right meaning

OHT 6.6

i

Using Appropriate Media
You remember 20% You remember 40% You remember 80% of
of what you hear
of what you see
what you hear and see
1. Conversations
1. Posters
1. Video
2. Dialogues
2. Leaflets
2. Cinema

3.
4.
5.

Lectures
Debates/
Discussions
Story telling

3.
4.

Pamphlets
Books

5.

Exhibitions

3.

Flash cards

4.

Stories based on
Flanellogram

5.
6.

Puppet shows

You remember 90% of

what you hear, see and do :

1.

Demonstration

2.

Role Play

3.

Games and exercises
L

Street plays

k

90

/b®

Oi^> /b®

°'o>

°<r» r^o

rb® °<>>

OHT 6.7

The Johari Window
Figure 1

Known to others

Known

Not known

to self

to self

Quadrant 1

Quadrant 2

Area of Free Activity

Blind area

(On top of Table)

Not known to others

Quadrants

Quadrant 4

Avoided or hidden

Area of unknown

area (Under the table)

activity

Figure 2
Known to

Not known

self

to self

Known to others

I Free Activity

II Blind area

Not known to others

III Hidden

IV

L

Figure 3

Known to others

Known to

Not known

self

to self

OPEN

BLIND

HIDDEN

UNKNOWN

■

Not known to others

■

■

OHT 6.8

Errors In Counselling
•l Directing

•

Giving false reassurance

•

Breaking confidentiality

•i Labelling

•

Denying client’s feelings

•

Interrogating

•

Encouraging dependence

Moralising, Preaching

91
■

v ?.

c

i

t

OHT 6.9

Micro and Macro skills

i

Micro Skills

i

Clarification
Use questions such as “Did you say---------------“According to you —
ensure that the counsellor has understood the client’s message correctly

•?\“ Was it-” to
i

Asking open-ended and probing questions
"Couldyou tell me in detail what happened?"," Could you elaborate?" encourage clients to share
more information.

•

i
i

Empathy
Ability to see and feel the world from the perspective of another person while remaining objective.

i

Reassurance
Reassure the client by saying “ Don't lose hope" or “Don't worry, things will change for the
better” or “Have faith, things should be fine”

I

i

i

Summarising
Ensure that the counsellor has understood correctly. List all the important and main points of the
discussion.

Recapitulating
To find out if the information has been understood by the client. To gauge if the client is attentively
listening to the information.

Macro Skills
• Paraphrasing of content
Client
I know I shouldn’t be so hard on myself. But I can't seem to stop blaming myself..
Counsellor :
You are aware that being critical of yourself isn't helpful, even though you haven’t
found a way to give it up
• Reflection of Feeling
Client
I feel very agitated about how my husband is treating me and I really don’t know how
to change him.
Counsellor :
You seem to be very angry with your husband because of his behaviour. You also seem
to be worried about him.
• Appropriate use of silence
Client
How could this happen to me? What have I done to deserve this? (begins to cry)
(looking down)
Counsellor :
(softly after 10 to 15 seconds) Would you like to talk about this?
• Focusing
Client
I went to my native place and my uncle died. He was very fond of my daughter. He left
his land in my daughter’s name. So I was busy getting the paper work done. I am
going iagain next month. We have a big house in the gaon.
Counsellor :
Okay, how, shall we come back to your daughter’s health? I think you want to discuss that.
•

Confrontation

Client
Counsellor :

92

/b*5

|

No odie in my office likes me, there’s no one I can talk to...
Now that’s an exaggeration, surely
I

i

I
■I

i

i

I
I
I

OHT 6.10

I

What is Woman Centred Counselling?

i

Values and Ethics in Woman Centred Counselling

I

Woman Centred Counselling

i

•

believes that women’s problems are not a result of personal inadequacies, but created by unjust
and oppressive social structures.

•

does not encourage women to adjust to their situation, women are challenged to become aware
of their rights.

•

advocates changes in society's institutions and structures to allow equattreatment and opportunity
for both men and women. Change has to take place in all the units of the society. Involving the
community is an important aspect.

•

is combined with improving self-esteem, challenging personal internalised values and gender
identities towards a process of self-realisation and self-discovery.

•

challenges male expectations which are based on traditional role models and stereotypes of

I
I

I

I
I
I
I

women by introducing counterculture and different ways of looking at these stereotypes.

•

gives value to the woman’s own self (her way of thinking and analysis, feelings) which reveals
the inner resources that she possesses.

•

assumes women’s right to self-determination and control over their own lives.

•

asserts every woman's right to be an active participant in her own healing, where she makes her
own decisions.

•

validates a woman’s right to her feelings, decisions and intelligence - and also validates her
experiences

The process of woman centred counselling

•
•
•

challenges the subordinate status of the woman in her family and inspires confidence. (Usually

women have the experience of being silenced by their families.)
helps the woman to break her oppressive support system in life-threatening situations.
helps women to identify negative responses that break communication and gives practical

suggestions to improve their communication.

Results of woman centred counselling

•

Attempts conscientisation of women to oppose oppression in their daily lives and to dialogue
around their own women’s issues.

•

The women, whose perception of their individuality is raised, start asking questions about being
battered and realise that they need not have suffered so.

•

Information regarding the support system is also shared. These activities make women active

•

participants, they form groups and act as pressure groups and help other women in the community.
This facilitates women to overcome isolation and also to relocate themselves in different

•
•
•

relationships, besides the family and community relationships.
WCC increases women’s vocabulary to define their own experiences. It provides them objectivity
about their own lives.
Women are empowered with knowledge, skills and are also helped in changing their attitude.
The acquired knowledge helps women review the entire situation and tp take informed decisions.

93

annexures
Annexure 6.1

Role play for Non-Verbal and Verbal Skills

Non-verbal Skills
Facilitator explains that 70% of our communication is non-verbal hence its importance.
Each of the non-verbal skills are then enacted through short role plays, episodes
demonstrating appropriate and inappropriate ways of counsellors behaviour. After
each episode facilitator draws attention of the participants, to the bahaviour and

feelings of the client in response to the counsellor's appropriate or inappropriate
behaviour..

Episode 1 (a) No eye contact
Woman:

Madam, I want to clean my thalli (I want MTP)

Counsellor:

(Does not look-up and starts asking questions and writing on the paper without looking

at the patient) What is your name? (patient answers and the counsellor writes down

on a form) What is your age? How many children you have? (Patient answers all the
questions and counsellor writes them down) Ok tell me what you want ?

Woman:

You know what happened actually —(expects counsellor to look up) the condom

tore and I thought my period is irregular so —(seeing that the counsellor is not

acknowledging the woman feels uncomfortable and dissatisfied and stops talking)
Counsellor:

Go on — I am listening (...still looking at the paper)

Woman:

So actually madam I want to------(stops talking and says to herself: ‘what is this,

I have come to talk about my problem and she is not even listening to me’).

Facilitator’s Note :
We saw that since the counsellor was not making any eye contact the woman feels

discouraged and stops talking. She feels rejected, not listened to which can result in
anger or sadness and obstructs communication completely.

Episode 1 (b) Staring at the patient
Above episode is repeated with the counsellor staring at the woman while

talking. This makes the woman feel uncomfortable and she starts looking

scared and avoids the eye contact.

Episode 1 (c) Proper Eye contact
Same episode is repeated with proper eye contact. Counsellor maintains proper
balance between keeping eye contact and writing on the paper. The woman is able

to share her problem without hesitation and looks at ease and satisfied by the attention

I

given by the counsellor.
*

94

XT*

xfv

XT*

Episode 2 (a) Facial Expression

Counsellor:

Yes, please come in, have a seat - what do you want?

Woman:

You know what - actually I missed my period - and -

Counsellor:

Are you pregnant?

Woman:

Yes, I think so but - this child is -1 mean my lover - lover’s child , I am not married
to him.

What? (exclaims shockingly) You are not married and pregnant? Lover’s child?

Counsellor:

(the expression is like the woman has done something terrible and she should be

ashamed of it).
Woman:

I

Looks scared and ashamed (says to herself: ‘oh! I should not have told her the truth,

now I don’t know how they are going to treat me’).

Episode 2 (b)

Same episode is repeated with the counsellor showing concern and does not show
an expression of shock, but tries to ask questions and clarify the situation so that

woman could be further guided.

Woman.

You know what - actually I missed my period - and -

Counsellor:

Are you pregnant?

Woman:

Yes, I think so but - this child is -1 mean my lover - lover’s child, I am not married to

him.

Counsellor:

When did you get your last period?

Woman:

Almost 2 months before.

Counsellor:

Ok, has your lover come with you?

Woman:

No, I have come alone.

Counsellor:

Are you thinking of marrying him?

Woman:

No, actually he ditched me and ran away.

Counsellor:

Ok, see first of all we need to check whether you are really pregnant.

Woman:

But I don’t want this child, I want MTR

Counsellor:

Ok , first let’s check whether you are pregnant and how many weeks. Don’t worry

depending on that doctor will decide whether it is safe to do MTP and how to do it.
Don’t worry, we will try to help you out.

Woman:

Ok.

Counsellor:

So, first you go for urine test. Doctor and sister will guide you for that. Then you can
come back to me and we will discuss what would be the next step. Ok.

Woman:

i

(Smiles) Thank You.

95

Episode 3 (a) Body language

Counsellor:

(The counsellor is sitting very casually, in a too relaxed position, leaning backyard

on a chair with her feet on a stool. She does not change her sitting position even
after client enters the room and says) Yes, sit down.

What do you want?
Woman:

I am having this heavy bleeding after the MTP. That day I went home from the hospital
I was all right but next day suddenly there was bleeding. 1 thought it will reduce but

- (woman realises that counsellor is not showing any interest) - madam it is too

much today.
Counsellor:

Ha. Ha. bolo main sun rahi boon, (ye^ go on, I am listening to you).

Facilitator’s Note:

Such a relaxed posture of a counsellor does not show that the counsellor is listening.
Such body language shows a careless and casual attitude, and the woman may feel

dejected and lose trust in the counsellor.

As opposed to this a too tense posture also does not help in reaching out to the
patient. Let's us see how counsellor’s tense body position affects the counselling
situation.

Episode 3 (b) Tense body position

The above episode is repeated with the counsellor showing anxiety by moving in the

chair too often, fidgeting with the hands and looking tense and restless.

Woman:

Repeats the same problem as above and then when she sees the counsellor's

restlessness also gets anxious and looks more tense.

Facilitator’s Note:

So now we will see what body position is more appropriate to make the client feel
comfortable during a counselling session.

Episode 3 (c)- Relaxed and attentive body position
The above episode is repeated with the counsellor changing her position from too

relaxed to the attentive position when she sees the client entering the room. Counsellor
puts her feet down from the table, moves the chair closer to the table and leans a bit

forward with her hands folded with elbows on the side of the table, or on the table.
Woman repeats the same problem as in episode 3(a) but this time is more relaxed
and is better able to articulate her problem.

96

Facilitator's Note:
We saw how the counsellor is leaning forward to relax the body and be more attentive
to the client. (During this commentary the counsellor in the role play suddenly pulls

her chair very close to the client’s chair and the client suddenly gets alarmed and pulls
her chair backward away from the counsellor).

Episode 4 (a) Distance

Counsellor:

(sitting very close to the woman) Yes tell me, what is your name?

Woman:

(The woman again moves her chair away from the counsellor and answers the question).

Counsellor:

Tell me what happened (again pulls her chair closer to the woman’s chair)

Woman:

(Fumbles while talking and moves away again).

1
I

Episode 4 (b) Distance

Facilitator:

Interrupts the above role play and asks the counsellor to pull his chair away from the
woman’s chair and points out that the woman is not feeling comfortable.

Counsellor:

(Pulls her chair away to a distance of more than 4 feet from the woman’s chair and
asks in a loud voice) How are you feeling ? What do you want today?

Woman:

(Woman looks awkward and answers in a low voice) I am okay.

Facilitator’s Note:
What we just now saw is that the client may experience pressure, fear or tension, if

the distance is less than 2 feet or more than 4 feet. So what is the right distance
between a counsellor and a client?

Episode 4(c) The right Distance

Counsellor and the client in the role play hold a measuring tape between them and
adjust their chairs at a distance of 3 feet.

Facilitator’s Note:

This is the right distance. Client finds it easier to talk openly, if the distance between
the client and the counsellor is three to four feet.

Episode 5 (a)

Attentiveness

Counsellor:

(Scratching her head) Okay tel! me what happened to your second child?

Client:

Actually when I was pregnant second time I was not well—doctors advised bed-rest,

Counsellor:

(opens the drawer of the table and starts searching for something and inbetween is

nodding her head)
/b®/b®

97

Then I fell down and the child d.ed-.n the abdomen (Just then counsellor's cell

Client.

phone.rings and she attends to it. It is a casual phone call from a friend)
(after attending tp the call, asks the same question again) Okay so what happened

Counsellor:

to your second child, you said?
It died - (and starts looking down and is annoyed actually to repeat the hurtful episode

Client:

again Just then a colleague walks in and asks the counsellor whether she is busy).
Oh, Hi'J No, no, please come „i. (Friend sits in the other chair in the room).

Counsellor:

Did you see that last night episooe of 'Ghar ghar ki kahani ? Such a sad thing.

Friend:

I know it was really sad. I almost cried. So what else is happening’’

Counsellor:

(She looks really sad. frustrated, annoyed and tries to get up saying) I will come

Client:

later and walks out.

Facilitator’s Note:
Counsellor's insensitivity and unattentiveness made the client walk away from the

counselling session. Do you think she will like to talk about her problems to this

counsellor next time? Certainly not.

Episode 5^b)
Same episode is repeated, but the counsellor is listening very carefully to the client.
When her cell phone rings she checks it, puts it off and apologises to the client and
starts listening carefully. Also, when the friend walks in the counsellor tells her that

she is busy right now and if there is nothing urgent, promises to visit her in the lunch
time When the friends goes away again repeats what the client was saying and

asks her to continue. Client feels encouraged to talk more.

Episode 6 (a) Inappropriate use of smile
Counsellor:

Yes, Usha tai, Please sit. How are you feeling today? (Counsellor smiles and asks

her to sit).
Client:

I am okay but look at my legs, so much swelling is there.

Counsellor:

(Keeps smiling and looks at her leg. Yes, there is swelling).

Client:

Yesterday I went to the market, slipped and fell down. Could not get up.

Counsellor:

Oh really? (Smiles again).

Client:

I was really in pain. I only know how I managed to come to the hospital.

Counsellor:

(Smiling). I know it must be paining.

Client:

I am really telling the truth. You don’t believe me.

Facilitator’s Note:

Smiling continuously or inappropriately could be interpreted as a negative response
V ancbcan discourage the client from sharing.

98

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Episode 6 (b) Appropriate use of smileCounsellor:

(Welcomes patient with a sm le) Please come Usha tai. How are you feeling today?

Client:

I am very happy today. I got a granddaughter. My daughter delivered yesterday.

Counsellor:

Oh I am happy to hear that. Congratulations. What brings you to the hospital.

Client:

But see what happened to rriy legs. Fell down in the market

Counsellor:

Oh’! Must be hurting. Lot of swelling.

Client:

Yes.

Counsellor:

Did you show it to the doctor?

Client:

Yes I did.

h

Counsellor:

That is good. I know you are very prompt in seeking treatment. Isn’t it ? (smiles)

Client:

Actually I came to ask you about my daughter’s problem.

Counsellor:

Ok. Tell me.

I

Facilitator’s Note:

Clients feels encouraged to talk, if the counsellor smiles and nods while responding
to the client.

Verbal Skills
This forms 30% of our communication. Verbal skills can be used effectively along
with non-verbal skills

Episode 1 (a) Allowing the client to complete the sentence
Counsellor:

How many children do you have?

Client:

During Ganapati festival I went to my native place. And I had my third delivery. During

that delivery.
Counsellor:

We will talk about that later. First tell me how many children do you have.

Client:

Three - no two -1 was telling you the same thing - when I went to -

Counsellor:

Two or three?

Client:

Three.

Episode 1 (b) Allowing the client to complete the sentence

Counsellor:

How many children do you have?

Client:

During Ganapati festival I went to my native place. And I had my third delivery. During
that delivery my second child met with an accident. So now I have two children. But

actually I had three.

Counsellor:

Oh - When was that?

Client:

Almost five years now. God’s wish -

Counsellor:

(Waits for some time) Ok. So you have two children now.

Client:

Yes.

Episode 1 (b) Allowing the client to complete the sentence

Same episode is repeated but now the woman keeps talking atjout irrelevant things

during her visit to the native place.
Counsellor

How many chidren do you have?

Woman:

Who kya hua na,? I went to native place. My native place is very beautiful. I met

that ganga mausi there What she started telling me, that your husband is in the

city he must be having an affair. I got very tensed. So then I started coming here

every year, in that i got two more children. I got so fed up. My husband says not to

use anything. So every year I had delivery. Last child diedin the abdomen. Then
my husband agreed for operation. Now I stay in the native place. I do farming. All
my relatives are there. What is there in the city? But my husband does not
r

understand.

Counsellor:

One minute Usha, I understood that you like to stay in the village. We will talk more

about that later. But can you tell me how many children you have.
Woman:

Total four and one died.

Facilitator’s Note:

If the client is wandering away from the subject it is necessary to intervene politely
and direct the conversation back to the topic.

Episode 2 (a) Use of verbal encouragers

Client:

You know what - actually I missed my period - and -

Counsellor:

Are you pregnant?

Woman:

Yes, I think so but - this child is - (client keeps silence)

Counsellor:

(Keeps quiet for some time) Ha Bolo.

Client:

I mean my lover - lover’s child, I am not married to him.

Counsellor:

Uh - Uh-

Woman:

Actually he ditched me and ran away. I was in love with him. We were together for 4

years, (keeps silence again).

.z

Counsellor:

After a pause. Then what happened?

Woman:

Then he started suspecting my character. Now he says this is not my child.

I don’t want to see his face again. I just don't want this child, I want MTP
Counsellor:

100

You must be feeling terrible.

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Episode 3 (a) Appropriate Use of Voice and Tone

Counsellor:

(To a pregnant wom^n) - Achha, Gauri, tell me how are you feeling? Are you eating

well? And are you going for regular check-up? It’s 6 months right?
Client:

Yes didi!! I am being very careful this time. You know what happened last time. Till end
everything was okay and suddenly I had that pain and bleeding. I lost my child.

Counsellor:

(In a soft voice) I know Gauri. It must have been really hard for you. But remember

you did not register till the last month. That is the reason I keep asking you about

your health check-up. You don’t lose hope. Does it help you to think of the past?
Then why think.

Client:

Didi, I hope every thing goes well this time.

Counsellor:

Just keep visiting the doctor and take care of your health.

Client:

Ok.

Episode 3 (b) Appropriate Use of Voice and Tone

Client:

Didi!! My husband agreed for vasectomy. He said if you are having so many problems
then I will go for it. I never thought he will agree. I told you he cares for me.

Counsellor:

(Ina happy and loud tone) Wah! That’s great!! I am really happy for both of you. Good
you talked to him openly.

Client:

So when can I bring him? He has some questions.

Counsellor:

Anytime between 9.00 to 5.00. You can bring him right now or any time convenient to
him. I will be happy to clarify his doubts.

Episode 4 (a) Quality of information given to the client

Client:

I hope I won’t have any problems with the Cu-T?

Counsellor:

Not at all. I have advised so many women. No one has problems. I have never heard
anyone having any problem with the Cu-T. Why worry? I am sure you won’t have any

problem. Otherwise why would I tell you to use it?

Episode 4 (b) Quality bf information given to the client
Client:

I hope I won’t have any problems with the Cu-T.

Counsellor:

Some women experience problems with Cu-T and some don’t. I know many women

who are very comfortable with the use of Cu-T. But there are few women who might

get menstrual problems like heavy bleeding or irregular period. Many a times these
problems are temporary and disappear after 3-4 months after insertion. So you have

to wait and see if you get any problems. If you don’t then you have protection for 3
years. The follow-up after insertion is very important. You have to come for check up

Tw" IS'o
10605

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after one month and then ever y six months. And whenever you feel discomfort

But unless you try how will you know whether you have problems or not.

Client.

Can I remove the copper-T if I have problems?

Counsellor:

Yes. if your problem persists more than four months you can come and discuss it

with me. But as I told you follow-up is very important. If ycju experience menstrual
problems, white discharge, pain in abdomen or miss your period you should
immediately report to the clinic for check-up.
Client:

Maybe I should try it.

Facilitator’s Note:

It is important to give the woman correct technical information rather than giving

incomplete and faulty information. The woman otherwise will get information from her
friends, relatives and neighbours and may form misconceptions about a method
based on other people’s experiences. She may not trust the health worker and that
can affect her contraception decisions.

Episode 5 (a) Avoiding Technical Language
Client.

I am married for two years and I don’t have a child. My husband travels a lot.

Counsellor:

(Explains in Hindi using a lot of technical English words) - Dekho main aapko batati
boon ke bach ha kaisa rahta hai. Dekho Aurat ke ‘body' mem yeh bachhedani rehta
hai. (Shows a picture) Yeh hai ‘ovaries'. Is mein bahoot saare ‘ovum’ rehte hai.
Harek Mahina is ‘ovary’ se ek anda bahar padta hai. Phir who fallopian tube mein
aata hai. Jise hum Ovulation bolte hai. Yeh ovulation ka time mahina aane bad 12-14
din me hota hai - Samza. To ab batau bachha rehne ka chance kabhi hota hai?

Client:

Mujhe kya pata? Main to aapke jaise padhi likhi naho boon Aaap hi batao

Facilitator’s Note:
Using language familiar to the client is an important aspect of verbal communication.

It is necessary to consciously avoid using technical words. To simplify the technical

information for clients is the most challenging task of a counsellor working in a

health setting.

i
102

Annexure 6.2

Role play ■ Errors in Counselling
The facilitators perform the following role play and at the end of it ask the participants
to list down the errors in counselling.

Roles

Dialogues

Errors

Counsellor:

Tell me how many children do you have?

Client:

One and now I am pregnant again.

Counsellor:

Don't lie. Only one child!! You are lying!!Tell me the truth. (Ek hee Interrogating
bach ha? Jbooth bol rahi ho kya)?

Client:

(Scared) Why will I lie?

Counsellor:

I know you people very well? You are from ‘’ community. You Labelling

are liars. First of all you come to the city and then want to keep on
producing more children. Do you have any brains?
Client:

What could I do? I conceived by mistake. (Kya karu? Reh gaya galti se).

Counsellor:

Why did you not use anything (contraception)? (Pehle kuchh waapra Moralising
kyun nahi).

Client:

I am thinking of going forMTP. (Abhisoch rahi boon saafkardoo).

Counsellor:

What do you think MTP is? Very simple?.. You should have thought Moralising

earlier. You people don’t have any other work so does not mean you

go on producing children (Aapko kya lagta hai? Saaf karna itna

aasaan hai? Pehlehisochna chahiye tha na? Aaap logon ko kuchh
kaam nahi hota to bachhe piada karneka hai na)?

Client:

(Feels very helpless) Then you tell me what to do. (To aap hi batao
mein kya karu)?

Counsellor:

If you have only one child, continue with this pregnancy. (Agar aapko Directing
ek hi bachha hai to isko kyun ko saaf karna hai? Rakh Io yeh bachha).

i

Client:

(lekin....)But...

Counsellor:

I am telling you , so you better listen. Why have you come to me Directing
otherwise? (Main bol rahi boon na - agar aapko nahi sun na hai to
aap aate kyun hai hamare paas).

Client;

But my first child is very young. (Lekin mera pehla bachha bahotchhota hai).

Counsellor:

Okay then you insert Cu-t after the MTP. (To phiryeh saafkarke Cu- Directing

T laga Io).____________________________________________
Client:

I am very scared of Cu-T (Cu-Tse to mereko bahoot darlagta hai).

Counsellor:

All this is fuss. There is nothing to get scared of Cu-T (Yeh sab tumhara Denying

j

naatak hai. Chhodo yeh Sab bakwas aur kaamki baat karo).

r1

Feelings

Roles

Client:

Dialogues

Errors

But I am really scared (Lekin . mujhe sach much dar lagata hai).
(Just then another woman walks in and she knows the client so she

comes in and says hi to the client).

Counsellor:

Oh! So you know her? (To aap ise jaante hai)?

Other

Yes, she is my neighbour.

woman:

Counsellor:

Oh! So you must be knowing how many children she has. Tell me

the truth. (To aap jaanti hongi ki inko kitne bachhe hai? Aap sahi

batao).

Other

She has only one baby. She breast feeds her. (Iska to ek hi baccha

woman.

hai - doodh peeta hai na ?)

Counsellor:

And you see she already conceived another and now she wants

Breaking

MTP (Aursuno isko doosra bhi reh gaya - Aaye hai saafkarwaane).

Confiden

tiality
Other

What you are getting MTP done? You want to kill the foetus? (Kya?

woman:

thailisaaf karegi, doosre bachhe ko kya maar dogi)?

Counsellor:

Ok you please wait outside. (Achha abhi aap bahar baitho).
To mein kya bol rahi thi (directing to the client). Ok what I was

False

saying is that the Cu-t does not harm in anyway. I have not heard any

Reassurance

woman complaining. You will not have any problems. It is the best
method.

(Cu-T se koi takleef nahi hoti hai. Mein ne aaj tak nahi

suna ki kisiko cu-T se takleef hoti hai. Aap ko bhi nahi hogi - hum
kyun yeha baithe hai).

Client:

Is there any risk in MTP? What if something happens to me - My
husband may not agree at all (Thaili safaa karne mein kuchh dhoka
to nahi.. .Agar kuchh ho gaya to, Aadmi bhe nahi maanega.)

Counsellor:

That all you leave it to me. If anything happens come and tell me.

Encouraging

What am I here for? (Who sab turn mujhparchhod do - kuch ho gaya

dependency

to mere paas aane ka. Mein boon na). MTP is a safe procedure. Nothing

will happen. Tell the doctor that you want MTP with Cu-T. Hurry up

now. (Kuchh nahi hota thaili saaf karne mein, doctor ke paas jaake
bolo mujhe thaili saaf karke Cu-Tlagwaani hai karke. Chalo jaldi).

Client:

I
104

Okay (Thhik hai) (Client walks out with a long face).

Annexure 6.3
Role Play on Verbal, Nonverbal Macro and Micro skills
You are encouraged to adapt the following role play to suit your own context. Divide participants

into four small groups. Ask each group to identify and note down one of the following:

•

Non verbal communication
Verbal communication
Macro skills
Micro skills

Devi is referred to you for counselling by a doctor. Client Devi is 23 years old and has a 10-month old
baby boy. She has amenorrhoea since six weeks and wants an MTP, after which does not want a

Copper-T inserted, as she is scared.
Client :

Can I come in please?

Counsellor:

(Gets up, takes the client in —> greets with a smile and says) Yes, please come in,
have a seat. (Counsellor shuts the door)

Counsellor:

What is your name? (Attentiveness throughout session)

Client:

My name is Devi.

Counsellor :

Devi, My name is. What brought you to the hospital today? (Counsellor
leans forward and looks concerned (facial expression), while also maintaining eye

contact) (Body language and eye contact)

Client:

I don't want this child.

Counsellor :

When was the last menstrual period? ? (Counsellor also refers to case paper)

Client:

I think it was a month or a month and half.

Counsellor:

Can you please tell me the exact date? Was there any festival close to the date?

Client:

I think it was around Diwali

Counsellor:

Diwali was last month, so may be a month and half.

Devi, you said you don’t want this child—what is the problem?
Client:

I have another child who is 10 months old, and I don't want another so soon.

Counsellor:

Do you know how a bag is cleaned? (How MTP is done?)

Client:

Yes, by taking an injection and some tablets.

Counsellor:

(Removes uterine model) Ok Devi. I will now explain to you how a child is conceived.
(Demonstrates on the model). This is a Uterus. During intercourse the male penis

enters till here, and when the semen comes out of the penis, it contains the sperms.
These sperms travel towards the fallopian tubes. This is where the ovaries are. The

female egg (Ovum) comes out of the ovaries and comes in the tube. Is that clear? If
not, please ask me.

Client:

I understand.

105

Counsellor:

When the ovum and the sperm meet they come to th$ womb, attach themselves to
the wall of the uterus and start growing. Every da^l their link with the wall gets

stronger. As time passes the link becomes stronger and the embryo grows Is that

clear? If you have not understood anything till now you can say so. Since the embryo
has attached itself so strongly it is difficult to remove it using tablets and injections.

Some blood clots may come out and the rest may remain inside. As p result you
may experience abdominal pain and bleeding. And the part of the embryc may still

remain inside. Finally it may have to be removed in a hospital

I just told you how

a MTP is done, do you want to ask any questions on this' subject?

Client:

No, I understood.

Counsellor:

Ok, can you tell me what did you understand? So that if required I can explain it to
you again.

Client:

Yes, when the sperm and ovum meet and attach themselves in the uterus they hold
the walls very strongly and may not come off using tablets and injections. Then it is

required to come to the hospital to clean the uterus.
Counsellor:

Yes, Devi, that’s absolutely right. Now that you have understood how the uterus is

cleaned and the risks involved do you still want to go ahead with your decision to
clean the bag or do you want to continue with the pregnancy.

Client:

No, I understand there could be a problem but I don’t want the second child so
soon, I am unable to look after two children.

Counsellor:

Ok, Devi.

Client:

So will they clean my thaili today itself?

Counsellor:

First you will have to do your blood and urine test, depending on your reports of the
tests, doctor will further advise you about MTP.

Client:

All this will take very long I suppose. Why do I need to go through all these
investigations?

Counsellor:

Your blood report will tell us about your Hb and if it is low then MTP can cause

further weakness. Through Urine test we will know if there is any infection. If so
doctor will first treat the infection and only then you can undergo MTP. If you have

any more doubts you can ask me.

Client:

Do I have to be admitted in the hospital?

Counsellor:

Not right now. After seeing your reports doctor will give you a date for admission.
You have to come on the previous evening and get admitted. Next day doctor will do

MTP and then after you regain consciousness and if you have no other problems
you can go home the same evening.

Client:

Will it be painful?

Counsellor:

You will be given an injection for making you unconscious, so you will not feel the
pain during the operation. But after regaining consciousness you may experience

some pain and weakness. You will be given medicines to take care of that.

106

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Client:

Will I be very weak| I have to do a lot of work at home.

Counsellor:

You will need to res| after you go home for few days. By the way who all are there at

your place?

|

Client:

My husband and the child. He does help me in the work.

Counsellor:

Ok. now tell me Ddvi, what do you think about preventing conception the next time

if you don't want the second child soon?

Client:

Don't know for sure. I will have the pills. Actually I was talking pills even now but I
don’t understand how I still conceived.

Counsellor:

With pills you have to be very careful. If you forget to take, then you will conceive.

Client:

Yes. you are right. I forgot to take the pills. I think that's the reason for the failure.

Counsellor :

Apart from pills, your husband can use condom to space the children. What do you

know about the condom?

Client:

My husband was using it but then it tore once or twice and then there was such
tension.

Counsellor.

Condoms come in different types. And there is a way to use it. If worn in the right
way it will not tear. You can also use Copper-T.

Client:

No, no I don’t want Copper-T! What I have heard is it travels up to your chest.

Counsellor:

(Using uterine model and Copper-T) See, this is Uterus and this is Copper-T Once

inserted, copper-T is effective for 3 years. Then it can be removed and replaced. Can
you see that it is inside the uterus and the uterus is closed from the top so it cannot

go up to the chest?

Client:

I have heard it causes lot of problems.

Counsellor :

Not for all women. But yes, some women do get heavy bleeding during menses for
first few months after insertion. It is a foreign body so our body takes some time to

adjust with it

Client:

But still

Counsellor:

Yes, tell me ..

Client:

I am scared

Counsellor:

Yes, I do understand your feeling. You can think and take a decision. You can

discuss this with your husband. And in case he wants more information bring him
along, next time, when you come back with all the investigations. I can explain to

him too so that you both can decide together.

Client:

Ok.

Counsellor:

So today we discussed about MTP and about spacing methods. When you came
back after two days and if you have any doubts don’t hesitate to ask me.

Client:

Ok I will go now and I will get my husband along the next time.

Counsellor:

Ok so when will you come next? Today is Monday, You will get all the reports by

Wednesday, so you can come with your husband in the morning between 9.00 to

11.00 a.m.

Client:

Ok I will come with my husband on Wednesday.
(Counsellor smiles and stands up to see client off)

I
Chapter 7
Communication and Counselling around Sexuality Issues

Linkages between Sexuality and Health

Most, if not all, gynaecological and reproductive health problems are ultimately linked with

sexuality. Choice of contraceptive methods and satisfaction with methods, safe pregnancy and
delivery, treatment of infertility, protection from sexually transmitted diseases, all have some

underlying issues related to sexuality. Women’s and men’s sexual attitudes and behaviour

influence contraceptive choice and effectiveness of use. At the same time, the use of particular
methods can affect the way people experience their own and their partner’s sexuality (in positive
and/or negative ways).

Sexual relationships often incorporate power disparities based on gender, age, class and patronage
(for example, landowner-laborers, employer-employee, upper caste-lower caste relationships). The

disparities are due to both physical strength, and access to material and social resources. Girls and

women have little control over what happens to them sexually. They have little control over men’s

sexual access to their bodies and the conditions under which their sexual encounters take place.
However, the extent to which a woman is able to negotiate the terms of a particular sexual act or

relationship defines her capacity to protect herself against unwanted sexual acts, unwanted pregnancy,

or sexually transmitted diseases. On the positive side, it defines her ability to enjoy sex and to seek
health care and family planning advice. Thus, interpersonal power relations intrinsically affect a

woman’s sexual and reproductive health outcomes.

Understanding Gender and Sexuality
Sexuality is the way society looks at what is basically a biological drive. It is multidimensional and

dynamic. An individual’s experience of sexuality is influenced by biology, gender roles, power relations,
as well as age, social and economic conditions. An individual’s sexuality is influenced, perhaps

most profoundly by prescribed gertder roles - the social norms and values that shape the relative
power, responsibilities and behaviours of men and women. For example, women’s prescribed role in

sexual relations is to be passive. Women are not encouraged to make decisions regarding their

choice of sexual partners, to negotiate with their partners the timing and nature of sexual activity, to
protect themselves from unwanted pregnancy and disease, and, least of all, to acknowledge their

own sexual desire. Men on the other hand are socialised to ‘conquer’ to prove their manhood. Men

are encouraged to think primarily of sexual performance; women’s sexual pleasure is valued usually
as proof of male performance^ Also, the proof is sought in the form of fertility— ability to have children,
that too, male babies.

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109

Men’s, and women’s, mutually reinforcing gender roles have particularly debilitating consequences
for reproductive health and contraceptive practice. These roles place a woman’s health at risk when

they lead her to neglected health, gender-based abuse and violence, harmful practices such as rape

and other forced sex, STDs, unwanted pregnancies and unsafe abortions.

Barriers to talking about Sexuality

Despite the close links between sexuality and health, discussions on sexual issues are generally left
out in health provider - patient interactions. Or if it takes place at all, the concept of sexuality is
reduced to the notion of sexual intercourse and peno-vaginal penetrative sex in heterosexual
relationships. Some of the reasons why sex and sexuality are never discussed are :

•

These are considered a very private area of one’s life and very early in life, we are socialised

to hide our sexual selves and to be silent about this aspect of ourselves.

•

Sexuality is an area which is tightly wrapped by morality and societal prescriptions of what is

'good' and ‘bad’. These moralistic values and attitudes prevent us from really expressing our

true opinions around sexual matters.

•

There seems to be a lack of an acceptable language to talk about sexuality. While on the

one hand, there is a rich stock of metaphors and terms related to sexuality in most subcultures,

these are inaccessible to persons outside those subcultures. On the other hand, common
terms related to sexuality in the vernacular languages sound crude and also have the
connotation of ‘bad’ words and abuses and not considered acceptable for use by ‘decent’

people.

Because of the reasons described above, health care providers generally do not talk to patients about

the sexual dimensions of their health conditions. If they do, they may talk about these in highly
sanitised bio medical terms, bereft of all emotions, which remove the discussion from the arena of
daily life experiences.

Learning to talk about Sexuality
Health care providers need to be equipped to talk sensitively about matters related to sexuality.

Firstly providers need to understand how elements of sexuality like sexual partnerships, sexual acts,
sexual meanings, sexual drives and enjoyment affect reproductive and sexual health outcomes (Dixon

Mueller, 1993). For example, providers need to know about the range of the clients' sexual partnerships
(with both the same and the opposite sex) and practices, if they are to offer appropriate advice on

protection from disease as well as from pregnancy. Clients should be asked routinely about genital

discharge or sores, and whether they experience pain or discomfort during intercourse or other sexual
acts and providers should not feel uncomfortable when clients ask for information and advice.

110

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Secondly, just as clients’ sexual attitudes and behaviours affect their reproductive health, providers’

sexual activities and values influence the quality of their service e g. Providers may withhold
contraception or abortion services from sexually active, unmarried women, or fail to deal realistically
with STD prevention if a client is homosexual.

Training modules for providers should include basic information about sexual functioning (physiology,
male and female sexual response, capacity for orgasm), about life cycle changes in sexuality, fertility

and menstrual patterns. Training on perspective and attitudes is equally important: Health care
providers need to examine their own attitudes, biases, and values related to sexuality so that they
reflect a non-judgmental and supportive stance in their interactions with their clients. Thus training of

health care providers has to be built around self-reflection and self-examination to their own sexuality
followed by sharing personal opinions, values, attitudes, and experiences.

Going through such a process gives words to personal experiences and will help health care providers

adopt the same process with their clients making it an extension of a common human experience.

Sexuality Counselling
This section describes the essential elements of Annon's PLISSIT model (IPPF, 1992). This model
suggests that clients need PERMISSION as an acknowledgement of their need for intimacy and a

validation that their sexual concerns are normal. They need LIMITED INFORMATION of the factual kind

to address their sexual issues. Further they need SPECIFIC SUGGESTIONS for ways to induce
behaviour changes. In ideal conditions, the counsellor and the client work together to find satisfying

solutions to overcome barriers to sexual functioning, including alternatives to intercourse. If problems
cannot be managed through the stages of PERMISSION-GIVING, INFORMATION PROVISION and
SPECIFIC SUGGESTIONS, clients may have to be referred for INTENSIVE THERAPY.

Permission giving is an important task of sexuality counselling because people need to hear from

someone ‘in authority’ that what they are feeling, thinking or doing is normal, that sexuality is
acceptable and not a sign that they are mad or deviant or dangerous. Realising that their feelings,
thoughts or behaviours are acceptable to the counsellor can be the beginning of self-acceptance for

the client. Women need Permission to accept that they have a right to sexual pleasure. Women also

need Permission from the counsellor to express their ‘no’ in sexual relationships.

Women may need permission:

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to talk about their sexual feelings in the first place.

•

to have (or not to have) sexual feelings and or fantasies.

•

to do (or not do) particular sexual things.

•

to like (or dislike) particular terms of sexual expression.

•

to respond physically to sexual stimuli.
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Sometimes peoples’; difficulties with sexuality relate to a lack of information, or to inaccurate information.

In many societies arrange of myths exist about sexuality. Myths are commonly held beliefs that are
assumed to be facts. Because of strong taboos which exist in many cultures on talking about sexuality,

many people are likely to be sexually ignorant and such ignorance can lead to anxiety, fear and
feelings of total isolation. Providing the relevant information in an empathetic way can go a long way

to resolving difficulties related to sexuality. Care should be taken to ensure that the information

provided is directly relevant to the client's immediate concern. For instance, many young persons
believe that masturbation results in weakness and illness and feel extremely guilty because they

masturbate. It is important to provide them with scientific evidence rejecting that masturbation leads
to mental illness or any other problems.

There are times when it is appropriate for counsellors working with clients with sexual difficulties to
make specific suggestions that fit with the client’s sexual feelings, thoughts and behaviours.

Suggestions need to be sensitive to prevailing cultural beliefs and taboos about body and sexuality.

At the same time, they may also gently challenge these.
All sexuality counselling which is woman centred must strive to help the partners to transform the
traditional gender roles and societal notions of male and female sexuality and explore the dynamics
of power within a particular relationship so that there is greater negotiation between partners and they

move towards equitable power relations. Equitable power relations cannot be expected to become a

reality within a short span of time or without the involvement of men. Therefore, women need to be
helped on an on-going basis, so that they become committed to self-empowerment. Also, their
partners need to be taken into confidence and convinced of how they stand to gain by improving

power relations with their partners. They can have a more fulfilling partnership. Male health workers
(MPWs) have a very important role to play in counselling the male partners of the women clients who

come for counselling.

Module Objectives

At the end of this module, the participants will

•

understand the links between sexuality and reproductive and sexual health

•

understand how male and female sexuality is constructed i.e. how gender norms influence
characteristics of male and female sexuality

•

become aware of their own attitudes and biases in relation to sexuality and the notion of sexual

rights
•

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increase/improve their skills in talking about sexuality and counselling women in the OPD.

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Concept of Sexuality

Session 1
5 .

Learning Objectives
At the end of the session participants will

•

describe the various dimensions of sexuality

•

understand that sexuality is a multi dimensional concept.

Time

60 minutes

Resource

Cards— 3 per participant, OHT 7.1

Methodology
Brainstorming and word association

1.

Facilitator distributes 3 cards to every participant and asks them to write three
words that come to their minds when they think of SEXUALITY. Each card should

contain one word or phrase.

The words that emerge will fall into categories like:
Body parts, Physical aspects, Feelings, Beliefs and meanings (e g. bad, secret,
sinful). Sexual behaviours or acts (e.g. masturbation, kissing). Sexual identities

or orientations (e.g. homosexual) Use of power (rape, sexual harassment,
violence). Many other categories can emerge.

2.

Ask each person to read out their cards and stick them on the wall in clusters of

categories. Do not name the categories yet.
3.

When all participants’ cards are up on the wall, ask participants to review the

clusters and name the categories.
4.

Add any aspects that you think have been left out e.g. PLEASURE or FANTASY

5.

Sum up by saying that Sexuality is a multidimensional concept, (have all the

dimensions portrayed on the wall).
6.
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Establish that it is different from Sex which generally refers to sexual intercourse
between a man and woman.

7.

Show OHT 7.1 - What is Sexuality?

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What is Sexuality?

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Sexuality is more than sexual behaviour. Sexuality encompasses eroticism, sexual behaviour,

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social and gender roles and identity, relationships, and the personal, social and cultural

meanings that each of these might have. (Chandiramani et al, 2002)

8.

State that it is this wider understanding of the concept of sexuality that should
guide our interventions.

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Facilitator’s Note
Sexuality is a difficult concept to talk about. The participants may be hesitant to share.
| Go along with them, do not push too hard. Try and create a safe and non-judgmental
atmosphere so that participants with extreme views also feel emboldened to share.

; Do not give the examples at the beginning. These are only for your understanding.
Give examples only if participants are stuck.

Points to Emphasise

•

Sexuality is a multidimensional concept, more than sex’

•

We need to be aware of each dimension when we plan our interventions like

< counselling or training

Session 2 Gendering of Male and Female Sexuality
Learning Objectives

At the end of this session participants will be able to
•

describe the difference between male and female sexuality.

•

understand how male and female sexuality is socially constructed.

•

analyse the double standards that underlie how society perceives male and
female sexuality.

Time

60 minutes

Resources

Blackboard / Whiteboard and chalk / Markers Cards

Methodology
Brainstorming, interactive discussions, listing
1

Facilitator introduces the session to the participants saying “we are going to look at
whether male and female sexuality are different. And if so, what are the differences?"

2.

Facilitator asks participants to state what they believe about male sexuality and

what they believe about women's sexuality and starts listing responses in two
columns on the board.
The following are some typical responses.

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Male Sexuality

Female Sexuality

•

Aggressive

•

Passive

•

Difficult to control

•

No desire or urge

•

Always initiates

•

Cannot initiate

•

Has to ‘know’ everything

•

Has to be pure, chaste

•

Exhibitionist, conqueror, many conquests

•

Modest

•

Virility, masculinity associated with high

•

'Good' woman vs. whore

sexual activity

•

Sexual activity allowed only within

marriage and for child bearing

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Facilitator asks participants whether they see any connections between gender

3.

and female aind male sexuality as listed on the board. Through discussions,
facilitator establishes that male and female sexuality are not biologically given
but are socially prescribed.

Facilitators asks participants to recall any proverbs or sayings from their cultures

4.

that describe different characteristics of male and female sexuality and write

these on cards. E g. Apne khet ka khud khayal rakho. (look after your field
yourself/ Saandh paala hai to dand bharenge (male can do anything, we will

provide space for this and pay fine for this). Khoonta agar mazboot hai to bhains
idharudharnahin jayegi (If the nailpost is strong, the buffalo won’t stray hither

and thither).

The cards are read out one by one and later pasted on wall.

Facilitator asks participants on whether they see any differences in standards

5.

by which society judges male and female sexual behaviours. E g. a girl must be
a virgin at marriage but a boy must know everything and be experienced. It was

considered okay for kings to have many wives and many children by their many
wives, but a queen could not have many husbands.

Facilitator’s Note

Once again, try and establish an atmosphere wherein participants can venture to

share their views without feeling judged.

Points to Emphasise

•

Sexuality is socially constructed and not biologically determined.

•

There are double standards by which society judges male and female sexual

behaviours

Session 3

Links between Sexuality, and Reproductive and Sexual Health

Learning Objectives

At the end of this session participants will be able to
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•

identify how various RH conditions are linked with sexuality

•

describe the barriers faced by health care providers in addressing issues related
to sexuality

•

list ways of overcoming the barriers

Time

60 minutes

Resources

Blackboard, Chalk

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Methodology

1.

Facilitator asks participants to list various reproductive and sexual health problems

and conditions. These are listed in one (jolumn on the blackboard.

2.

For each of these, the facilitator asks whether there are any sexuality issues
related to the particular condition The facilitator lists these in the second column,

3.

The facilitator summarises by saying that many RH problems/conditions have
underlying sexuality dimensions. And yet what do we, as health care providers,

do about these?
4.

Facilitator encourages participants to list all the barriers that they perceive prevent

them from addressing sexuality issues. These are listed on th& black board.
The facilitator states ‘Let us think about these barriers and what can be done to

overcome them - we will see how to address them in a later session.

5.

Facilitator gives inputs based on Ruth Dixon Mueller s Linkages between the
Sexuality/gender framework and reproductive health’ (OHT 7.5).

Points to Emphasise

Each reproductive health condition, from contraception to infertility to pelvic

inflammatory disease to pregnancy and ante natal care, has some underlying sexuality
dimensions. It is important for health care providers to be able to talk about these so

that clients can raise these issues with them.

Session 4

Exploring Attitudes Related To Sexuality

Learning Objectives

At the end of this session participants will
•

state their own values around sexuality

•

discuss and begin to accept aspects of sexuality, which were hitherto
unacceptable to them

•

articulate the principles of acceptable and unacceptable sexuality

Time

60 minutes

Resource

Sheet with statements (Handout 7.1)'

Methodology

1.

Divide participants into four groups and distribute 3 statements from Handout 7.1
to each group for discussion and arriving at consensus.

Group discussions will take 30 minutes.

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2.

In the plenary, take up each statement. First get the group s opinions with reasons.
Then throw open discussion to larger group. Give your input

Discussion on 12 statements will take up to 45 minutes.

3.

Elicit principles of what is acceptable, and what is absolutely not acceptable in

relation to sexuality.

Acceptable : respect, caring and mutual consent, safe'

Unacceptable : use of force, non-consensual, wide power differentials
(e.g. child and older persons, junior person and boss), unsafe’

Points to Emphasise
•

Value and attitudes towards sex and sexuality are deeply internalised. We need

ongoing reflection in order to become aware of them and how they affect our
behaviour towards others.

•

In accordance with principles of tolerance and respect for diversity we need to

learn to accept others whose ideas of sexuality do not match ours.

•

Use of force and power in sexual relationships is absolutely not acceptable.

Facilitator’s Note
By the end of this session participants will feel free to state their beliefs and values
For value clarification to take place sufficient time should be kept for discussion.

How will you counter each statement: (Handout 7.1)

1.

Men are by nature polygamous but women should be faithful

This statement is constructed illogically. While the first part' men are by nature polygan .
purports to be a fact, the second part “women should be faithful' is prescript' .tv--.'- ' >

••

polygamous nature is a social construct and not quite a biological fact Women's r-resc'

faithfulness is also how society demands they be And why can t th^re be the same Sc..
standards for both men and women?

2

Homosexuals are abnormal and rare
A homosexual is a person who is attracted to people of the same sex and derives sev..

pleasure from them. Both men and women can have such an attraction At different
times in a person's life they may find they are attracted to different kinds of oeopiv M

some time in most people's lives they will experience some level of attraction to
of the same sex. Homosexuality is quite common and should be ccns’de-eo noi ~ s

3. Most women with HIV are sex workers

No, no. not at all. The natureof the epidemic has changed. Ordinary, faithru!'. mc/’cso

.

wives are today at grave risk of the HIV infection brought onto them by the ns- ■.
of their ‘polygamous' husbands..

4.

Masturbation leads to weakness

It is a normal sexual activity practiced by both males and females If it leads to v. ea <'s

the weakness is due to the guilt and shame of masturbating and not due -o loss ot
semen, as is commonly believed.

5.

A girl should not have sex before marriage

And what about a boy? Can he have sex before marriage9 Why is he allowed to have sex
before marriage and a girt is not? Why the double standards? Boys too should not have sex
before marriage, lightly and loosely. We must promote the same standards of respect, cornty
safety and responsibility for both boys and girls.

6.

Sexually explicit literature or visual material corrupts the mind and should be banned

Banning anything has been known to push it underground So banning is not the answer.

Sexually explicit literature, which is scientific and respectful of men and women, is
required for sex education. We have to ensure that material that does not objectify
women should be produced.

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7.

Women should stay indoors to be safe from sexual abuse

What about so many women who stay indoors with their husbands and are victims of
marital rape? What about the number of girls who are victims of child sexual abuse within
their homes, often at the hands of people who are known to them? That homes are safe

havens for women, is a myth.

8.

When women say "no" they may actually mean yes
Until women have the societal permission and freedom to say yes, their ‘no’ will never be
taken seriously. Women are not allowed to express their sexual desires. Any woman

who does so, is considered loose and wanton. The argument given above ‘When women
say “no” they may actually mean yes’ is what is typically used by men who rape women:
‘ she was enjoying it.’.
9.

The main purpose of sex is to have children
Then there should be many more children in this world,right? Enjoyment and pleasure

are the main reasons to have sex. Actually it is Religion that dictates that the main
purpose of having sex is procreation. And therefore sex is permitted and legitimised only

within marriage and only till childbearing is over. All other sexual activity is considered
either sinful or indulging one’s sensuous desires.

10. Women who are sexually teased or abused, act or dress provocatively

What about little girls and older women? Many of them without dressing provocatively
are victims of sexual abuse. And what does ‘dress provocatively’ mean? Dressing for the
pleasure of looking and feeling good is taken to mean ‘dressing provocatively’. And who

decides what is dressing provocatively? Generally, it is men and the patriarchal mindsets

who want to control women who lay down dress codes for women in society.

11. The vagina is the most sexually sensitive organ of the female
No, women can have many erogenous zones. Different women feel aroused with touch
I

on different parts of their bodies. Those who are sensitive to their partners’ sexual pleasure

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will take the time to discover what is pleasurable for their partner. Fewer than 30% of

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women are ever able to achieve orgasm through vaginal penetration. The clitoris is the
primary sexual organ of a woman. It has no other function than to provide sexual pleasure.

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12. Oral and anal sex are unnatural

No, different people have different preferences. As long as there is mutuality and consensus

any sexual act is natural. In our opinion, rape and non-consensual sex is unnatural.

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Alternative B

Small group exercise on Mapping Sexual Hierarchies
Exercise contained in Handout 7.2

■

Material required

Chart paper and markers for Sexual Maps.
Copies of Handout 7.2.

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2 hours

Activities / Steps

Step 1 Small group exercise on Mapping Sexual Hierarchies

•

Divide participants into 3 or 4 small groups.
Each group should come out with a listing of ‘From society’s perspective

most acceptable to least acceptable forms of sexual relationships’.
Around 45 minutes will be required for group work.

•

Let each group present their sexual map with their explanations.

•

Facilitator asks what did we learn out of this exercise.

Example of Sexual Map

Most Acceptable
relationship between heterosexual married peson of same caste, class, for

procreation.
sex before marriage for males.
sex outside marriage for males.

sex outside marriage for women.

Least acceptable

same sex relationships.
sex with animals.

Some Learnings

120

•

What are the social norms aropnd sexuality, depending on worldviews and contents ?

•

What is considered ‘deviant’ of ‘abnormal’ ‘sexuality’?

•

Double standards around sexuality.

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Step 2

•

Give out Handout 7.2 and ask participants to complete the exercise contained

therein in 10 minutes.

•

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Conduct a large group discussion on what participants learnt about
themselves while doing this exercise.

Facilitator’s Note
1.

All erotic behaviour is considered bad unless a specific reason to exempt it has
been established. The most acceptable uses are marriage, reproduction and love.

2.

Individuals whose behaviour stands high in the hierarchy are rewarded with certified
mental health, respectability, legality, social and physical mobility, institutional

support and material benefits.

3.

As sexual behaviours or occupations fall lower on the scale, individuals who
practice them are subjected to a presumption of mental illness, disreputability,

criminality, restricted social and physical mobility, loss of institutional support
and economic sanctions.
4.

Sometimes it is the fear of stigma that gives certain sexual behaviours a low
status. However stigma is also a result of religious traditions.

5.

Medicine and psychiatry also reinforce the stigma. The section of psycho-sexual
disorders in the Diagnostic and Statistical Manual of Mental and Physical

Disorders (DSM) of the American Psychiatric Association reflects the current
moral hierarchy of sexual activities.
6.

Sexual morality has more in common with racism than true ethics. It grants

virtue to the dominant groups and relegates vice to the underprivileged.
7.

A democratic morality should judge sexual acts by the way partners treat each

other, the level of mutual consideration, the presence or absence of coercion,
t

and the quantity and quality of pleasure they provide.

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(Gayle S. Rubin, 1999)

Session 6
i

Sexual Rights

Learning Objectives

i

By the end of the session, the participants will be able to
•

f

define the concept of sexual rights and the underlying values and principles of

sexual rights.

•

begin using the sexual rights’ framework.

Time

90 minutes

Resources

OHTs 7.2, 7.3, 7.4

ft

Methodology OHT Presentation and discussion
t

Activities
Step 1

Facilitator presents a brief history of sexual rights, definition and values
underlying sexual rights based on OHT 7.2 & 7.3.

Step 2

Facilitator divides participants into small groups and asks them to draw up
lists of important Sexual Rights from their own contexts (15 minutes).

Small groups share their lists and facilitator consolidates these using OHT 7.4.

Step 3

•

Facilitator asks participants how they could use the sexual rights framework in

their work situations.

-

As managers of organisations, would your personnel policies include
pregnancy/matemity leave for any woman (including single women) ?

-

As health care providers, what would you do to ensure contraceptive services

or abortion services to single women and men?
-

As landlords would you rent your house to a gay couple ?

Facilitator’s Note
You might be asked to address the question ‘Are not Sexual Rights a western
concept and western agenda? We have more important problems in our country,

why are we bothered about Sexual Rights?’ You can reply by taking up the example

of hijras and how they are discriminated against in our country. They are made fun pf
and feared sometimes. Do they not have a right to be treated with dignity and respect?

Session 7 Developing a Sexual Vocabulary
Learning Objectives

At the end of the session participants will be able to
•

state various words related to sexuality or having sexual connotations.

•

increase their comfort levels with the words and become more at ease with

these.

•

Time

122

describe the social conditioning we go through about sex.

45 minutes to 1 hour

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Resource

Flip chart paper, marker pens

Methodology
(1) One by one, write the following items on a piece of flip chart paper:

vagina, penis, sex, semen, erection, masturbation, orgasm, breasts, testes.
After writing each word, ask the participants to react with whatever thoughts,

feelings or associations they may have about them. Write down the words or feelings
they express (e.g. with "sex" they ma; associate dirty, enjoyable, children, etc.)

(2) Ask the participants to brainstorm words or phrases of their own that have to do
with sex - Hindi/other local language and English slang, technical, anything,

and repeat the process of recording their response as above.
(3) Ask participants to read out the lists one by one. Facilitate a discussion about
the words and their response.

•

How did it feel to use these words?

•

Which words were the hardest to say? Why are these so difficult?

•

What kinds of people use these words?
(Good people/bad people/doctors/adults with each other/ children or young
people with each other/women/men/mixed groups)

•

Which words are they most happy with? (Words I like. Words I don’t.)

•

Why are there such different - even contradictory - responses to the words?

•

Are there words which are used to abuse others? In what instances are the

words used as terms of abuse ?

What are the cultural and sexual attitudes that are revealed in the language
we use?

This final question can be enhanced by calling out a word and asking the

participants for the equivalent word for the opposite sex. Why are there no
equivalents? Possible words could include the following, but think about

examples in your local language/the language of your participants, as well:

WOMEN
Slut Nymphomaniac Whore

MEN
Stud Gigolo Pimp
(Source: NAZ Foundation, 1996, Guide to Teaching about Sex and Sexuality)

Points to Emphasise
The facilitator points out that when we work with sexual health issues, we have to be
comfortable using certain words that are generally perceived as offensive.

123

Sessions: Sexuality Counselling
Learning Objectives
At the end of the session participants will be able to
apply principles of woman centred counselling to sexual health issues

•

Time

90 minutes

Resource

Blackboard, chalk.

Methodology

1.

Facilitator generates principles of woman-centred sexuality counselling from the

group and lists them on the board. (See the section on Sexuality Counselling

and Chapter 5 on Woman Centred Counselling.)
2.

Facilitator divides participants into 4 or 5 small groups. Each group is given a
case study of an ORD patient and has to apply the listed principles of woman

centred sexuality counselling. Role plays have to be prepared.

3.

Role plays are presented by each group. Other members are asked to observe
and present positive feedback first and then suggestions for better counselling.

4.

Facilitator summarises by going back to the principles on the blackboard and
adding more from the feedback if any are missing.

Facilitator’s Note
Woman Centred Sexuality Counselling
Women need permission to accept that they have a right to sexual pleasure. Women

also need permission from the counsellor to express their ‘no’ in sexual relationships.
Women may need permission:

•

to talk about their sexual feelings at all.

•

to have (or not to have) sexual feelings and or fantasies.

•

to do (or not do) particular sexual things.

•

to like (or dislike) particular terms of sexual expression.

•

to respond physically to sexual stimuli.

►

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Case Studies
If you are in-charge of this OPD and have been through this counselling training, what
would you do differently?

Case Study 1
i

In the internal examination room

While checking, the doctor asked, “Do you want this baby7"
Patient said, "yes, doctor saab."

Then the doctprsaw her case paper and said (in a raised voice), ‘You have two children already.
Two children are enough. Don't you understand?"

Patient said, “If my husband wants, what can I say?"

Case Study 2

Lalita (age 28 years) is pregnant for the third time. She lost her previous two pregnancies due to
miscarriage. She comes to the ANC clinic complaining of spotting. The doctor tells her not to have

sexual relationship with her husband. Her husband is waiting outside the OPD.

Case Study 3
A woman comes to the OPD with her old case papers. Doctor sees her papers and tells her. “your

report is okay. No problem with you, but there is a problem with your husband's report. He has
problem with the dhatu (semen)." Doctor asks her to call her husband. The husband comes in. There

are many women around the doctor's table and both the doctors in the OPD are women. The doctor
tells the husband, “your sperm count is less. You have to take treatment. With the treatment it will

increase. I am also giving treatment to your wife. She has to take these tablets on the 10th day of her
menstrual cycle and continue for one week, you need to have intercourse from the 10th day for one

week. You have to take the medicine for three months and then we will again do the test and see if

sperm count increases."

Case study 4
Sushma and Raju, a young couple, come to you for contraceptive advice. During the course of your

conversation, you discover they are not married. What will you do?
Case study 5

►

Krishna, a 47-year-old woman is suffering form rheumatism and excessive bleeding. You also find out
that she is diabetic. She feels exhausted after sexual intercourse and does not know how to tell her

husqand. What will you do?

I

Alternative Session Plan for Session 8 - Sexuality and Health

Learning Objectives

At the end of the session participants will
•

know the concepts of sexuality and it’s various dimensions and complexities

•

realise the importance of discussing issues related to sexual practices in most
of the gynaecological conditions

•

clarify their values related to sexuality and understand its effect on their work as
health care providers

Time

2 hours

Resources

OHT 7.5 explaining the linkage between sexuality and reproductive health, list of
statements for value clarification - Handout 7.1 and Handout 7.2

Methodology

1.

The facilitator asks the participants to think of a word, phrases, feelings associated
with the word sexuality.

2.

The words associated are listed on the board and the facilitator brings out the

various dimensions of the term sexuality.

3.

Participants are then asked the reasons why they are not comfortable discussing

these issues with clients.

4.

Facilitator asks the participants to list gynaecological conditions associated
with sexuality, and hence establishes importance of talking about the issue and
being comfortable with it.

5

Participants are then divided into 3 groups. Each group is asked to discuss 3

statements from the list of statements (Handout 7.1) and share the views in the
larger group.

6.

j

In the presentation, discussion is held on the reasons for agreement or
disagreement related to the statement.

7.

After this exercise the participants are given a list of statements on sexuality,

sexual behaviours and practices (Handout 7.2). They are individually asked to

specify whether they would accept the behaviour for self, or they will not accept

for self but do not mind if others prefer it and the third option is it is not acceptable
for self and others. The data of this exercise is then collated and presented back
to the group and the group is asked to reflect on the values of health care

providers. Some of the statements are discussed in the group.

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Facilitator’s Note
Use the explanations given on pages 8^ and 83 for each statement

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References

1.

Dixon Mueller, Ruth, (1993): The Sexuality Connection in Reproductive Health, Studies
in Family Planning 24, no. 5: 269-82.

2.

Zeidenstein, Sondra and Kirsten Moore (ed) (1996): Learning about Sexuality: A Practical

Beginning, Population Council/lnternational Women's Health Coalition, New York.

3.

Annon, Jack. Sexuality Counselling- the PLISSIT Model (1992), in Counselling and
Sexuality. A video-based training resource, International Planned Parenthood Federation,
London.

4.

Naz Foundation (India) Trust (1996), Guide to Teaching about Sex and Sexuality,

New Delhi.

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HANDOUTS
Handouts 7.1
Statements

1.

Men are by nature polygamous but women should be faithful

2.

Homosexuals are abnormal and rare

3. Most women with HIV are sex workers

4.

Masturbation leads to weakness

5.

A girl should not have sex before marriage

6.

Sexually explicit literature or visual material corrupts the mind and should be banned

7.

Women should stay indoors to be safe from sexual abuse

8.

When women say “no” they may actually mean yes

9.

The main purpose of sex is to have children

10. Women who are sexually teased or abused act or dress provocatively

11. The vagina is the most sexually sensitive organ of the female

12. Oral and anal sex are unnatural

•<

128

*

Handout 7.2
Exercise: Personal Reflection on Values Around Sexuality
Instructions
(•)

Given in the boxes below are some aspects/behaviours related to sexuality. In each

box mark
okay for me.

(ii)

?

Maybe/ maybe not OK for me

0

not okay for me but okay if others do this

x

under no condition, is this acceptable to me

After marking each box, reflect on what you learnt about yourself.

(a)
(b)

(c)
(iii)

i
i

I

I

Share your learnings in the large group only if you wish to.

Kissing

Oral Sex

Masturbation

Sexual relationship with minor

Anal sex

Read or view sexually explicit
material

Hugging and caressing

Hugging HIV positive person

Have sex with person of same
sex

Forcing sex

Have sexual relationship
before marriage

Forcing partner to have sex
despite his/her wishes

Ask for a HIV test of a person
you would marry

Have sexual relationship with
person other than partner

Complimenting opposite sex

Telling partner what gives you

for looking/dressing
attractively

greatest sexual pleasure and
ask him/her to do it for you

Hugging persons of same sex

Have a love affair

I
I
1

B

to show affection

Refuse to have sex with your

Hugging a person of opposite

partner

sex to show affection

Holding hands of partner in
public

Hugging partner in public

Sex in exchange of favors

Wearing

*
salwar-kameez

without dupatta (women) or
shorts (men) in front of motherin-law
Using abusing words-describing

sex with the mother

Share sexual problems with
partner

Have a commercial sex worker

as a friend

Stay back in office till late at
night with a colleague of the
opposite sex

Have a homosexual friend

Discuss a sexual problem with

a colleague

I
i

130

OVER-HEAD TRANSPERENCIES
OHT 7 1

What is Sexuality?
Sexuality is more than sexual behaviour. Sexuality encompasses eroticism,
sexual behaviour, social and gender roles and identity, reiationships, and the
personal, social and cultural meanings that each of these might have.

(Chandiramani et al, 2002)

OHT 7.2
Sexual Rights
“Sexual rights are a fundamental element of human rights. They encompass the right to

experience a pleasurable sexuality, which is essential in and of itself, and, at the same

time, is a fundamental vehicle of communication and love between people. Sexual rights

include the right to liberty and autonomy in the responsible exercise of sexuality”.
HERA Statement

OHT 7.3
Principles of Sexual Rights
Based on certain ethical principles -

1.

Bodily integrity - the right to security in and control over one’s body. This means that all women

and men have the right to not only be protected from harm to the body but also to enjoy the full
potential of the body.

2.

Personhood - the right to self determination. This means that all women and men have a right
to make decisions for themselves.

3.

Equality- all people are equal and should be recognized as such without discrimination based
on age, caste, class gender, physical ability, religious or other beliefs, sexual preference or
other such factors.

4.

Diversity - respect for difference. Diversity in terms of peoples’ sexuality and other aspects of

their lives should not be a basis of.discrimination. The principle of diversity should not be
misused to violate any of the previous three ethical principles.

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131

OHT 7.4
Sexual Rights Include:
1. The right to sexual pleasure without fear of infection, disease, unwanted pregnancy, or harm.
2.

The right to sexual expression and to make sexual decisions that are consistent with ones

personal, ethical and social values.

3.

The right to sexual and reproductive health care information, education and services.

4.

The right to bodily integrity and to choose, if, when, and with whom to be sexually active and

engage in sexual relations with full consent.
5.

The right to enter relationships, including marriage, with full and free consent and

without coercion.
6.

The right to privacy and confidentiality and seeking sex work and reproductive health

care services.

7.

The right to express one’s sexuality without discrimination and independent of reproduction.

t

132

V

OHT 7.5
Linkages between the Sexuality-Gender Framework and Reproductive Health

Sexual partnerships

I

Sexual health

Number of partners

Partnership timing, duration

Protection from STDs

Social identity of partners

Protection from harmful practices

Conditions of choice/coercion

and violence

Conditions and rate of change

Control over sexual access

■

&

£

Frequency of sexual acts

Sexual meanings
Masculine/feminine sexuality
Perceptions of partnerships

Meaning of sex acts
Sexual drives and enjoyment
Formation of sexual identities

Socially conditioned sex drives
Perceptions of pleasure

co
co

Information on sexuality

Nature of sexual acts

Conditions of choice/coercion

&

Sexual enjoyment

Sexual acts

Reproductive health

Social Organization of
gender differences

Safe, effective protection from (and

of)

unwanted

from

harmful

termination
pregnancies

Protection

reproductive practices
Contraceptive

choice

and

satisfaction with method
Contraceptive and reproductive

information

Safe pre jnancy and delivery
Treatment of infertility

f ——

Chapter 8
Counselling around Gynaecological Health Issues

Gynaecological Out Patient Departments (OPDs) receive patients for consultation for different conditions.
The services offered at the OPD range from family planning advice to complicated surgeries of the

reproductive system. Every woman comes to the OPD with the expectation of getting immediate
relief from the pain or discomfort that she is experiencing, and seeking advice on decisions related to
family planning methods—spacing as well as permanent—or opting for medical termination of

pregnancy (MTP). Patients either want the doctors to take decisions that are best for their health, or

they want doctors to give them information so that they can themselves take decisions related to
their reproductive health. Once the decision is taken, they want information and guidance. More
important, they need advice that is practical and relevant to their socio-economic realities, and

information they can understand with their limited education.

Health care providers find it difficult to meet all these information needs due to barriers related to

language, culture and class differences, lack of appreciation of the socio-economic realities, and
gender factors that have led to a woman's decision.

Other communication barriers include lack of resources in the OPD (which hampers quality of care),
privacy, limited time and lack of patience with the patients. Health care providers are generally trained
only to focus on the bio-medical aspects of health, ignoring the socio-economic and cultural factors
that determine health status and treatment seeking. This limits their view of gynaecological patients
as reproductive organs rather than seeing them as a whole - as women and human beings. In the

existing culture of silence and shame related to reproductive issues, women are considered as mere

producers of children having little say in decisions related to their marriage, sexual relationship in
marriage, how many children to have and when to have them. In spite of these ground realities, it is

women who are made the targets for family planning programmes or are held responsible for their

husbands’ irresponsible sexual behaviour.

A qualitative study carried out by WCHP on the communication between health care providers and
patients in the Gynaecology OPD of a secondary peripheral hospital using the participant observation

technique1 showed that health providers lacked sensitivity and did not understand the background
and context against which women express their needs and choices. This is illustrated in several
case studies observed during the study (the case studies are presented in Handout 8.9).

The project had undertaken a study on observing communication between the health care providers and
the patients in the Gynaecology OPD in a secondary peripheral hospital. The observer hung around the
OPD, during the consultation, followed patients outside the OPD and noted the interaction between the
doctor and the patient, verbatim. Eighty episodes of interactions between the doctors and the patients were
observed and recorded over 15 days during this exercise.

135

The health providers imposed their views on what is best for the women, ignoring the fact that these

women had really very little freedom to decide whether or how many children they wanted. Thus,
sometimes target-oriented policies make the providers insensitive to women's needs, leading to

delayed treatment and further health complications.

Women are afraid of treatments that require major invasive procedures. It is therefore essential that

the health providers also prepare these women by giving them detailed information about the procedures

that they are about to undergo. Often health providers ignore patients’ need for information to allay
their fears.

Sometimes barriers like language and educational attainment affect the history-taking process
and the doctors fail to understand what the woman is trying to communicate and vice-versa

Such women need more patient and sensitive handling.

The case studies show that Health care providers need to be informed on how gender, social and

cultural factors affect women's lives. They need to know the woman’s background and the social and

cultural burdens she carries with her apart from presenting with physical problems, since all these
factors are also likely to affect her ability to follow the treatment and the advice given by the doctor.

Health care providers thus need to be aware and sensitive about the socio-economic factors, gender
issues, and also use appropriate communication skills to help patients make informed decisions.

It is also evident that the counselling would depend mainly on different aspects of the patient’s

gynaecological condition. Thus the counsellor takes into account the following factors for any

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gynaecological condition before deciding on the course of intervention in a counselling session.

1.

Specific condition or problem that the woman has

2.

Discomfort caused by it and the woman’s other experiences related to this condition

3.

Socio-economic realities of the woman

4. Information she already has on her condition and her need for more information
5. The woman’s perception of the treatment that she feels is best for her

6. Ability to articulate her problems and assert her needs
7. Freedom to make a choice and decide to follow the medical advice

8. A woman’s right over her reproductive organs and health
9. Ability to convince her partner/other decision makers in the family to support her in the
decision that she has made along with the doctor.

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136

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Studies done by WCHP revealed that women’s expectations from the health care providers in the

gynaecological OPD were:

History-Taking

Someone to listen to her problems sympathetically and completely

Help her to clarify and specify the symptoms as accurately as possible

Help her to articulate the facts related to her history
Ensure privacy for talking about sensitive issues like sexual practices
Listen without labelling or making judgments on her life style

Believe in her experiences of the symptoms

Preparing for internal examination
•

Telling her why the internal examination is done, how it is done

•

Reducing her fear and shame by providing privacy for removing her clothes

•

Instructing her clearly on how to position herself

•

Inform her about the findings

Investigations
Giving instructions clearly and in simple language

Explaining why, where, when, cost and so on regarding the investigative

procedures

Explain the preparatory requirements, for example, coming on an empty stomach
or after how many days of the menses

Communicating the diagnosis or the findings

Treatment and follow-up

•

Clear instructions to follow the advice

Follow-up date and assurance that she can come any time in case of complications

or severity of the symptoms
Advice on sexual aspects of the relationship to the husband

Help to take decisions regarding use of family planning methods or surgeries
that are best suited in her case
Give after-care instructions that are practical

Reassurance that she will be all right

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137

Prevention
Preventive instructions
Information related to causes, treatment options

Referral
Clear instructions about where to go, location of the referral centre, timings, and
cost involved etc.

To fulfil the expectations of the patients, the health care providers need to have patience, caring
and non-judgmental attitude, understanding about unequal gender relations, socio-economic cultural

factors affecting women’s reproductive and sexual health, and general counselling and
communication skills.

Training sessions related to sensitive gynaecological counselling are included in the following module.

Module Objectives
This section of the manual includes training sessions for counselling based,on information needs of
women related to specific gynaecological conditions. We have also given the general steps that the

counsellor can follow during the counselling or information session for any condition that the patient
approaches him/her.

This section includes sessions that will address the needs of patients according to the conditions
that are commonly seen in the OPD and the checklist that can be followed for each of these

conditions. The checklist for infertility is included in Annexure 8. 1 as an example.

At the end of this module the participants will be able to

•

Identify gender issues in reproductive health conditions

•

Follow the steps in the sensitive consultation and communication process for several

gynaecological conditions.

•

Guide and help the patient to her satisfaction

Some sessions in this section can be clubbed with sessions from the section on Communication
and Counselling Skills. The session outlines are divided into different phases of the consultation

process, for example, History Taking, Internal Examination, Investigations, Treatment and Follow

up, Referral etc.
Many of the sessions in this module are designed to include actual visits to the OPD and observing

and talking to women. One should be careful to follow ethical principles and take permission or
consent from the women and health care providers wherever there is an interaction in terms of observation

or actual interviewing. If such permissions or consent are not given, the sessions should be conducted

in the classroom with case studies and OPD episodes available in this module.

138

*

Gender Perspective in Reproductive Health

Session 1

Learning Objectives

At the end of the session participants will

•

describe differences between ‘sex’ and ‘gender’.

•

state how gender affects aspects of reproductive health

Resources

OHT 8.1 Pictures of gender stereotypes on transparencies

OHT 8.2 Sex and gender, characteristics of gender
OHT 8.3 Gender as a System

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OHT 8.4 Gender Issues in Pregnancy
Handout 8.1 Gender issues in Reproductive Health

Handouts of gender stereotype pictures-1 to 2 sheets per group
Papers and marker pens.

Time

2 hours

Methodology

•

Participants are divided into four buzz groups.

•

Each group is given the 2 sheets of pictures, and they are asked to identify the sex
of the person in the picture after discussing among themselves. They also have to

state the reasons why they say the picture is of a man or a woman. (15 minutes)

•

Facilitator then asks each group to share their views. The reasons for their

choice are listed on the board. (15 minutes).

•

Through summarising these reasons the facilitator helps participants to distinguish

between SEX and GENDER with help of OHT 8.2 (10 minutes).

•

Facilitator explains GENDER AS A SYSTEM with the help of OHT 8.3

(10 minutes).

•

The facilitator shows gender analysis of one reproductive health issue - e g.
pregnancy - using OHT 8.4. (10 minutes).

•

Participants are then divided into three groups. Each group is asked to analyse
one reproductive health issue from the gender perspective. The RH issues can

be RTIs/ STIs, Infertility, MTP. They are asked to write their analysis either on a

transparency or on chart paper (30 minutes).

•

Each group then makes a presentation (25 minutes).

•

Facilitator adds the points if missed by the group, and summarises the session

on the basis of Handout 8.1.

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139

Facilitator’s Note
Gender is a challenging concept for male participants. Many will resist accepting
that women are not subordinate and discriminated against. Point out that gender
construction does not allow even men to be themselves, to be humans. Men are also

victims of patriarchy and gender, although to a much lesser extent than women.

Further Sessions
The following sessions will enable participants to enhance their skills related to all stages of theConsultation Process - History Taking, Internal Examination, Investigation. Instruction for Treatment

and Follow up, Contraception Counselling and Referrals.
The sessions in this section are numbered accordingly

A. History-Taking
This topic is an example of the application of interviewing skills described in the

communication and counselling chapter.
Use of Open-Ended and Probing Questions

Session A1

Learning Objectives
At the end of the session participants will be able to

•

convert the close ended questions into open and probing questions

•

use the different types of questions effectively to elicit information from the patient

Time

60 minutes

Resources

Examples of questions of each type written on OHT 8.5.

Copies of list of different types of questions, (Handout 8.2).

Methodology

1. Facilitator explains each type of question with the help of examples put up on the

OHT 8.1.
Participants are then given the list of different types of questions (Handout 8.2) -

closed, open-ended, judgmental, leading questions - and are asked to classify
the questions into different types.

2.

Facilitator then asks the participants to convert some close-ended questions

into open ended questions and initiates a discussion on the type of questions to
be used at different times during the interview process.

*

140

ay*

Points to Emphasise

•

The type of questions one asks often determines the quality of information that

one gets
•

Session A 2

To get detailed responses, we need to use open-ended or probing questions.

Practicing the Skills of History-Taking

Learning Objectives
At the end of the session participants will be able to

•

Time

elicit the history of the patient in a sensitive and effective way

2 hours

Resources

Copies of the case studies - Handout 8.3, checklist for monitoring consultation on
different conditions (Handout 8.4, 6.8), OHT- 8.6 with the main points of effective

history-taking.

Methodology

1. Participants are divided into three groups. Each group is given a case study; they

plan a role-play of the history-taking session on the given condition in the case
study. (20 minutes)

Case 1

A woman investigated for leucorrhoea comes with her investigation report. Her

report shows presence ofgonococci. The woman is illiterate and has four children.

Her husband is a construction worker and stays away from home for several
days at a stretch. She does not know if her husband has any health problem

The doctor has sent the case to you asking you to ask her husband to come for

a check-up.

Case 2
A woman married for 6 years has been unable to conceive. She is 28 years old.

Her husband is working in an office as a manager while she is a school teacher.
Her family members are constantly abusing her. She had one MTP 5 years ago.

She starts crying and tells the doctor that she wants to have a child soon or her
in-laws will send her away to her mother’s place. The doctor asks her to get the

necessary investigations done and sends this case to you for counselling.
I

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141

Case 3

A 26-year-old woman wants TL. She has a 5-year-old son. who goes to pre

primary school. Her husband is 30 years old. She has been advised by the

doctors to wait fora few years to conceive her second child. The doctors have
also suggested copper-T. But the woman is firm on her decision. She wants TL.

2.

Each group presents the role-play and the other participants observe it. After
each roie-piay the participants and the facilitator fill the checklist and give feedback

to the presenting group. (15 minutes per group)

3.

Facilitator then summarises the feedback and revises the main points in Effective

History-taking with the help of a transparency or flip chart.

Facilitator’s Note

The facilitator should emphasise that the point of the role-plays is not to demonstrate
what good actors we are, but to demonstrate principles of sensitive and effective

history-taking.
The facilitator will have to be strict about time. Each role-play should be about 8
minutes and the feedback should be given in the remaining 7 minutes. The facilitator
should highlight principles of woman centred counselling

Points to Emphasise

•

Be aware of, and sensitive to, the needs of women.

•

Provide privacy — visual and audio

•

Establish rapport — making the patient comfortable

-

Make her sit down

-

Be respectful

Maintain eye contact

-

Ask simple questions in the beginning
Be patient

Ask open-ended questions
Avoid leading and judgmental questions
Use local terminology
Use knowledge of local cultural festivals to determine the onset of a problem,
Believe in women

Get correct obstetric history - use a sympathetic and gentle tone and avoid judgements
Sexual history - Are you comfortable talking about sexuality?

I
142

I*

Session A3

Applying the Skills of History-Taking

Learning Objectives
At the end of the session participants will be able to

Time

•

state the principles of taking history of patients in a sensitive and effective .•.?/

•

demonstrate the importance of the social history for a gynaecological consulia: u. <

1 hour

Resources
Copies of format for history-taking (Handout 8.5)

Permission to talk to the patient in the waiting line in the Gynaecological OPl1 a< <d

follow them during consultation.

Methodology
1.

Participants are asked to go to the Gynaecological OPD. Each participant i

s

to a woman (after taking her consent and explaining the purpose of the exercise)

waiting outside the OPD.

2.

Each participant tries to gather all the relevant social facts related to the wonx-> s

condition and write these down in his/her notebook or on the format give:record the social history of the patient.

3.

They stay with the woman in the OPD, observe her interaction with the cc . /
and see whether the social facts they gathered have any significance

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outcome of the consultation in terms of decisions related to use of family plam . i'.q
methods, or surgeries that the doctor advises. ( 30 minutes)

4.

Participants come back to the classroom, share their experiences of the histc ;

taking and the consultation process observed. (25 minutes)

5.

Facilitator summarises the discussion. (5 minutes)

Facilitator’s Note

•

Facilitator discusses and ensures that the participants understand the importa’- .'e
of ‘taking consent’ before talking to women in the OPD.

•

Also facilitator draws out socio-cultural and gender-related issues from the sharing

of the participants and helps them reflect on these.
Points to Emphasise

•

Gynaecological problems and their implications for women are not only phv -r ai

or physiological but are related to her socio-economic and cultural conditio .s,
status of women in the family, and gender dynamics operating in the family
and the society.

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143

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B. Internal Examination

Session B1

Sensitivity during Internal Examination

Learning Objectives

At the end of the session participants will

understand, to some extent, and have an increased sensitivity towards the feelings

•

of shame/fear, associated with the process of internal examination

list down the do’s and don'ts of internal examination

•

Time

45 minutes

Resources

Flip chart and a marker

Methodology

1.

Women participants are asked to share their first experience of internal
examination.

2.

•

When was it done, at what age, before or after marriage

•

Why they had to do it

•

Which clinic ( private or public sector)

•

Whether male or female doctor

•

How did they feel about it

•

What would have made them feel better, more comfortable

I

Facilitator writes on the board the factors that made the participants feel better

or uncomfortable during the internal examination (30 minutes)
3.

From this list the do’s and dont’s during the internal examination are drawn out.

(15 minutes)

Points to Emphasise
SAMPLE OF DO’S AND DONT’S

Do’s
•

Be sensitive to women’s shyness and fear

•

Be respectful, gentle and caring

•

Reduce fear and shyness

-

Explain what examination is going to be done and why

-

Give her sufficient time to prepare herself mentally and physically
Take her consent before examination.
Provide visual and audio (if possible) privacy
Provide a sheet to cover her body.

If a male doctor is going to examine her, tell her before the examination

144

i

t
Give proper instructions

Ask whether she is menstruating before the examination
Ask her to pass urine before you do an internal examination.
Explain that she needs to loosen or untie her garment or remove her
underclothes.

Instruct about proper position
Allow her to hold the attendant’s hand, if she feels some pain during examination.

Explain the findings without scaring or humiliating her.

Don’ts

•

JDo not yell, shout, talk with disrespect

•

Do not hit her on the legs as a way of directing her to take a proper position.

•

Do not express shock about findings. Do not exclaim, “Oh, my god !" .’’Look at

this”, “Oh, it is so bad" , “Yeh Kya Kiya hai?,"etc.
•

If a child or a person who has never had intercourse no vaginal examination
should be done. Only rectal examination should be carried out.

•

Session B2

Do not think of the woman’s expression of pain as fuss and neglect it.

Instructions during Internal Examination

Learning Objectives
At the end of the session participants will
•

know the instructions that have to be given during internal examination that will
make the patient feel comfortable.

Time

1 hour

Resources
Checklist for observing internal examination ( Handout 8.6),

Permission to observe the internal examination process in the OPD.
Methodology
!

1. Participants are asked to go to the OPD and observe the internal examination

i

process for a few patients after getting consent. The participants note down the

instructions given by doctors or nurses to the patient (Handout 8.6). Also note

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down the positive features and the negative features (refer to list of do’s and
don’ts) and their effect on the patient and the patient’s response to the

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examination (20 minutes).

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2.

They come back and discuss their observations. (20 minutes)

3.

Participants are then asked to prepare a poster of instructions that can be put
up in the OPD for the patients and the doctors to see. (20 minutes)

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145

Facilitator’s Note

The facilitator can arrange for the participants to go back to the OPD the next day. to
demonstrate how to give instructions to the patient Each participant gives instructions

to at least one woman before they are asked to go for the internal examination

Points to Emphasise
If the doctors and nurses communicate in a gentle, respectful, sensitive way with the
patient, the other staff members present will also follow the role model The clinician

and the nurse have great responsibility in establishing a role model for responsible

and respectable behaviour towards the patient.

C. Investigations

Knowing about Investigations required for different

Session C1

Gynaecological Conditions

Learning Objectives

At the end of the session participants will

•

know the investigations that are generally required for common gynaecological
conditions, their need, use, how and where they are done, cost involved, and

so on.
Time

1 hour

Resources

A medical doctor (preferably Gynaecologist) as a resource person.

List of conditions and investigations required to be done for each of the conditions (OHT 8.7)
Handout 8.7 (A), 8.7 (B), Samples of filled-in case papers.

Annexure8.1 Poster on Investigations.

Methodology
1.

The resource person explains the various investigations that are generally done

for certain Gynaecological conditions using OHT 8.7. (20 minutes)
2.

The resource person also explains the short forms that clinicians use to indicate

the investigations on the case papers. (10 minutes)
3.

Participants are then given copies of case papers and they interpret the short
forms and prepare instructions that need to be given to the patient. (15 minutes)

4.

Participants present the instructions and the resource person gives them the

feedback. (15 minutes)

»

5.

A

Facilitator ends by refering to Annexure 8.1 which shows a poster on investigations

to be displayed in the OPD.

146

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Facilitator’s Note
.

Facilitator discusses the importance of the counsellor knowing the investigations

for all the conditions.

Points to Emphasise
•

Most commonly asked questions and doubts by the patients are related to,

what, where and cost of the investigations

•

It is important for a counsellor to know the terms and short forms used by the

doctors for the investigations advised so that they can answer patient's questions.
•

Keeping a list of all the investigations required for different conditions would be

helpful in the counselling process.

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for Investigations

Learning Objectives

At the end of the session participants will

•

know all the departments to which gynaecological OPD patients are referred to
for investigations.

Time

1 hour

Resources

Notebook and Pen, permission to visit all the departments, and appointments at the
departments.

Methodology

1.

The participants are asked

to play the role of patients and go to various

departments in the hospital. They are given following instructions:

t

•

Do not say or show that you are a staff member

•

Register yourself at the case paper counter as a gynaecological patient

•

Go to a doctor in the gynaecological OPD and ask him/her to write one or
two investigations to be done for training purposes

•

Go to the particular departments and ask for information on when, where,

how the investigation is done, when patients can come for actual tests
(generally appointments for tests are given after two days). (30 minutes)
2.

The participants come back to the classroom and share the information and
their experiences.

X

3.

The problems and their probable solutions are discussed. (20 minutes)

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147

Participants in small groups make

4.

•

a poster on all the information related to various investigations and display it
in the OPD. (See annexure 8.2 for the sample)

The participants display their work in the larger group.

5

Facilitator’s Note

If it is not possible for the participants to act as patients for ethical reasons, they

can be told to go as trainees and talk to the providers in each department and
gather the information

Points to Emphasise

•

If women understand why and what needs to be done, they will be motivated to

follow the instructions and get the investigations done.
•

If explanations are not clearly given, women do not understand, and feel that the
doctor is just sending them here and there. They may get fed up and may leave
the treatment or investigations half-way.

•

If we want the patient to co-operate and participate in the treatment process it is

important to explain the results of the investigations in simple language.

D. Instructions on Treatment and Follow-up
Session D1

Learning Objectives
At the end of the session participants will

•

state the reasons for giving clear instructions to the patients regarding treatment

and follow-up.

Time

1 hour

Resources

Permission to observe interactions in the OPD

Checklist to observe instructionsand information regarding treatment and follow-up
(Handout 8.8)

OHT 8.8 Instructions on treatment and follow-up

Methodology

1. Each participant is asked to imagine that they are suffering from a particular

gynaecological condition. They are asked to write down what they would like to‘
know about their problem during the doctor’s consultation (5 minutes)

148

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2.

These points are listed on the blackboard. These should look something like
contents of Handout 8.9 (10 minutes)

3.

Participants go to the Gynaecology OPD and observe the interaction between
the doctors and the patients before the patient leaves the OPD. The checklist

derived in the classroom or Handout 8.8 is used to observe this interaction. They

also note the points that could have been included in the information given by the
doctor. (20 minutes)
4.

Participants come back to the classi oom. share their observations. (15 minutes)

5.

Points that need to be included in the information given to the patient before the

patient leaves the OPD are listed out of the sharings. (10 minutes)
6.

Facilitator generates “reasons for failure of follow-up", from experiences of
trainees, and discusses do’s and don’ts in giving information related to treatment
and follow-up. with the help of transparency (OHT- 8.8 )

Points to Emphasise

•

Women will feel motivated to follow the advice given by the providers if the providers

exhibit and express genuine concern for women’s health

•

Women, and especially sick women, perceive doctors to be very powerful figures

As a result, they become powerless and lose their confidence in the presence of
doctors. It is important for doctors and other health care providers to be conscious

of this and try to infuse their patients with confidence by listening patiently,

encouraging women to ask questions, and providing information that will help
them to take informed decisions.
o

Women may have genuine problems to come for a follow-up. Explore the reasons
first rather than assuming that women are careless about their health. Once the

reason for a woman's failure to come for follow up is understood, one can attempt
to resolve and deal with the situation accordingly. Encourage her to come for
regular follow ups by suggesting solutions to her problems.
«

After helping her to deal with her problems, if she repeatedly fails to come for

follow up, one can firmly explain to her what would be the results of noncompliance and irregular treatment. Importance of follow-up can be stressed.

I

E. Contraception Counselling
Session E1 Understanding ‘Personal Is Political’ - Sharing personal

experiences of using Family Planning methods
Learning Objectives

At the end of the session participants will be able to
•

state problems and concerns of women related to various contraceptive methods.

•

recognise the universal nature of women’s experiences in relation to contraceptives.

(Experiences of women from different backgrounds like class, education, caste,
religion related to the contraception could be similar).

•

realise that being health workers does not mean that they are different 'as
women’ from other women, or that “other women” can also have the same

problems as them and hence learn to empathise with the community women.

Time

90 minutes

Resources

Black board and chalk, OHT 8.9.

Methodology
1. Participants are asked to pair up with the person sitting next to them. They share
with each other: (20 minutes)

•

Whether they have ever used any contraceptive methods

•

Which method, why did they choose a particular method, who took the

decision

2.

•

How long did they use it

•

What were the reactions of the family members

•

Whether they had any problems with the method

•

Each pair shares their experiences within the larger group

Facilitator lists the methods used, and the problems they had with the method,

on the board (20 minutes)
3.

Facilitator draws attention to the fact that women in the community also go
through the same experiences, and hence as women health workers we need to

be sensitive to other women’s problems. (5 minutes)
4.

Facilitator presents the OHT 8.9 on Reproductive Rights and discusses these

in the context of contraceptive methods. (20 minutes)
5.

Facilitator asks participants to remember the principles of Woman Centred

Counselling in the context of contraception methods (refer to OHT 6.10)
|15 minutes)

150

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Facilitator’s Note

•

Men in the group can be paired with men

Points to Emphasise

•

For woman-centred counselling, the health workers should first reach out to clients
as ‘women’, create a sense of trust and sisterhood, so that the client will share

full and correct information, articulate problems and other relevant details.
•

Time and space could be created for the client to feel strong and capable to take

decisions by giving her time to think, and return when she is ready.

Session E 2

Reproductive Rights

Learning Objectives

At the end of the session participants will be able to
•

state reproductive rights of the clients visiting gynaecological OPD

•

reflect on whether women's reproductive rights are upheld in the current set-up
of the health post or gynaecology OPD at the general hospital

•

reflect on barriers to uphold Reproductive Rights and suggest ways to overcome
them.

Time

90 minutes

Resources

Biack-board, chalk, OHT 8.9 on Reproductive Rights, Episodes from the OPD-Handout
8.9. Handout 8.10 on Reproductive Rights, Transparencies on Woman Centred

Contraception Counselling (OHT 8.10).

Methodology

1. Ask the participants to list one expectation from a gynaecologist or a doctor or a

health centre related to contraceptive services which would satisfy them or

make them feel good about the service or the centre.

2.
I

Facilitator lists the expectations on the board. These expectations are then
classified as related to technical competence, choice of method, information

and interpersonal relations, continuity of service, integrated services.

I

3.

Facilitator then shows the transparency on reproductive rights (OHT 8.9)

I

4.

Participants are then divided into groups of 3-4 and each group is given two

I

recorded episodes from the OPD. They have to read the episode to the group

I

and discuss the following points and write them on transparencies.

i.
1

I

Which rights are violated or ensured?

ii. What are the barriers to ensure these rights?
iii. Suggestions to overcome barriers and ensure rights?

151

I
I

TH US’

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1

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5

Participants present the discussion to the larger group with the help of the

transparencies.
6.

Facilitator summarises the session with the help of OH I 8.10 on Woman Centred
Contraception Counselling. (OHT 8.10)

Facilitator’s Note
Facilitator can highlig' t the fact that the barriers to ensure reproductive rights could be
•

Policy/Progran .me related

•

L.t/UlOUV<UI

•

Personnel problems

I

nrnhlomc

A lot can be achieved by trying to overcome the personnel and logistic related problems
to ensure Reproductive Rights within the constraints related to population policies
and resources.

Technical information on contraception methods

Session E3

Learning Objectives
At the end of the session participants will be able to
•

Time

state when each method can be advised, how it works, contra-indications.\

2 hours

Resources
A medical doctor and a contraceptives counsellor as resource persons
Samples of all the contraceptive devices available in the market

OHT 8.11 on Contraceptive Counselling

Methodology
1.

Participants are asked to write down their questions related to the contraceptives.
They are also asked to include the questions generally asked by women in the

community, their concerns and fears about various contraceptives. (10 minutes)
2.

The questions are then given to the resource person. Resource person conducts
a technical session on different contraceptives with the help of the Handout

8.12. (45 minutes)

I

152

1

I

I
Counselling Women on use of contraceptives

Session E4

Learning Objectives

At the end of the session participants will be able to

•

state how to counsel a woman on contraception issues from the gender and
rights perspective.

•

demonstrate the use of the cafeteria approach

3 hours

Time

Resources

A contraception counsellor as resource person
Copies of the “Protocol for Contraception Advice",
Handout 6.8 (refer to Handout 6.8 in chapter6on Communication and Counselling)

Role-play situations - Handout 8.11

IEC Pamphlets on Contraceptive Methods (not contained in this manual).

Methodology
1. Participants are divided into two groups. Group A participants are asked to form
3 subgroups and each group is given a role-play situation from Handout 8.11 to

l

demonstrate the effective counselling technique for contraceptive use. They are

I

encouraged to use the IEC pamphlets as a part of their counselling. They are

l

asked to go to another room to plan their role plays. (30 minutes)

I

2.

The facilitator also joins the group and guides them on how to demonstrate the
rights perspective, and the cafeteria approach

I

3.

Participants of group B discuss the “Protocol for Contraceptive Advice", Handout

I

6.8, while group A prepare role-plays.

I

4.

Each of the 3 subgroups performs a role play, and the other participants, including
the facilitator, observe them using the Contraceptive Protocol and Checklists (30
minutes-10 minutes each)

5.

Feedback is given to each group after their presentation (15 minutes)

6.

Common mistakes, or don’ts and do:s, are listed on the board and are revised at
the end of the session (5 minutes)

7.

The participants then go to the OPD or wards to talk to women who are users
of any contraceptive method, after obtaining consent from the women. They are

asked to find out how and why did the woman choose a particular method, her
experience with that method. (30 minutes)

8.

rb®

Participants then share the womens’ stories in the classroom. (45 minutes)

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153

1

Common points are then drawn out on the decision-making process, problems

9.

with a particular method as well as positive experiences of the women, once

again from the Reproductive Rights framework. (15 minutes)

Facilitator’s Note

•

The men trainees can talk to the men who are waiting outside the PNC ward, or

accompanying a woman for the ANC check-up, or men awaiting outside the
gynaecology OPD whose wives are in the ward.
The feedback to the participants should be related to the reproductive rights

•

discussed in the earlier session.

Points to Emphasise

Based on the actual experiences of women, a discussion is held on the gaps between
what should happen and what happens in reality. And hence it is necessary to
understand that the same or ‘one package of advice’ does not suit everybody.
Contraceptive counselling has to differ from person to person, based on the needs of
that person, man or woman.

I

I

F. Referral

I

Session Fl

Referral Centres for Gynaecological ORD

Learning Objectives

I

At the end of the session participants will be able to

*

state names of referral centres around the hospital and their location, timings,

procedures for investigations, cost of travelling to the referral centre and cost of
the services offered at the centre

Time

90 minutes

Resources

List of referral centres around the hospital, OHT 8.11 - referral guidelines.

Methodology
1.

Participants form pairs and visit one centre each. They are given following instructions

•

Pretend that you are a patient

•

Visit the centre and find out all the details about different tests and
investigations, by interacting with the staff at the centre (45 minutes)

2.

They come back to the classroom and share their finding^ and experiences

3.

A list is made of all the centres visited and the details about each centre in

terms of location, timings, etc. (45 minutes)

4.

154

Facilitator summarises using OHT 8.11.

'

Facilitator’s Note
Choose referral centres to which women are most commonly referred e g. sonography

centre, shelter home for battered women and ‘unwed mothers’, adoption counselling
services.

G. Preventive Information

Preventive information is an important part of the consultation process. Often health care providers

find it difficult to explain the necessary technical details to non-literate patients because of language
barriers and lack of time. Use of IEC material to explain facts, can ease this difficult task for the

health care providers.

Session on effective use of IEC material for giving information to the patients is included in the

previous section on communication skills.

Session G1 Practical experience of working with clients visiting the
Gynaecology OPD
Learning Objectives
At the end of this session participants will be able to

•

identify needs to talk to women in the gynaecological OPD

•

introduce themselves to clients and build rapport with them

•

demonstrate sensitivity and empathy towards the emotional and informational
needs of the client (new and follow-up cases)

•

demonstrate sensitivity towards women undergoing P. V. Examination

•

know how to approach and talk to men accompanying women in the OPD

•

know the locations of different investigation departments, procedures and cost
of all the investigations carried out in the hospital

•

build rapport with referral centres and know the referral procedure

Time

3 hours, 30 minutes

Resources

Appointments and consent of the hospital staff and administrators for the field visits

Methodology

1.

Participants are divided into pairs and each pair is asked to visit the different

departments in the hospital like gynaecology OPD, labour ward, gynaecology
ward, VCTC (AIDS counselling centre) and a referral centre for ‘unwed mothers',

women facing domestic violence, an adoption centre, around the hospital.

o<^\

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155

2.

Discussion is held on the essentials of rapport building and talking to clients
like introducing oneself, consent of the client, ensuring privacy and confidentiality

3.

Participants are given following tasks

.

Speaking to a client outside gynaecology OPD who has a new case-paper

.

Speaking to a client outside gynaecology OPD who has come for a follow-up.

.

Observing the intern of the gynaecology OPD during history-taking from the

client.
•

Observing the doctor of the gynaecology OPD doing a PV examination.

•

Speaking to a PNC client in the labour ward.

•

Speaking to a client in the gynaecology ward.

•

Observing VCTC counsellor during counselling.

.

Speaking to spouse/relative of the client outside the gynaecology OPD.

•

Speaking to spouse/relative of the client outside the labour ward.

•

Find out the location, timings, procedures for various investigations done in

•

Visit to a temporary shelter home for unwed mothers to gain an insight

the hospital.

about their functioning procedure.

4.

Participants write about their field visit experience and make a presentation to
the larger group.

5.

Participants are asked their feelings regarding the experience and comments
from all the participants are invited after each presentation.

6.

Essentials and importance of sensitive gynaecological counselling are discussed

at the end.

References

1.

Improving provider-client communication style in selected health facilities of
Brihanmumbai Municipal Corporation, by Swati Pongurlekar, Renu Khanna, Korrie de
Koning, and Nandini Roy. Paper presented at the Sth Asia-Pacific Social Science and Medical

Conference, Kandy, Srilanka September 24-28, 2000.

156

HANDOUTS
Handout 8.1
Reproductive Health (RH) in India : A Gender and Rights Issue
What is Gender?

Gender is the socially created differences between women and men
•

It is not natural or biological

•

It is different at different places and times

•

It changes and can be changed (though not easily)

•

It is hierarchical

r

Gender Differences

Aspect
Roles and responsibilities

Women

Men

Work at home

Go out to work for money

Look after children

Cannot be expected to cook or

Look after the sick

clean

Access and control over Does not own or inherit property Property is in his name/inherits
resources

No choice regarding having sex/child property

Time of having child is decided by More educational opportunities
Behavioural stereotypes

others

Entitled to leisure

Weak

Strong

Emotional

Rational

Dependant

Independent

Shy

Tough

Some Gender Differences

Life cycle

Differences

Before birth

Sex selective abortion of the female foetus

At birth

Celebrating the birth of a boy

In childhood

Differential treatment- food, care in sickness,

education, work, play, age at marriage
Adult life

Women’s mobility restricted, violence, cut off
from natal home, limited rights etc

Older age

Desertion, lack of physical and emotional

security for women
157

r
Some Important RH concerns in India
Unwanted pregnancies
Contraception as well as infertility
Unsafe abortions, sex selective abortion

Maternal morbidity ar.d mortality

Cancers
Reproductive tract infections, HIV/AIDS

Concern for adolescent health

Why is Reproductive Health a gender issue?

Because most reproductive health problems arise from, or are complicated by, unequal gender relations

Manifestation of Gender and Rights violations in RH issues

•

At the level of cause

•

At the level of the individual’s own response

•
•

At the level of family response to the situation
At the level of the treatment - accessibility and availability of treatment as well as the attitude
and behaviour of the provider

Gender dimension and Rights violations: Anaemia in Pregnancy

Gender and Rights Dimension

. Aspect

Dietary customs; workload , repeated

Causes

pregnancies/abortion s etc.

Response of the family

Accused of malingering; no sharing of
workload; no treatment___________

Response of the individual

Self-blame; works hard despite weakness

Response of the provider

Not available; Blames her for not seeking
help in time

158

XS

_

__________

Gender dimension and Rights violations: Unwanted Pregnancy

Aspect

Gender Dimension

Causes

No control over sexual negotiation; lack of

contraceptive knowledge, violence

Accused of bringing dishonour to family;

Response of the family

sex-determination tests
Response of the individual

Self blame, resignation, suicide

Oncr\r>ncp of fho nrox/iHor

Blames, ridicules, no respect for privacy/

IXCOL/OHOC

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• o • • V4

•

confidentiality, extortion

Gender dimension and Rights violations : RTIs/STIs

Aspect

Gender Dimension

Causes

No power of sexual negotiation, no knowledge

about own body, violence
Response of the family

Husband doesn’t take responsibility, stigma,

no treatment
Response of the individual

Shame, inability to disclose, suffering in silence

Response of the provider

Male provider—lack of knowledge,

insensitivity, stigma

RH and Gender - No compromises

It is not possible to deal with Reproductive Health Issues and Problems of the people, especially of

women, until we acknowledge and deal with the gender-based discrimination and violence which

gives rise to, or aggravates these conditions.

159

Handout 8.2

Types of Questions

1.

Are you married?

2.

What do you think about limiting your family?

3.

What do you think is good about breast milk?

4.

How do you feel about the treatment in the hospital?

5.

How many years ago did you get married?

6.

What other medicines or treatment did you take?

7.

What is the colour of your discharge?

8.

You had heavy bleeding when using copper T. Can you tell me a bit

more about what happened?

9.

Do you have any other problem?

10. Did you decide on the number of children you want to have?

11. Is it good to space children?
12. Do you think inserting Cu-T soon after MTP has caused you problems?

13. You said that you felt giddy after the pills that your family gave you.

For what were the pills given?
14 Do you get thin discharge? Is it yellow in colour?
15. Do you have pain during intercourse?
16. Did you take oral contraceptive pills to regulate your period?
17. You said that you have discharge. How is the discharge?

Does it smell? What does it smell like?
18. Many women feel shy to talk about their genital infections.
What do you feel about it?

19. You are not married and you missed your period?

160

----------------

Handout 8.3
Case Studies for History-Taking
Case 1: A woman investigated forleucorrhoea comes with her investigation report. Her report shows

presence of gonococci. The woman is illiterate and has four children. Her husband is a construction
worker and stays away from home for days together. She does not know if her husband has any

health problem. Doctor I.as sent the case to you asking you to tell her husband to come fora check

up.

Case 2: A woman married since 6 years has been unable to conceive. She is 28 years old. Her
husband is working in an office as a manager while she is a school teacher. Her family members are

constantly abusing her. She had one MTP 5 years ago. She starts crying and tells the doctor that she

wants to have a child soon or her in-laws will send her away to her mother’s place. Doctor asks her to
get the necessary investigations done and sends this case to you for counselling.

Case 3: A 26 year old woman wants TL. She has a 5 year old son, who goes to pre-primary school. Her
husband is 30 years old. She has been advised by the doctors to wait for a few years to conceive her

second child. The doctors have also suggested copper-T. But the woman is firm in her decision. She

wants TL.

(Tl_ - Tubal Ligation, MTP - Medical Termination of Pregnancy)

I

l

r
F

161

Handout 8.4

Observation Checklist for Monitoring Counselling for
Menstrual Disorders
Client number:

Name of the observer:

Time:____ ___________

Date:

For each question, please circle the appropriate option

i. Assuring confidentiality: Did the counsellor

tell the client that the discussion in the session

1.1

1. Yes

2. No

3. Not

applicable

will be kept confidential?

4 Do not
know

2 . Involving accompanying person in the counselling session

If the woman was accompanied by a partner/relative, 1. Yes

2.1

2. No

3. Not

applicable

was the accompanying person invited into the

4. Do not
know

counselling centre if the client desired? (together or

separately)

3.

Description of the current problem/Exploring facts: Did the counsellor

3.1

ask the client about her problem in detail, using 1. Yes

2. No

3. Not

applicable

open-ended questions? (symptoms, since when,

4. Do not
know

details about menstrual cycle, whether taken any

treatment before coming to the hospital any

associated probable causes and so on)

3.2

explore whether the patient has any other 1. Yes

2. No

applicable

psychological or family problems or tension?

3.3

explore the food habits and diet of the patient9

3. Not

1. Yes

2. No

3. Not

applicable

3.4

1. Yes

see all reports and papers?

2. No

3. Not

applicable

4. Do not

know
4. Do not
know

4. Do not

know

4. Exploring client’s understanding about her problem : Did the counsellor

4.1

ask the client to explain what she knew about the 1. Yes

2. No

3. Not

applicable

treatment/investigations advised by the doctor9

4. Do not

know

5. Giving Information: Did the counsellor provide information about

5.1

anatomy and physiology of menstrual cycle?

1 Yes

2. No

3. Not
applicable

5.2

how the brain controls the hormone level which 1. Yes

rgz’ rb-

3. Not

applicable

affects the menstrual cycle?

162

2. No

4 Do not

know
4. Do not

know

rtr

I

5.3

the probable causes of irregular menstruation?

1. Yes

2. No

3. Not

applicable
5.4

1. Yes

the importance of investigations?

2. No

3. Not

applicable

5.5

1. Yes

the importance of a balanced diet?

2. No

3. Not

applicable
5.6

the importance of completing the course of

1. Yes

2. No

applicable

medicines prescribed?

5.7

3. Not

1. Yes

the importance of follow-up visits?

2. No

3. Not

applicable

4. Do not

know
4. Do not

know

4. Do not

know
4. Do not

know
4 Do not

know

6. Giving reassurance

6.1

Did the counsellor reassure the client, telling

1. Yes

2. No

3. Not

applicable

her that the investigations and treatment may

4. Do not

know

take time and that she should not become
impatient?

7. Information on man’s responsibility to the partner: Did the counsellor provide information to
the partner regarding:

7.1

the anatomy and physiology of the menstrual

1. Yes

2. No

cycle?
7.2

applicable

how the brain controls the hormone levels which

1. Yes

2. No

affect the menstrual cycle?

7.3

3. Not

3. Not

applicable

the probable causes of irregular menstruation?

1. Yes

2. No

3. Not

applicable
7.4

1. Yes

the importance of investigations?

2. No

3. Not

applicable
7.5

the importance of a balanced diet?

1. Yes

2. No

3. Not

applicable
7.6

the importance of completing the course of

1. Yes

2. No

medicines prescribed?
7.7

3. Not

applicable

the fact that investigations and treatment may

1. Yes

2. No

take some time and therefore the need for

3. Not

applicable

4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know
4. Do not

know

patience?

7.8

the importance of follow-up visits?

1. Yes

2. No

3. Not

applicable

4. Do not

know

8. Encouraging clients to ask questions and share difficulties: Did the counsellor

8.1

ask if the client had any queries or doubts?

1. Yes

2. No

3. Not

applicable

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4. Do not

know

163

8.2

8.3

1 Yes

answer the questions raised?

2 No

applicable
1. Yes

ask the client if she had any difficulties regarding

2. No

1. Yes

(If the client had any difficulties) discuss the

2. No

3. Not
applicable

problems and suggest ways of overcoming them?

9. Confirming whether the information given is

3. Not

applicable

treatment or investigations?
8.4

3. Not

4. Do not

know
4 Do not

know
4. Do not

know

understood by the client before she/he

leaves:
__ __________________
Did
the
counsellor
ask
the client whether she
9.1

1. Yes

2. No

3. Not
applicable

had any doubts or queries regarding the

4. Do not
know

information given?

9.2

ask her to repeat the key points of the information

1. Yes

2. No

applicable

provided?

9.3

ask the client to repeat the date fixed for follow-

up visit?

164

3. Not

1. Yes

2. No

3. Not
applicable

4. Do not
know

4. Do not

know

Handout 8.5
Client Card
Fact Sheet for Recording Counselled Cases

Age:

Date:

Name of the Patient.

Centre Sr. No.:

Address: T/P

Husband’sAA/ife’sSr. No.:

Code No..
Case Paper No.:

Visiting Mumbai

Resident of Mumbai

Referred By:

Gynaecological History (To be copied from the case paper)

Household / Family Information
Household Size:

Earners:

Children:

Adults:

Age

Education

Occupation

Monthly Income

Patient

Husband/Father

I

NL - Non literate

HM - Home Maker

UN - Unemployed

165

Handout 8.6
Checklist for observing Internal Examination
Yes

No

n.a.

1 Did the provider explain the procedure of PV. and what was going to
happen to the patient ?
2. Were the following instructions given to the patient before the examination^
a. Empty your bladder

b. Remove your underwear

c. Please lie down on the table inside the room
d. Please step on the stool and get onto the examination table
e. Keep your legs here and move down slowly
f. Take your clothes up from behind

g. Bring your waist down

h. Spread your legs or/and fold them
3. Did the female Attendant/Nurse giving Gynaec. position

explain to the patient politely ?

4. Was the patient made to take the lying position hurriedly ?

□

5. Was the patient given time to prepare (untying , loosening clothes)
for the examination ?

6. Was there privacy during derobing?

□

7. Were the legs of the patients covered with a sheet during

the examination?
8. Were the following instructions given during internal examination
a. Loosen your tummy

b. Take a deep breath
c. Don’t get scared

d. Spread your legs
9. Were the above instructions given politely?

10. Was the doctor trying to distract her by talking to her

during the examination?

166

□ □ □
□

□ □

11 Was the woman made to get up from the examination table
hurriedly?

12 How much time elapsed between giving position to the woman

1

□

Eq]

and doctor’s examining her? (minutes)

13 Was P.V. done in a careful, gentle way?

c

(To be judged from the reactions of the patients).

14. Was the nurse or attendant present during the examination?

15 Were the findings of the internal examination explained

□
□ □ □

to the woman ?

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Sample of Case Paper

Ape

L HISTORY

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Handout 8.8
Checklist to Observe the Instructions and Information

Regarding Treatment and Follow-up
Name of the observer:

Client number:

Date :

Time:________
For each question, please circle the appropriate option

1.

Diagnosis

1.

Did the provider explain the Diagnosis?

r
1. Yes 2. No

3. Not

applicable
2.

Treatment

2.1

Did the provider tell from where to take medicines / 1. Yes

2. No

applicable

drugs
2.2

3. Not

Did the provider tell how to take or use the medicine? 1. Yes 2. No

3. Not

applicable
2.3

Did the provider tell for how long to take the 1. Yes 2. No

applicable

medicine?
3.

Follow-up

3.1

Did the provider tell her when to come back?

3. Not

1. Yes 2. No

3. Not

applicable
4

Giving Instructions

4.1

Did he/she repeat the instructions if patients did not 1. Yes 2. No

applicable

understand?

4.2

Did the provider ask the patient if she has any

1. Yes 2. No

Did the patient ask any questions?

3. Not

applicable

doubts/questions?

4.3

3. Not

1. Yes 2. No

3. Not

applicable
4.4

Did she ask anything related to sexual

1. Yes 2. No

relationship or any other sensitive questions?
4.5

Did the doctor clarify or answer them?

3. Not
applicable

1. Yes 2. No

3. Not

applicable

4 Do not
know

4. Do not
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4. Do nc
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>

-------------------------------------------------- :------------------------------------170

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Handout 8.9

Episodes for Analysis of Reproductive Rights
Case 1
A woman who had two children came to remove the copper-T after three and a half years. She told the

doctor that her husband wanted to have another child and she was having profuse white discharge

Doctor asked her for proof that the woman was using the copper-T for three years and also insisted
that she could not remove this copper-T unless the woman was willing to insert another one. The

doctor also told her that two children are enough. When the patient tried to express her point of view,

she was told to go away to the place where she had got the copper-T inserted and was accused of
lying about the symptoms. The patient left the room looking dejected.
Case 2

A woman came fora pregnancy test. While checking, the doctor asked her if she wanted to have the

child. The patient replied in the affirmative. The doctor looked at her paper and said in a raised voice.
“You already have two children, don't you? So why do you want to have another one9 Two children are

more than enough, don’t you understand?" The woman said, “my husband wants it. what can I do?"

Case 3

After examining a patient internally, the doctor asked the patient, "Are you accompanied by your
husband?" When the woman said, ‘yes’, the doctor asked her to call him in. The doctor told the
husband, before explaining to the woman, “She has got ‘gaanth’ (a lump ora swelling) on her 'pishvi'

(Uterus). Get all her investigations (tests required before the surgery) done. You need to donate
blood for the operation or get a donor s card to get the blood from the blood bank. One never knows
she may need a bottle or two. After she is taken for the operation nothing can be done so keep the

blood ready. The operation is big because the ‘gaanth’is big. Therefore it is essential to remove her
‘pishvi’ and anyway, now, what does she need the ‘pishvi’ for? She does not want to have children; she
does not get her periods..."
While the doctor talked to the woman’s husband over her head, she looked increasingly uncomfortable

and worried. When the patient heard the doctor’s last words, she immediately tried to say. “No, no. I
still get my period." The doctor dismissed this by saying, “Oh, but it does not make any difference.

Now you come after your menses for the operation."
Case 4

The doctor told a woman who had come for antenatal care (ANC) not to have intercourse with her

husband. The observer asked the doctor whether she could tell this to the patient's husband and
asked the woman whether her husband was accompanying her. The husband was waiting outside the
>■

OPD and the patient was ready to go and call him but the doctor said that she did not have time to

talk to the husband.

•2

171

4

1

1

F
CaseS
A woman wanted a Copper-T instead of tubal ligation (TL) after the MTP. She has already had two
children aged 5 and 3 years. The doctors insisted that she choose TL as her younger baby was three

years old She revealed to the observer that she was reluctant to accept TL as a method because
she was concerned about the aftercare. She lived in a loft, which had a steep ladder, and she had to

fill water everyday from a tap in the neighbourhood and was worned about climbing the ladder carrying
the weight. She wanted the Copper-T till she could arrange for some relative to come and stay with

her who could help her to fill the water. Also she wanted the operation after two months when her
children s exams would be over.

Case 6

A woman came to the OPD requesting forMTP She already had two daughters. The doctors refused

to do only MTP and insisted on also doing a tubal ligation. The woman was also anaemic. She kept

repeating her request for an MTP while agreeing to getting a copper T inserted. She left the OPD,
crying . Outside the OPD, she and her husband started discussing what had happened inside the

consultation room. From this conversation the observer found that the couple had already done the

Amniocentesis (foetal sex determination test) and wanted to abort the female foetus, as they wanted

a male child. During the conversation the woman kept telling her husband, "Let's keep this baby and
do the TL or let’s go for TL after the abortion". The husband got angry and started shouting at her.
Finally they left the hospital saying that they would go to a private clinic.

Case?

The mother of one child came for an abortion. She started crying, when the doctor asked her the
history of her previous deliveries. She kept insisting that she wanted to abort this baby. The doctor

patiently asked her for reasons. After sometime the woman revealed that her first child was mentally
retarded and she had had two still births after that. She said that she was scared that this time too

she would have an abnormal child. After listening to her carefully the doctor assured her that she, the
doctor, would take all the care and precautions to see that the child was healthy. The doctor referred
the patient and her husband for a blood test and advised her to come regularly for the follow up. The

patient looked relieved and satisfied.

Case 8
A new patient came to the OPD and the doctor started interviewing her for the history.

Dr.

Kitna bachha hua? (How many children do you have?)

Patient:

Do (Two)

F

Dr.

kya tu abhiphir se pet se hai? (Are you pregnant again?)

|

Patient: Nahi (No)

172

Dr.

Yeh mahine mein masik aaya tha? (Did you get your menses this month?)

Patient :

Han (Yes)

I

Dr

Phir bachha chhahiye kya? (Do you want another child?)

Patient

Nahi (No)

Dr.

Phiraapko kya chahiye? do bachhe hai na gharpe? (You have two children at
home then what more do you want?)

The patient removed a small piece of paper and gave it to the doctor. The doctor spoke out impatiently,
yeh sab hamko mat batao (Don't show me all these notes)", and threw the paper on the floor. The

patient got very scared and went out of the OPD. The observer picked up the paper which the doctor
had thrown. On the paper was written (in broken Hindi) 'Do bachha hoke mar gaya. Phir char mahina
masik nahi aaya. Phir kabhi masik aata hain, kabhi nahi aata hai. Thodasa khoon jata hai. Phir pet
mein bhi dard hai. Abbi bachha chahiye (Two children died. Then she did not get her menses for 4

months. Now in some months she gets her periods and in other she does not. The menstrual flow is
very little. She also has pain in the abdomen. Now, she wants to have a child).

On reading the paper, the observer went out of the OPD to look for the woman. She was standing

outside with a scared look on her face. The observer asked her whether that paper belonged to her.

She said, ‘‘ha, hame bolneko ata nahi, is Hye aadmi ne likhke diya hai." (“Yes, my husband has
written this because I cannot speak Hindi and cannot express my problem.")

The patient was asked to come in again and a student doctor took her history. The doctor had to

struggle to understand the patient because of her difficulty to talk in Hindi, but the information on the
slip helped the student doctor to identify her real problem and get started on the history taking.

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173

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Handout 8.10
Reproductive Rights

REPRODUCTION AND SEXUALITY AS HUMAN RIGHTS

Reproductive and sexual rights are founded on many principles common to human rights that
governments are obligated to respect, such as

•

Uiimnn
i iui i tai i

•

Equality and non-discrimination

•

Bodily integrity

•

Self-determination (the ability to make decisions for one's self)

•

Privacy

•

Liberty and security of person

•

The right of access to health care, including reproductive health care

•

The rights of the child

my

Another way of thinking about reproductive and sexual rights focuses on the ultimate goal of equality.
Since control over reproductive and sexual life is central to women's existence, women need to have

these rights in order to be able to participate fully in society, not just in a manner equal to, or identical
with, men but in a fair manner that addresses women’s needs. Equality for women in their reproductive
and sexual lives improves the conditions of men and children as well; when these human rights are

more respected in society, the standard of living is higher, birth rates lower and health care better.

Reproductive Decision-Making

Women and girls make many decisions about their reproduction and sexuality, including:
Whether to obtain information regarding sex
i

Whether to engage in sexual activity and with whom
Which contraceptive methods to use, if any

Whether to request a male sexual partner, including a spouse, to use a condom

Whether to have children
Whether to seek medical attention during pregnancy

With whom to have children
When to have children

How many children to have
Spacing of children

With whom to bring up children

Whether to abort an unwanted pregnancy

174

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However, women's choices are often imposed or limited by direct or indirect social, economic and

cultural factors. For example, in some countries where women are allowed little participation, or
where governments impose strict population policies, women may feel forced to decide between
abortion of the female foetus, infanticide of the female newborn baby or neglecting a female child until

she dies. In many countries an unmarried pregnant girl is told to have the baby quietly and then give

the child away to a married couple. Otherwise, her only other option is to raise the child alone in
poverty with few prospects for the future.

THE LEGAL FOUNDATIONS OF REPRODUCTIVE HUMAN RIGHTS

•

The right to liberty and security of the person: Universal Declaration of Human Rights (UDHR),
Article 3: International Covenant on Civil and Political Rights (ICCPR), Article 9(1).

•

The right to health: International Covenant on Economic, Social and Cultural Rights (ICESCR),
Article 12.

•

The right to non-discrimination in the provision of health care and in the family. Convention on
the Elimination of All Forms of Discrimination Against Women (CEDAW), Articles 12(1),
16(1).

•

The right to marry and to found a family: UDHR, article 16(1): CEDAW, Article 16(1): ICCPR,
Article 23(2).

•

The right to freedom from arbitrary or unlawful interference with privacy, family and home:
ICCPR, Article 17(1).

•

The right to enjoy scientific progress and consent to experimentation: ICESCR, Article 15(1).

•

The right of sexual non-discrimination: CEDAW, Article 1-2; UDHR, Article 2; ICCPR, Article
2(1); ICESCR, Article 2(2).

•

The right of men and women to have, on a basis of equality, access to family planning:

CEDAW, Article 12(1).
I

•

The right of rural women to family planning: CEDAW, Article 14 (2) (b).

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175

Handout 8.11
Role-Play Situations on Contraception Counseling

Case study 1
A woman has three children, two sons aged 7yrs. and 5 yrs. and one daughter 3 years old. The woman
is a housewife while the husband works as a salesman in a cloth shop. She comes wUh her husband
to you because they do not wish to have any more children. How will you deal with the s.tuabon^

Case study 2
r
A woman has a two year old daughter and has been using oral pills since the last year. She comes
to you saying that nowadays she gets headache and nausea which she is associating w,th mtake of
the pills. She wishes to discontinue the pills but does not wish to have another ch,ld for next two

years. Also she is scared of Cu-T as she has heard from her neighbour that there is heavy bleeding
during menstruation. She has come to you for consultation.

Case Study 3
A woman comes to you saying that she is getting a lot of foul smelling white discharge and pain m
lower abdomen since three months now. She had got an IUD inserted a year back and she associates
the discharge with the IUD use and wants to discontinue it. She has two daughters aged 7 and 5.

Advise her. (On examination it was found that she had a reproductive tract infection)

>

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176

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Handout

8.12

Technical Information on Contraceptive Methods
IUCD - Copper-T
When can a Cu-T be inserted?

1. After MTP
2.

Last day of menstruation

3.

After a delivery

Most useful for maintaining spacing between children

Complications
1.

Problems during menstruation
Abdominal pain

More bleeding than normal

Irregular period
2.

White discharge

3.

Displacement or expulsion of cu-T

4.

Ectopic Pregnancy

5.

Conception along with Cu-T

Types of IUCD
1.

Cu T 200 B (Government Supply)

2.

Multiload 250/375

3.

Silverlily

4.

Merina (IUD with hormones)

Follow-Up

1. One month after insertion, or after the first period after insertion
2.

After every 6 months

3.

Whenever woman feels discomfort or experiences problems

•

Cu-T is effective immediately after the insertion

•

When used for spacing between two children, a woman should plan for the next conception

immediately after the removal of the Cu-T

•

Once family is complete and the couple does not want any more children they should opt for

terminal methods like Tubal Ligation (TL.) or Vasectomy because it could be harmful to keep
changing Cu-T

•

Cu-T never causes cancer. But if proper follow-up checking is not done, frequent infections could
lead to cancer.

rb>°

177

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Oral Contraceptive Pills

Advantages of pills
1.

Helps in regulating menstrual period

2

Prevents excessive bleeding during menstruation

3.

Increase in weight

i

Types of Oral Contracptive pills

•

Hormonal

Non-hormonal

Hormonal pills

Sequential pills
Combined Pills
Mini Pills

It is absolutely necessary to take a

pill everyday without fail

Harmful side effects of pills
1.

Excessive weight gain

2.

Less bleeding during menstruation

3.

Post pill Amenorrhoea

4.

Increase in blood pressure

i

These effects are observed only after continuous use for many years

t

Condom

l

Not very popular

I

Failure rate is due more to irregular and faulty use

I

Other advantages
1.

Prevention from STIs

2.

Prevention from Al Ds

Some people (men and women) experience allergy due to Condom

Tubal Ligation

Woman’s sterilisation method

Types

178

•

Laproscopic T.L.

•

Abdominal T.L.
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Laproscopy

•

One day surgery

•

Can be done by use of general or local anaesthesia

•

Only one stitch

•

Not much after care required

Abdominal
Done by opening abdomen

Most suitable or advantageous

1.

For women who are medically fit

2.

When done along with the MTP

3.

After a delivery

4.

On the last day of menstruation

Pre-operation -Investigations

1.

Hb/CBC/ESR

2.

Blood group

3.

Urine

4.

X-ray chest - PA

Vasectomy
-

Not very popular
Need to promote this method

Advantages of Vasectomy over T.L.

1.

No need for anaesthesia

2.

No need for admission in the hospital

3.

Very easy to perform (no scalpel vasectomy)

4.

No need for post-operation rest

Role of men in contraception decision- making

1.

Initiate dialogue and communication with the partner and decide together

2.

If woman experiences some discomfort with adopted method accompany her to the doctor

3.

Be aware that contraception methods for men are safer and make a responsible decision

to use them

I

4.

If woman is not medically fit forT.L. volunteer for vasectomy

5.

Respect woman’s wish and support her at home and outside

179

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OVER-HEAD TRANSPERENCIES

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OHT 8.1
Gender Stereotype Pictures

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OHT 8 2
What ,s Gender?

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Characteristics of Gender

Definitions of Sex and Gender
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Sex refers to the biological differences

_________________________________

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Relational

•

Socially Constructed

between men and women.

»

Hierarchical

•

Power relations

Gender refers to roles (behavioural norms)

.

Changes

•

Changes over time

that men and women play and the relations

•

Context

•

Varies with ethnicity,

that arise out of these roles. They are soci
i

ally constructed, not physically determined.

class, culture, etc.

•

Institutional

•

Systemic

I

185
I

OHT 8.3 (A)
Gender as a System
Certain beliefs in society about men and women

■

(e.g. men are strong, women are weak, men are rational, women are emotional)

I

—^Defining different gender norms which govern the behaviour of men and women in society

(e.g. men can express themselves, men can be articulate,
women must not express themselves or be articulate)

------------------------------------------- > Different gender norms

) Define different gender roles for men and women
(e.g. men must be breadwinners, women must be carers, nurturers)
I

—?

Sexual division of labour

(Productive for men—earning income/wages Reproductive for women—caring, nurturing social
reproduction; Community leadership for men (e.g. Sarpanch). Informal leadership

I

without public or formal recognition for women (e.g. dai, wise women)

-^Different activities and tasks for men and women (Women’s tasks undervalued and invisible,

I

(e.g. cooking, cleaning, women’s work fragmented, public domain for men, private for women)

?

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.. Differential Access to and control over resources

(Resources like money, land, technology, knowledge, self esteem, time, space)

——————

Differential decision making and power

Those who make decisions and have power are the ones who influence social beliefs and gender

norms for behaviour, sexual division of labour and access to and control over resources.

Thus, this is a system which feeds on its subsystems and perpetuates itself. The beauty of the
system is that it can be broken anywhere - either by changing social beliefs, or by changing norms
for behaviour of men and women, or by changing the work that men and women are supposed to

do, or in the allocation of resources. Thus it can be seen that gender constructs can be changed

over time, over space, over contexts.

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OHT 8.3 (B)
Gender As a System
How gender works as a system

—Beliefs in society
—Gender norms
—Gender roles for men and women

Sexual division of labour

—7

—Different activities and tasks for men and women
Differential Access to and control over resources

—7

Differential decision making and Power

OHT 8.4
Gender Dimension and Rights Violations
■

Anaemia in Pregnancy
_______________________________________________________________________ ■

Aspect

______

Causes
Response of the individual

Accused of malingering; no sharing of workload; no treatment
Self-blame; works hard despite weakness

Response of the provider?

Not available; blames her for not seeking help in time

■

■

.

.

.

'

■■

■

_______________________

i

I

Gender and Rights Dimension__________________

Dietary customs; workload; repeated pregnancies/abortions

Response of the family

i

__________ .

OHT 8.5
Types of Questions
Cfosed questions
Closed questions are short answer are in terms of: yes/no/number.
Are you educated?
Do you have problems when having intercourse ?
If / understand you well then you are saying that your periods were regular till last year, and

then you got MTP (thaili saaf) done, after which you are having heavy bleeding ?
Open questions

Open questions invite respondents to give their ideas, feeling and opinions in their own words. Start

with how, what, when.
Tell me more about your relationship with your husband.
What do you think about a person having AIDS?

Lading questions
Leading questions are questions which suggest a certain answer

Do you think bleeding occurred because you traveled so far in the bus ?

3i5dgments
Avoid statements that indicate what you find good or not-so-good.

What? You have four children already! Do you think it is right?
It is very good that your husband does not mind using condoms.

Pcccr.c questions invite the respondent to talk in more detail about an issue.
You say you did not come for the follow-up because you had family tensions. What was the
fami.’y problem you had?
Tc get the maximum accurate information and facts, in the history-taking one should try to avoid
asking leadmg, judgmental and only closed questions.

OHT 8.6

History-Taking in Gynaecology
3e aware of, and sensitive to, the needs of

women.

Provide privacy- visual and audio
Establish rapport - make the patient feel
comfortable
• Make her sit down
■
"

•
-

1S8

Be respectful’
Maintain eye contact
Ask simple questions in the beginning
Be patient
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•

Ask open-ended questions
Avoid leading and judgmental questions

•

Use local terminology, knowledge of local
cultural festivals to determine time of onset
of the problem
Believe in the woman

•
•
•

Use a gentel tone and avoid judgments to get
correct obstetric history
Sexual history - Are you comfortable talking

about sexuality?
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OHT 8.7
List of Conditions and the Investigations Required
anc

Menstrual problems

•

Haemoglobin (Hb)

Blood

Urine

•

Complete Blood Count (CBC)

Hb

Proteins

•

Sonography

VDRL

Sugar

•

Hormonal assays

Blood group

Sonography

Infertility
For Women

For Men

•

Hb

Hb/CBC

Blood Group

Blood Group

VDRL

VDRL

•

Post prandial blood sugar

•

Fasting and post lunch blood sugar

•

Urine

•

Urine (routine and microscopic) fasting and post glucose

•

Semen analysis

•

TSH

HSG

T' Xy •
■

s?

•

Ovulation Tests

•

X-ray PA View

»

USG Pelvis

■

Hysterectomy
Hb

•

Urine (routine and microscopic)

•

CBC

.

Blood sugar

•

Blood group

IB

ft

I

■

189

OHT 8.8
Instructions on Treatment and Follow-up

No money to buy medicines or travel to health

Violence by husband / family member.

care facility frequently.

She forgot the date.

•

May be going out of town

She could not get leave from work.

•

May not have anybody to take cafe of her.

Time was not convenient.

•

Children small- problems arranging for child care.

Reaction to the prescribed medicines

•

Fallen sick or someone at home was sick

Heard something about the treatment or

•

Arrival of unexpected guests at her place.

operative procedure from neighbours and

•

Urgent family matter to attend like death,

discontinued the treatment

•

marriage or festival celebration.
If a woman fails to follow-up

Avoid saying

Reassure her

If you care for yourself, you won’t be doing this

ul have understood your problem and we will

or would be doing this.

try to do all the needful to minimise your

I know or you know better? —who is the doctor?

problem."

If you do all that I tell you, you will be all right.

Emphasise woman’s responsibility and

Instead, one can say

participation in the treatment process

It will require both of us to make efforts for

-

Taking the whole course of medicines

your well being, I expect your cooperation,

-

Coming in time for follow up

only then I can do my Job properly.

-

Sharing personal problems relevant to her

Do you think you can do this? Is it possible for

you to follow the advice?

I

health issues.

-

t

Following advice and preventive behaviour

Kindly tell me or feel free to express or ask

and by expressing openly her inability to

about all your difficulties regarding the

do the above.

prescribed treatment.
Can you tell me next time what your husband or
mother-in-law says about this?

I
190

i

OHT 8. 9

Reproductive Rights of Clients Using Contraceptive Services
(Source: IPPF)

Right to Access: Clients can obtain •

Rights to Privacy: To have private

services regardless of sex, creed, colour,

environment during counselling or services

marital status or location

•

Right to Information: Accurate and

any personal information will remain

detailed information related to the benefits

confidential

and availability of contraception services
•

Right to Confidentiality: To be assured that

.

Right to Choice: Clients given choice to
.

z

Right to Safety: To be able to practice safe

and effective use of contraception
Rights to Comfort: To feel comfortable

when receiving services

&

consideration and attentiveness

...

decide freely whether louse contraception .
•
and which method to use
•

Rightto Dignity: lb be treated with courtesy

Right to Continuity: To receive contraceptive
services and supplies for as long as needed

Right to Opinion: To express views on
services offered

OHT 8.10
Woman Centered Contraception Counselling
Mission Statement

Statement of Purpose for which our programme exists

•

To provide gender sensitive, women- centered Reproductive Health Services to our clients

•

With special reference to Contraceptive Counselling in Public Health Sector

Our Goals
Make the clinics

•

Assure confidentiality

-

Client-friendly-

•

Inform them adequately about various contraceptive

-

Men-friendly

•

Respect clients dignity

•

Protect client s privacy

methods
e

Give them Right to Choose
Prepare concrete Plan of Action for giving Quality Care

Identify Constraints

•

Infrastructure

•

Community Education Material Requirement

Space

•

Recurring expenses

Restructuring Plans Budget

•

Face-Lift to the Clinic

Curtains, Comer

•
•

Attitudinal Change
Suggestions/Solutions/Modifications in Existing

-

Furniture

Manpower

•

System

Training Needs
-

Topics, T«me, Methods

Reproductive Health Services

Need to Be Added

Offered

Ante Natal Care

•

Comprehensive Care for RTI/STI

Post Natal Care

•

Adolescent Health Care

MTP

•

Well Woman Clinic

Contraception

•

Menopause Clinic

RTI/STI/Genital Cancers
Paradigm Shift
Patients

I know what’s good for her

-

192

Clients
She can choose what she feels is

Prescribing
| Telling

good for her
Informing
Counselling

[ Advising

Helping

Client-Friendly Clinic

•

Women should feel like attending

•

Recommending it to others

•

Dignity

-

Do not undress her whout covering her properly

-

Instructing UG Students

-

Restricting number of educational Examinations

-

Addressing her with respect

-

Make her and the accompanying person comfortable

Men-Friendly Clinic

•

Current clinics unfriendly to Husbarfas

•

Men remain uninformed/uninvolved resulting in low participation

•

Concept of Couple Counselling

•

Men are Decision- Makers in the family

•

Men participation vital
-

Condom Use & Safer Sex Practices

-

Vasectomy

-

STI/HIV Transmission Prevention

Client’s Privacy

•

Cabins/Curtains/Partition

•

Allowing ONLY one Client with her accompanying person in the cabin at a time

•

Not only while examining but even during CONVERSATIONS, Sample Collection

•

Constraint - Inadequate Space

Confidentiality
•

Privacy

•

Talking in soft tone

•

Avoid quoting her problems/diseases

•

Avoid writing embarrassing facts on the Hospital Record like Unwed Primi

Information about Contraception

s

Ensuring Understanding

•

Benefits - Contraception & Non-contraception •

Exit Interviews

•

Side effects & adverse effects

Direct Observation Technique

•

How much?

Test of Understanding

-

What is Too Much?) Client dependant

Information

-

What is Too Little? )

•

Client should understand & grasp

•

Standardised IEC Material

-

Simple & easy to understand

-

Focused key messages

•

-

Adequacy

-

Accuracy

OHT 8.11
Referral Guidelines
Before referring

1

Know complete information about the referral centre

2. Make umely referrals.
3. Build rapport with referral centre staff
4.

1Consider Time, Distance, Cost when deciding where to refer

I

financial constraints, if any, with the patient
5. Discuss
I
reason for referring, importance of attending the referral unit and implications
6. Explain
I

7. IBe aware of reasons, difficulties that the patients may have for not visiting the referral centre.

i

1
I

Reasons or barriers for not attending the referral services

•

Past negative experience with a particular referral unit

•

Not convenient in terms of cost, distance, time

•

Urgent work

•

Patient was unwell

.

Restrictions from family members

i
i

i

How to deal with the problems of failure to attend referral centre

i

•

Ask reasons for not visiting and suggesting alternative referral centre if necessary.

•

Check whether patient wants to go to a particular centre of her own choice for referral and
reasons forthat

•
•

SB

Fill the referral slip completely.
Follow-up referral by asking for feedback from patients and doctors from the referral unit

i
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1

ANNEXURE
Annexure 8.1

Sample of Poster on the Investigations to be Displayed in the OPD

Investigations
Hb

Cost

Why is it done

What time

Where is it done

OPD No.

CBC

Sonography (USG)

Urine
Stool

X-ray
Blood sugar
Blood group
ECG

VDRL
Semen analysis

Serum TSH
Proteins

Hormonal assays
LET

RET
Serum Prolactin

Note: One can add the details depending on the facilities available in the hospital

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__

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Chapter 9
Communication and Counselling around Adolescent Girls’ Health Issues

Adolescence is a transient phase, marked with storm and stress. All age groups have their somewhat

clear-cut developmental demarcations, but when we talk about adolescents, the range may have no
limits. As we all know it is a stage where the person is neither a child nor an aHult, so neither the

norms set for children, nor those for adults apply to them fully. In this stage of life adolescents want

to move away from adults and establish their own identity. Therefore, they may not appreciate any

long term relationship — with parents or guardians, or any adults, and are rebellious towards adults

in authority positions. It becomes a challenge for adults to build rapport with adolescents. This very
thing makes counselling adolescents a very unique feature.

This confusion along with varied physical and emotional changes, changing expectations and now
the effect of mass media and internet makes this group very vulnerable to experimentation, rebelliousness
and risk-taking behaviour. Hence counselling the adolescent population requires special skills. Though
adolescent boys and girls both may require counselling, this module focuses on the needs of adolescent

girls, in particular on unmarried, adolescent girls. Handling of adolescents is an extremely skillful job,
requiring knowledge of the developmental stages, and emotional maturity. The seeds of healthy,
confident and meaningful womanhood could be laid in adolescence.

Adolescent Girls coming to the Gynaecology OPD
Adolescent girls coming to the gynaecology OPD generally come with problems like menstrual

disorders, reproductive tract infections with symptoms like white discharge and itching on the genital

area and unwanted pregnancy without marriage Some may also come with indications of sexual
violence but they do not report these. Due to the sensitive situations they find themselves in, the
counselling techniques used for adolescents differ in their approach.

Many of the girls are lost in the crowd of women waiting in the OPD. The OPD looks like a place not

meant for them. They are scared of internal examination. Incase of primary amenorrhea, if the doctor

wants to check whether their secondary sexual organs have developed or not they also have to
undergo breast examination which may be extremely embarrassing for them. Adolescent girls who

come with menstrual disorders or with reports of white discharge find it difficult to give consent for
internal examination. They find the OPD atmosphere inhibiting and scary. This leads to tension
resulting in rude behaviour from the doctors or other staff and sometimes the girls go without the

consultation.

p
■■

In case of unwed pregnancies the girls have to face the awkward questions of the doctors, and other

staff who show more than necessary interest in their case. All these situations make adolescent girls

>

a vulnerable group among patients who come to the Gynaecology OPD. Therefore they need special

attention to reduce their fear, shame for seeking help from a doctor and for the examination. They also

need counselling to cope with the trauma of unwanted pregnancies and MTP.

Module Objective
The purpose of this module is to develop sensitivity and understanding of the social problems
associated with the health problems and needs of adolescents, particularly unmarried adolescent
girls, and to develop skills for counselling adolescent girls.

Session 1

What happens in Adolescence?

Learning Objectives

At the end of the session the participants will be able to
•

reflect on their personal experiences and relate it with adolescents needs

•

realise the importance of understanding adolescent behaviour

Time

1 hour 30 minutes

Resources

Handout 9.1 Understanding Adolescence

Methodology

1.

The facilitator asks the participants to form pairs

Each pair discusses their personal experiences of adolescence, with respect to one
of the following aspects, with each other. (15 minutes)

•

First menstruation (first experience of ejaculation or masturbation or night emission

for men), feelings associated with it and reactions of others

•

Bodily changes and feelings associated with it

•

Relationship with parents and siblings (expectations and conflicts)

•

Freedom and restrictions

•

Friendship and peer pressure

•

Friendship with opposite sex

•

Dressing and role models

•

Decision about studies/career chosen

The pairs share their experiences in the larger group (45 minutes—each pair 5 minutes)

highlighting feelings, reactions of people around and expectations from others

At the end of the sharing the facilitator draws out the salient features of the nature
and behaviour of adolescents and emphasises on the need for special skills to work
with adolescents, j

198

Facilitator’s Note
Make sure that participants do not repeat to others what they shared in their pairs.

They have to focus on their feelings during adolescence, reactions and expectations
of people around them.

Points to Emphasise

•

Adolescence is a phase of rapid physical and emotional changes.

•

Girls and boys have a range of special needs during this phase — social needs,

health needs, sexuality related needs, emotional, educational and career
guidance needs.

•

We need to be especially sensitive to needs of adolescents and develop skills to
keep communication going with them.

Session 2

Health and Information needs of Adolescents

Learning Objectives

At the end of the session the participants will be able to

•

list common, general and reproductive health problems of adolescent girls.

•

know what are the specific health information needs of adolescents.

•

analyse the needs of adolescent girls having reproductive health problems and

list the role of health care providers in terms of sensitivity and skills to work with
them in an OPD setting.

Time

1 hour

Resources
Black board, chalks

Handout 9. 2 FAQs by adolescent girls

Handout 9.3 Episodes of adolescent girls visiting the Gynaecological OPD
i

Methodology
i

I
i

1.

Divide the participants into four groups

Each group discusses the following aspects and make presentations to the larger group.

•

Common health problems (general and reproductive) occurring during

adolescence (can also share their own personal problems as they remember

i

them or those of their adolescent children)

x

•

What social factors underlie these health problems.

•

What are the likely ways of addressing and solving them.

•

Read the episodes Of client provider communication (Handout 9.3) and list down
role of health care providers in terms of addressing the needs of the adolescent

ft

in the case studies.

199

Facilitator’s Note
The participants are encouraged to share their own experiences.

Points to Emphasise
•
Girls have a range of information needs related to their bodies and health.

•

Girls need time to talk about their problems, health care providers need to be

gent! ? and patient while dealing with adolescent girls.

•

They need explanation of what an examination entails.

e

They need to be allowed time to ask their questions and seek reassurance from
health care providers.

Session 3

Practicing the skills

Learning Objectives

At the end of the session the participants will be able to

•

take the history of the adolescent girl in a sensitive and effective way

•

provide basic counselling services to the adolescents visiting the OPD

Resources

Copies of case studies for role play

Time

2 Hours

Methodology

1. Participants are divided into three groups
Each group is given a case study; they plan a role-play of the counselling session

Casel

A 16 year old girl comes with her mother to the health care facility Her mother
tells the doctor that she is having excessive white discharge. The discharge is

thin, watery having no smell. There is itching. She gets the white discharge
just prior to menses. She is having the problem since last six months. She

has discontinued her schooling after she failed in tenth standard. She stays at
home and helps her mother in household chores. Her menstrual cycle is normal.
Doctor finds no pathological cause and sends them to you for counselling.

Case 2

18-year-old Surekha comes to the hospital for MTP Doctor confirms the
pregnancy. She is not married. Her parents do not know about it. Her boyfriend

has left her after knowing that she is pregnant.

200

CaseS
17-year-old gid comes with the complaint of itching in vaginal area and foul

smelling white discharge. She is in a relationship with a boy in her community
Her mother does not know about this.

2.

Each group presents the role plays and the facilitator and other participants give

feedback emphasising the following points

3.

•

Communication Skills

•

Privacy

•

Sensitivity

•

Confidentiality

•

Knowledge

•

Woman centred and gender sensitive counselling

Facilitator summarises the needs of the adolescent in counselling for reproductive

health problems, based on the contents of the handouts and the principles of

woman centred counselling.
I

I

Facilitator’s Note

I

Affirm the developing communication and counselling skills of participants in the

I

role plays. Since this is the last session in this module, focus on summarising the

contents of the entire module.

Sources

Adolescent Girls’ Initiative, Mumbai, Amita Abichandani, Rohini Gorey, Vidula Patil

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HANDOUTS
Handout 9.1

Understanding Adolescence
According to the WHO, “Adolescence is defined both in terms of age (spanning the ages between 10

and 19 years) and in terms of a phase of life marked by special attributes. These attributes include
1.

Rapid physical growth and development

' 2.

Physical, social and psychological maturity, but not all at the same time

3. ^.Sexual maturity and the onset of sexual activity
4.

Experimentation

5.

Development of adult mental processes and adult identity

6.

Transition from total socio-economic dependence to relative independence.

Although researchers have defined and differentiated the stages of adolescence in different ways, all
definitions clearly indicate that the following changes occur during adolescence-

1.

Biological development in bodily size and shape

2.

Cognitive development

3.

Developing self-concepts and self-esteem

4.

Relationships with family, peers and society

5.

Sexuality and moral development

Bodily Changes on the onset of Puberty in Boys
1.

Increase in height, weight and muscles

2.

Deepening of voice due to larynx (voice box) growth

3.

Skin becomes oilier; appearance of pimples on face, neck, chest and back due to activation
of sebaceous oil glands

4.

Increase in production of sweat

5.

Appearance of pubic and facial hair

6.

Penis and testicles enlarge in size

7.

Development of testes and production of sperm accompanying first ejaculation

8.

Having strong sexual feelings

Bodily Changes on the onset of Puberty in Girls
1.

Growth in height and weight

|

2.

Widening of hips

|

3.

Increase in size and shape of breast

202;

4.

Appearance of pimples due to oily skin and activation of sebaceous oil glands

5.

Tendency to sweat more

6.

Under-arm and pubic hair growth

7.

Maturing of ovaries, uterus and vagina

8.

Beginning of menarche

9.

Romantic and sexual feelings

Sub-stages of Adolescence
Adolescence is generally divided into three sub-stages of development. The phase prior to onset of

ptiberty and adolescence is known as pre-pubescence or pre-adolescence. The person is not yet

aware of his/her sexual identity and is learning to master social skills and spend more time with the

family. Adolescence is divided in the sub-stages as :
1.

Early adolescence

2.

Middle adolescence

3.

Late adolescence

Studies available on adolescents suggest that adolescents exhibit different characteristics during

these sub-stages. Due to considerable overlapping of characteristics, these sub-stages cannot be
demarcated distinctly. These sub-stages are -

Early adolescence (11-13 years)
The stage is marked with the appearance of secondary sex characteristics along with rapid physical

growth. The characteristics of this stage are:
1.

Self-awareness regarding physical appearance; self-consciousness increases

2.

Self-esteem may increase/decrease due to parent or peer influences

3.

Emotional, impulsive, moody behaviour

4.

Risk-taking and adventure prone

5.

Movement away from family towards peers

6.

Unequal gender role distribution, inequalities in power and prestige affect self-esteem

7.

Increased socialisation among same sex groups

8.

Advances towards opposite sex

9.

Initiate sexual exploration

10. Dilemma regarding initiation and engagement in sexual activities

This stage also marks the beginning of formal operational stage of Piaget’s cognitive development

theory and cuts across the age of eleven years and above. The adolescents develop their

ability for abstract thinking and can “operate on operations” as compared to the previous stage
children who can only operate on reality" (Berk, 2001). The other aspects of development are-

11 Development of hypothetico-deductive reasoning capability
,2. cormal ooerahonal egocentrism, that Is. in.b.t, to d.stmguish abstract hemp.cb.es

se»

, 3 XosZai thought formation, that .s, th. ability to propose

*

14 DevelopmentofperspeclivetaKing.lhatis, lhecapacitytoimaginewhalotherpeople
thinking and feeling

Middle adolescence (14-16 years)
adolescence bungs dramatic changes m ado.escen.s due to
pressure The adolescents s« de.eloplng a varied o,

I

„ solve

deal with stresses of everyday life and improve attitude towards school. They

!
I

conflicts and problems. Common characteristics of the stage are

1

Physical and sexual maturation continues

2
3

Desire to seek privacy and isolation
Identity formation: increased ability to evaluate beliefs of self as ».« as others

4
s'

Growing distant from parents
Strong peer group Pending; peer Influence on self-image and social behaviour

6.

Development of personal code of ethics, values and beliefs

7.

Family influences religious values, education, and career

8.
9.

Attraction towards opposite sex increases
Initial sexual exploration, grows into sexual experimentation

I
I

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3
S

10. Masturbation

3

Late adolescence (16 - 19 years)
This stage calls (or a higher level of understanding as adolescents become comfortable and are able

stability in life. Some of the features are:
Understanding oneself better; developing self identification

51

1.

2.

Making career and vocation choices for future

3.

Becoming more reflective and responsible

4.

for balance between traditional and modern values
Striving
Conflict within self regarding acquisition of adult roles and responsibilities

5.

6.
7.
8.

Behaving according to social norms; greater social participation

Intimacy and commitment demanded in relationships

U

■
■

Peer influences lessen

w
4

1

204

Needs during Adolescence
Adolescence has its specific needs. These include....

1.

Social needs

2.

Difficulty in interpersonal relationship especially, communication with opposite sex

3.

Fantasy vs. reality

4.

Adjusting with environment - growing into adulthood from childhood

5.

Facilitating smooth adolescent-parent relationship

6.

Health needs

7.

General health needs for diseases

8.

Physical body changes at puberty

9.

Personal health and hygiene

10. Sex and sexuality needs

11. Counseling services for issues of sex, masturbation, sex abuse, etc.
12. Family life education and/or sex education in schools
13. Emotional needs

14. Adjustment with changing self
15. Mastering emotional stability
16. Emotional involvement/attachment with opposite sex

17. Educational/Career needs
18. Counselling and guidance

19. Inferiority complex due to poor performance

20. Adjusting with fellow students and environment
21. Coping with educational/professional stress

Source:

Women’s Health Training Research Advocacy Cell (WOHTRAC, 2003, January). Peer Education
Strategy to Build Life Skills of Adolescents for Healthy Living. Vadodara.

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Handout 9.2
What Adolescent Girls Want to Know

Frequently Asked Questions

regarding their Bodies and Health

Body Image concerns

How can one reduce weight?

•i

2.

Can we lose weight by not eating on certain days in a week?

3.

How should we take care of our body?

I
I
i

What should we do if our weight is not increasing?

4.

I

What causes acne? How can we be rid of them?

5.

6.
7.

I

What can we do to become good looking?
How should we take care of our face and hair so that they keep looking good?

8.

Does waxing body hair affect our skin?

9.

Is it possible to increase or reduce the size of our breasts?

i
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I

Diet and Nutrition concerns

i

i

10. What kind of food is harmful?

11 Why do we eat fruit and vegetables?
12. What kind of food should we eat to reduce weight?
13. What is a balanced diet, how is it beneficial?

a

14. From which foods do vegetarians get protein?

15. If one does not like milk, what should one do?
16. Is there an age from which one can start drinking tea or coffee?
17. What type of meal should we take to reduce our weight?

i

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Menstruation concerns

9

18. Why does menstruation occur? What causes menstruation?

fl

19. At what age should menstruation occur?

■

20. Some girls start menstruation at a later age, why?

a

21. What is ovary and where is it? How does it function?
22. If a girl does not start menstruating, does it mean she can not have a baby?

23. Why do we have stomach ache, backache or nausea during periods? Is it normal?
24. Is it harmful if the periods continue for more than five days?
25. Is it harmful if the bleeding stops after one day?
26. How much bleeding is normal?

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27. If one takes medicines to start one’s periods, can it cause any problem in the future?

28. If a girl does not get periods regularly or does not get it for 5-6 months, what should she do?
29. Do irregular periods cause weight gain?
30. How do we come to know that we will have periods? What are the signs?

31. How do we maintain cleanliness during periods?
32. What is better, using cloth or sanitary pad?

33. Why do older women not have periods?
34. Can we eat pickles in the time of periods?
35. Is it alright to touch others when we have periods?

36. What kind of exercise should we do during periods?
37. They say one should oot talk to boys during periods, is that right?

Sexual and Reproductive Health concerns
38. Why does hair grow on our private parts?

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Handout 9.3
EP.SODES OF ADOLESCENT GtRLS VISITING THE GYNAECOLOGICAL OPD

Episode 1 *.
Thl. -pisod. i. documented by an observer who was obs.rYtng dent provide,
communication in a gyanecology OPD in a general hosp.ta!

and an old case paper in her hand. The observer recognized her
A young girl walked in with a new
She had come yesterday but because she was late she was sent away.
She smiled at the observer.

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What has happened? What is your problem? Kyahuahai?
, nav. a growth, iump in m, genital area Memko » ga.n« aaya h.rpW.b

Dr.

i

Patient :

Dr.
Patient :
Dr.

Patient :

i

What is your age? Apka umar kya hai ?

19. Unnis
Since when do you have this? kabse aaya hai?
About 4 months Earlier it was small I showed it to a dodo, near where I l«e and he sa,

it is nothing, it wiii go away Now th., it has become bigger, be sard that I shookIgo .

i

f

g

the big hospital Ho gay. cMa.malwa Pahafe Mota rha. ma.™ hamare yeha doctor
*o Oikhaya

won bo,a, kuchh nattt. ottala.i,a,esa Rl Itada ho gaya to woh bo,a abb,

f

f

hade aspatal mein jaake dikhao.
Okay. Are your periods regular? Thik hai, mahina barabaraata hai?
Dr.

Patient :
Dr.

Patient :

a
t

Yes. ha
You are not married, are you? Shadi nahi hua hai na ?

t
K

No. nahi (she smiled and looked down)
Okay, take this paper and sit down there. Accha, yeh paper lake waha baitho

Dr.

■ ._j on the examination table by two students . They could not figure out
The girl was then examined
not opening her legs properly So the observer told her to open up properly
what it was. The girl wasi

I

for the doctor to see.

Suddenly .he tw s.uden. doctors left -.out .el.ng her anything The gid oiimhed down from he

table and asked the obse™e. whether she can wear her unde,ciothes Th. observe, went and asked

the students and the, said no, because the, wanted the RMO to examine her Then th. otn.r dooto,
went tn. The girl had almost got down Im th. tabl. not knowing what to do Sewng th. doctor.

again lay on the table.

After the examination the doctor came out and sat down The g« came out of the examination mom
with her paper Doctor wrote th. medicin. on he. paper and toid her to take the medicine and return

after two weeks Another patient came in between and showed her pt|per to the doctor.

208

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Doctor : (Hurriedly) take these tablets, yeh golilena.
The girl did not go away. She just stood there. Maybe she wanted to ask or know

something more.
Patient

Nothing else needs to be done? Aurkuchh nahi kameka ?

Doctor : (In an irritated tone) No, nothing else is required. Nahi, Aurkuchh nahi.
The girl left the OPD.

Episode 2:

On the same day an adolescent girl had come to the OPD. She too was reluctant to let the male

doctor examine her. The doctor explained to her what the examination was abotft, what he would

learn from the examination and why it was necessary. He also assured her that it would not hurt her

and sensing that she was feeling shy he asked one patient he had examined to tell the girl how it felt

during the examination. That patient told the girl that it doesn’t hurt, doesn’t take much time and
whether the doctor is male or female doesn’t make much difference. The doctor then gave the girl
some time to think and then asked her if she was willing for examination The nurse and the sweeper

also told her that since she had waited so long in the OPD she should undergo examination The
doctor had spent almost 15 minutes explaining to her.

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Chaper 10
Counselling for Gender-Based Violence

Domestic violence is defined as physical, emotional or economic violence done on women either by
their husbands or other members of the family, within the home. Domestic violence is also termed as
family violence. Gender based violence is a broader concept. It is defined as any act that results in.

or is likely to result in, physical, sexual or psychological harm or suffering to women, including

threats of such act, coercion on arbitrary depravation of liberty whether in public or private life (WHO)

Domestic or Family Violence is one category of gender based violence. Other categories of gender

based violence are those occurring due to

•

Traditional and cultural practices, for example branding women as dakins, dayans or witches

in certain societies, violence on widows - abandonment, food, taboos, social isolation etc.
•

torture and rape of detained women in custody.
armed conflict and displacement. In times of caste, communal and ethnic conflict, women’s
bodies are perceived as “territory to be conquered" and violence against women is used to

increase men’s subjugation and humiliation

•

forced prostitution and trafficking.

•

sexual harassment at public places and work places, e.g. burns inflicted on girls by unwanted

lovers, date rapes and so on.

Magnitude of the Problem
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A study of the records in the Emergency Police Register of the Casualty Department in a public

hospital in Mumbai revealed that 23% of the women who were brought into the Casualty

were
definite cases of domestic violence. They had suffered assault by a family person or a ‘known
person Another 44% of all women appeared to be possible victims of violence; they either

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refused to name the perpetrator of the assault (19%) or attributed the burns that they suffered to
accidental stove burst (9%), or were cases of attempted suicide, a measure to which women who

i

have suffered violence and harassment are likely to resort (16%). Thus up to two-thirds of women

(

reporting to the casualty department may have suffered domestic violence (Daga et, al. 1998).
Observations of client-provider communication in a Gynaec OPD, interviews with patients in the

i

OPDs indicate that there are incidents of domestic violence which go undiscussed and unreported

r

even within the hospital situation. (WCHP, 2000)

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211

Ecological Model of Violence
Lori Heise describes an ecological framework to understand the interplay between personal, situational

and socio-cultural factors that cause gender-based violence and abuse. This model can best be
visualised as four concentric circles. The innermost represents the biological and personal history
that each individual bungs to his/her behaviour in personal relationships. The second circle represents

the immediate context in which abuse takes place - often the family or other intimate and close

relationship The third circle. epresents the institutions and social structures, both formal and informal,

in which relationships are embedded i.e. the neighbourhood, work place, peer group. The outermost
circle is the social and economic environment, including cultural norms.

Ecological Model of Factors Associated

with Partner Abuse

Society

Relationship

Community

(

Individual
Perpetrator

Norms granting men

Poverty,

low

Marital

Being male

control over female

socio-economic

conflict

Witnessing

behaviour

status, unem

Male control

violence as a child

ployment

of wealth and

Absent or rejecting

Associating

decision-making

father

resolve conflict

with delinquent

in the family

Being abused as a child

Notion of masculinity

peers; Isolation

linked to dominance,

of women and

honour, or aggression

family

Acceptance

of

violence as a way to

marital

Alcohol use

Rigid gender roles

(Source: Lori Hiese. 1994)

This framework can be used in counselling victims of gender-based violence. Using the framework to

analyse her situation, with her, can help the woman develop appropriate strategies.

Violence is a result of power inequalities. The perpetrator generally has physical power as well as

power based on authority resulting from access to, and control over, resources. The victim of violence
is relatively powerless in terms of control over resources of any kind - economic, material, and

psychological. Violence against women is an essential part of the patriarchal ideology and structures

of domination and exploitation of women in society. Patriarchy, which means the rule of th0 father,

212

vests in men's control over economic and material resources. Women are considered a part of men’s
property and thus men have control over women’s productive power, reproductive capacities and

sexuality. Rape and the threat of rape is a significant way by which men control women's sexuality.

Violence against women is a violation of their human right. Sex selective abortions deny the female
sex the right to exist. Right to bodily integrity is denied through physical violence. Their right to

dignity is violated whpn they are subjected to degrading and inhuman treatment and mental torture.

Thus addressing violence against women, through counselling and other interventions, are acts that
uphold human rights of women.

Health Consequences of Violence

The health consequences of violence range from non-fatal outcomes that have impact on physical

and mental health, to fatal outcomes like suicide, homicide, maternal death and HIV/AIDS. Among
the physical health consequences are injury (lacerations, fractures and internal organ injuries),

unwanted pregnancy, gynaecological problems, STDs including HIV, miscarriage, pelvic inflammatory
disease, chronic pelvic pain, headaches, permanent disabilities, asthma, irritable bowel syndrome,
and self-injurious behaviour like smoking, unprotected sex. The mental health outcomes are depression,

fear, anxiety, low self-esteem, sexual dysfunction, eating disorders, obsessive-compulsive disorder
and post-traumatic stress disorder. Violence against women is a major public health concern and
should be a priority for the health sector because it causes immense suffering and negative health

consequences for a significant proportion of the female population. The costs of violence against
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women are tremendous, not only for the individual but also to society in terms of providing medical
care and legal services (Heise et al., 1994).

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Health consequences of violence against women
Non-fatal outcomes

•

•
•
s

Physical health outcomes

Mental health outcomes

Injury (from lacerations to fractures and

•

Depression

internal organ injuries, Burns)

•

Fear

Unwanted pregnancy
Gynaecological problems

•
•

Anxiety

STDs including HIV

•

Sexual dysfunction (examples)

Miscarriage
Pelvic inflammatory disease

•
e

Eating problems
Obsessive-compulsive disorder

Chronic pelvic pain

9

Headaches
Permanent disabilities

e

Low self-esteem

Post-traumatic
stress disorder
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Guilt, loss of self-confidence and self- |
esteem

Asthma
Irritable bowel syndrome

•

Self-injurious behaviour
(e g. smoking, unprotected sex)
Fatal outcomes

Suicide
Homicide

Maternal death

HIV/AIDS

•

Phobias

•

Psychosomatic disorders

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(Source

World Health Organisation, (2000) Health Impact of Violence Against Women,

WHO Regional Office for South-East Asia; Women of South-East Asia; A Health Profile,

WHO, New Delhi).

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The health care system and health workers are in a unique position to identify, document and
i

respond or refer victims of violence, because they are the first contact point for persons who have
I

been assaulted, as they will seek medical assistance for their injuries, even if they do not disclose
t

the violent incident. The health care providers can provide comprehensive, gender-sensitive health

services to victims of violence to manage the physical and mental health consequences of the

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assault.

The health system has to recognize violence against women in the different situations outlined above
and have different strategies for addressing each situation. For instance, in situations of armed conflict

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and in refugee camps, the health services which are already over stretched, need to recognise rape

and sexual abuse and be prepared to deal with the trauma associated with it. Health services in or
near red light areas have to deal sensitively with the incidents of violence against sex workers.

214

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Health Care Providers' Difficulties in dealing with GBV

A WHO consultation on violence against women in 1996 identified the following as issues to be
addressed so that the health care system can be more responsive to women victims
•

providers' negative feelings (e g. health personnel may feel inadequate, powerless and isolated,
especially in areas with few referral services)

•

cultural beliefs (e.g. violence by partners is a private or family matter)

•

beliefs about victims (e.g. women provoke violence, women are able to stop violence by
changing their behaviour, most women who stay with their partners have masochistic

tendencies) (World Health Organisation)

Health care providers generally seem to believe that the causes of physical injuries that battered

women present with are not their business. They perceive their role as limited to dressing the wounds,
and prescribing medicines. Some view domestic violence as a private issue and fear that clients

would be upset or offended if asked directly about violence. Others do not quite know how to ask and

how to respond if a woman does admit to being abused. Yet others feel that they have no time to
spare (within the context of overcrowded dispensaries and out patient departments) to deal with the
needs of victims of violence.

Another barrier to health workers addressing violence is that they belong to the same cultural and

social milieu as their patients. They share the values and attitudes towards abuse that are prevalent

in the larger societal context. For instance, many women and men believe that a woman is the
property of her husband and so an occasional beating is quite acceptable Or the constructs of

T

sexuality in many cultures define that women have to be available for sex whenever their husbands

I

‘need’ it. Male clinicians may hesitate to accept a woman’s account of violence because they identify

I

with the offender. Female health workers who have been victims of abuse may not find it easy discuss

I

violence with their patients.

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Another major barrier to health workers addressing violence against women in India is that these are

I

medico-legal cases and doctors are reluctant to get involved in legal liabilities and procedures. Lack

I

of referral services and poor coordination between health, legal and social welfare departments also
I

act as a deterrent.
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What do women victims of violence consider as supportive behaviour on the part of health care

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providers? Studies have shown that battered women value direct questions about abuse, referrals to

I

appropriate agencies that offer assistance, follow up and non-judgmental support (WHO, 2000).

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According to women in a Wisconsin Study, unsupportive behaviour on the part of physicians included

i

neglecting to ask how an injury occurred, not taking a history of violence, not asking about the safety

I

of children, and failure to refer them to support services and to schedule a follow up visit. The following

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were listed as desirable supportive behaviours:

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P ''IRRWR—»

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Medical support

[

•

Taking a complete history

•

Detailed assessment of current and past violence

•

Gentle physical examination

•

Treatment of all injuries

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Emotional support
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•

Confidentiality

•

Directing the partner to leave the examination room

•
.

Listening carefully
Reassuring the woman that abuse is not herfault and validating her feelings of shame,

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anger, fear and depression

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Practical support

•
.

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Telling the patient that spouse-abuse is illegal
Providing information and telephone numbers for local resources such as shelters, support

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groups, legal services

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Asking about children’s safety

•

Helping the patient begin safety planning

•

Scheduling a follow-up visit.

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Indicators of Gender-based Violence for Health Care Providers

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Women's organisations and other groups working with health care systems on gender based violence
have identified some indicators which can serve as warning signals to health care providers in clinics
and hospitals.
Warning Signs for Health Workers

•

A woman who makes an appointment but does not attend.

•

A woman with multiple injuries in places that are usually covered by clothing.

•

A woman whose partner comes with her and stays close at hand in order to monitor what is said.

•

A woman with evidence of strangulation attempts on the neck or fractures to the upper
arms, which may have been caused when the woman tried to defend herself.

.

A woman who is excessively shy, embarrassed or anxious, or who is reluctant to provide

.

information about how she was injured.
A woman or partner with a history of psychiatric problems such as depression, alcoholism,
drug abuse or suicide attempts.

•
.

A woman with a history of “accidents”.
A woman, particularly if pregnant, with injuries to the breasts, genitalia or abdomen.

(Source: ‘The Intimate Enemy: Gender |/iiolence and Reproductive Health in Panos Briefing
No. 27, March 1998.)

216
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The semiotics of domestic violence
Signs of violence

Symptoms of violence

Sensations and/or pains that women manifest j #
that can often be attributed to violence

Women who are anxious, fearful, sad,

dispirited

Minor or severe trauma that produces noticeable

Women who are aggressive without

bruises on the body, especially around the eyes

apparent cause

and face

ie

Prematurely-aged women

•

Injuries produced by blows or by sharp objects

«

Dejected, humble women who express

•

Loss of teeth, often associated with maternity or

worthlessness or refer to themselves as

malnutrition, can also be caused by kicks or blows

stupid or incapable

to the mouth

I•

muscle contractions, numbness, intestinal j

Deformation of the nose produced by fractures of
the bridge, even when the result of earlier injuries ■

or pelvic pains
•

often permits a diagnosis of current violence

Frequent nosebleeds, for which women seek

treatment, can in fact be produced by aggressions

Women who complain of unspecified pains, |

Women with frequent headaches or!

insomnia
•

Women who complain of pain or experience

no pleasure during sex or consider it a

Leucorrhoea, or vaginal secretions, caused by

sacrifice. Expressions such as the following

tnchomoniasis or other STDs, can frequently be

are typical of women subjected to frequent

signs of sexual violence
Vaginal haemorrhages produced by mistreatment

violence :’He uses me". "He relieves himself

with me". "This is the cross you bear in
marriage”. "It's a woman's martyrdom”.

of women, whether or not pregnant

i________________________ _____
(Source: World Health Organisation, Health Impact of Violence against Women, WHO Regional

Office for South-East Asia; Women of South-East Asia: a Health Profile, WHO, New Delhi. 2000).

Counselling for Violence
The most important question that we are faced with today is - How do you get a woman to speak

about her issues related to violence? Many factors could be responsible for a woman's
unwillingness to speak about her issues and more so when it involves violence in any form, and here

is where counselling plays a very important role.

A woman who is a victim of violence, first and foremost needs to be assured of her safety. By
providing her privacy and confidentiality, a space is created wherein a violence victim feels safe to

reveal the details of her problem. A woman who has been in an abusive relationship will be
psychologically upset - she may be afraid, anxious, insecure, angry, confused. The counsellor needs

to have patience and help the woman by naming her feelings, by reflecting back to her what she is

expressing. The counsellor has to convey upfront that violence is not merely a ‘private’ or ‘family
matter - it is a serious socio-political problem and violence of any kind is unacceptable. The counsellor

has to validate the woman’s feelings and relate them to the larger context, as similar to those stemming

from struggles against oppressive social and political structures.

It does not help the woman, if we as counsellors say anything that will indicate that we blame her for

her situation, for example, 'Couldn't you see how he was blackmailing you?' or 'Why did you stay on
so long?' Such questions will further disempower her As counsellors we need to find ways by which

we can help her to feel a sense of power and control and to handle even small decisions on her own.

Counsellors should be careful that they do not reinforce existing gender stereotypes or sexist beliefs,

for example 'yes, as women we are so emotional ...J or ‘what can you do around the house, or for

him that will prevent him from becoming violent?'

It is important to help the woman identify who she can rely on for various kinds of help next time there
is an episode of violence. It is important to help the woman prepare a safety plan. A few do s and

dont’s of a safety plan therefore would be as follows:

Do’s :

ask
express concern

listen and validate
offer help
support her decisions

Dont’s :

judge orblame
wait for her to come to you

1

pressure her
give advice

place conditions on your support
1

Here are a few steps that could be suggested to a woman and her children for

1

their safety:

1.

Practice getting out of your home safely. Identify which window, or door would be best.

2.

Whenever you believe that you are in danger, leave your home and take your children, no matter
what hour of the day it is. Go to a friend or relative’s house or a domestic violence shelter.

3.

Devise a codeword to use with your children, family, friends and neighbours when you need the

police.

4.

Plan where you will go if you have to leave home, even if you think you will not need to.

5.

Have a packed bag ready and keep it in a secret but accessible place so that you can leave
quickly.

6.

Identify neighbours you can tell about the violence and ask them to call the police if they hear any

disturbance coming from your home.

218

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7.

When an attack has begun, escape if you can.

8.

Call for help, scream loudly and continuously. You have nothing to be ashamed of - the batterer
does.

9.

During an argument stay close to an exit and avoid being near the kitchen or anywhere near
weapons.

10. Defend and protect yourself. Seek medical assistance for your injuries.
11. Trust your own instincts and judgment. Whatever you need to do to survive, is the right choice.

You have the right to protect yourself.

Module Objectives

At the end of this module, the participants will

•

recognize that GBV is a serious socio-political problem and has health
consequences for women.

•

describe their role in addressing GBV

•

acquire skills in identifying victims of violence in the clinic/hospital and when to

refer to more specialised counsellors.

Session 1

Personal Experiences of Gender-based Violence

Learning objectives

At the end of the session the participants will
•

recognize that GBV is not only a personal problem but also a serious socio
political problem

Time

1 hour

Resource

Flip chart and marker pens, OHT 10.1

Methodology
1. Group Discussions for 30 minutes on

a.

(i)

Where have we encountered GBV in our own lives personally?

(ii) What are the obstacles to our addressing GBV?

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(i) where have we encountered GBV in our professional lives
(ii) what are the obstacles to addressing it?

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2.

Group presentations

3. Facilitator highlights that GBV is a problem of epidemic proportions using OHT 10.1.
It is not merely an individual, clinical problem but has its roots in larger socio

political structures in which health care providers have an important role to play

in addressing GBV and the ways in which obstacles can be addressed.
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Cycle and Models of Violence

Session 2

Learning Objectives
At the end of the session the participants will be able to
• relate the incidences of violence to the concepts and the framework of gender

based violence
Time

90 minutes

Resources

OHT 10.2 and 10.3 on the Cycle of violence and Ecological framewoi of violence

Methodology
The facilitator conducts brainstorming session on What is Gender based Violence.

1.

•

Facilitator gives presentations of
- Cycle of Violence and

2.

- Ecological Framework for Violence
Has a discussion of these models, invites questions, reflections.

3.

Facilitator leads the discussion to

•
•

Psychological state of the abused woman
Reasons why a woman continues in an abusive relationship with or without

seeking help
Why does a woman continue in an abusive relationship?

She thinks he’ll change, he’s basically a good man

If she is a ‘good’ wife, her love will be powerful enough to change him

‘It is the duty of a wife to stick by her husband regardless of what may happen
Economic reasons

No support from natal family
For the sake of the children

BUILD UP PHASE
•

Tension

•

Anxiety

•

Depression

STANDOVER PHASE

Tension

Anxiety

Depression
VIOLENT OUTBURST

HONEYMOON

Physical injury

PHASE

•

Denial of

Fear

2

problem
REMORSE PHASE

•

PURSUIT PHASE

220

•
•

Tension
Depression

•

Anxiety

•

Fear

Temporary relief

of symptoms

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Violence and Health

Session 3

Learning Objectives

At the end of the session participants will be able to

•

understand the types of violence and its consequences on the life and health of

the victim

•

know where to refer cases of violence that come to the Gynaecology OPD

Time

1 hour 30 minutes

Resources

Chart papers and markers, OHT 10.4 Health consequences of Violence

Methodology
The facilitator conducts brainstorming session on whether and how GBV is health

1.

issue
The participants are then divided into three groups. Each group is asked to

2.

discuss type of violence, its physical, social and psychological effects on the
victims in the following situations

•

At home

•

At the work place or outside home

•

As a personal identity (like daughter, wife, married/ unmarried, widow,
divorcee, separated, deserted, childless etc.)

3.

The groups then make the presentation to the larger group.

4.

Facilitator summarises by showing OHT 10.4

Session 4 Screening Victims of GBV
Learning objectives
At the end of the session, participants will be able to

i

•

ask appropriate questions for screening possible victims of violence

•

Identify signs and symptoms of violence

Time

1 hour

Resources

OHT 10.5 on Warning Signs and Symptoms of Violence

Methodology

I

1. Group Discussion for 30 minutes on

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•

How can we tell whether a woman has been possibly abused?

•

What sort of questions can we ask to identify victims of GBV?

2. Group presentations

Facilitator’s Note
Facilitator sums up the group reports. Also cautions about the need to be sensitive
and observant and the danger of transgressing boundaries and being invasive.

Facilitator ends session by showing OHT 10.5 and 10.6 on 'warning signs' and
‘signs and symptoms’.

Session 5

Devising a Safety Plan

Learning Objectives
At the end of the session, participants will be able to

•

prepare a safety plan for victims of repeated violence

•

identify support systems in the immediate environment of the victim

Time

30 minutes

Resources

OHT 10.7 and 10.8 on Do’s and Don’ts and Devising a Safety Plan

Methodology

1. Participants will form pairs and discuss
(i) What would they do to ensure the safety of a woman who is facing repeated

episodes of violence (5 minutes)?
(ii) List the resources (people and institutions) that they could mobilise/contact

to help this woman (10 minutes).
2. Share in the larger group (15 minutes).

3.

The facilitator lists the responses and summarises by using OHT 10.7 and 10.8

on Do’s and Don’ts and Devising a Safety Plan.

*

►
>

222

References

1.

Domestic Violence against women: An Investigation of Hospital Casualty Records,

Mumbai, Daga, Achala, Shireen Jeejebhoy and S.Rajagopal. 1998.. Paper presented at the
International conference on Preventing Violence, Caring for survivors: role of the health Profession

and Services in Violence, organized by CEHAT, Mumbai, November 28 -30, 1998.
2.

Khanna Renu & Amita Verma, (2000). Gender - based violence; An impediment to sexual and
reproductive health and violation of human rights and presented at the Regional (SE Asia)
Workshop on the Impact of GBV on the Health of women, organized by SORT, New Delhi, April 5 which

year?
3.

Women of South - East Asia: a Health Profile-WHO (2000)fHealth Impact of Violence against

Women, Regional Office for South-East Asia,

4.

Population Reports

5.

The Intimate Enemy in Panos Briefing No. 27, March 1998

6.

Women Centred Health Project, (2000). Observations done at the Gynaecology OPD,
(Unpublished report, WCHP); and Training of Key Trainers, (Unpublished Training Report, WCHP)

K

B
£

223

OVER-HEAD TRANSPERENCIES
OHT 10.1
Magnitude of Gender Based Violence
1 in every 5 ever married women experienced domestic violence (NFHS, 1998 - 99)

.

1 in every 9 women reported being beaten in the last 12 months (NFHS, 1998-99)

.

Largest single cause of death among women in 15 - 44 years age group is violence (burns,

drowning, suicide, homicide 26.3%) (Maharashtra vital statistic handbook, 1996)

Between 1991 and 1995 crimes against women increased by 45%. (Crimes in India, 1995)

.

66.7% cases coming to Emergency Dept, of a Govt. Hospital in Mumbai in 1996 were definitely

or possibly due to violence (Daga etal. 1998)

OHT 10.2
Shortening of the Cycle of Violence
STANDOVER PHASE

BUILD-UP PHASE

•

Tension

•

Tension

Anxiety

•

Anxiety

Depression

Depression

I

3

!
VIOLENT OUTBURST

•

Physical injury

•

Fear

2
HONEYMOON
PHASE

•

REMORSE PHASE
•

Denial of

problem

PURSUIT PHASE
Tension
Depression

Anxiety
Fear

224

Temporary relief
of symptoms

■

OHT 10.3

Ecological Model of Factors Associated with Partner Abuse

Society

Community

Individual

Relationship

Perpetrator

Norms granting men control

•

over female behaviour

•'.-A'

■

‘

,

Acceptance of violence as

•
•

wealth

a way to resolve conflict

Associating with

Notion of masculinity linked

delinquent peers,|

to dominance, honour, or

Isolation of women

aggression

and family

Being male
Witnessing marital

•

Absent or rejecting

violencei as a child

and

- dedsforwnakingin

father

the family

•

Being abused as a
child

Rigid gender roles

•

•
•

Marital conflict
^eontrol of

jcioPoverty, low socio_ ___________ tus
economic status,

•

Alcohol use

: OHT 10.4
_______

Health Consequences of Violence Against,Women
~_____

injury (from lacerations to fractures and” I

internal organ injuries. Bums)
. Unwanted pr^nancy
• Gynaecological problems
. ~ngHIV
.. P^mmatc^
PeMcmflammatory
disease
yddeas.
.
Chrnni^noh^rMin
• Chronic pelvic pain
. HeadaX
• Headaches
•= Permanentdisabilities
‘^lt,eS

I

I

£
JK

.

Depression

. pear
.
.Lowself^sleem

V,

<
XpXr<examples)
' .; oKecd^pui^edisome,
.' Post-traumatic sstress disorder
. Guiltlossofself-confidenceandselfesteem

(e g smokmg, unprotected sex)

'wisfas—
;

U

t

.■

Non-fatal outcomes_________
- H
7" Mental health outcomes

Physical health outcomes

.

____________________________________________ -

'■

Homldde

.

H^os-

-Phobias

-

Maternal death

-

Psychosomate disordera

I
i

OHT 10.5
Warning Signs for Health Workers
•
.
.

A woman who makes an appointment but does not attend.
A woman with multiple injuries in places that are usually covered by clothing
A woman whose partner comes with her and stays close at hand in order to monitor what is said.

.

A woman with evidence of strangulation attempts on the neck or fractures to the upper arms,

.

which may have been caused when the woman tried to defend herself
A woman who is excessively shy, embarrassed or anxious, or who is reluctant to provide

.

information about how she was injured.
A woman or partner with a history of psychiatric problems such as depression, alcoholism,
drug abuse or suicide attempts.

•
•

A woman with a history of “accidents”.
A woman, particularly if pregnant, with injuries to the breasts, genitalia or abdomen.

(Source: 'The Intimate Enemy: Gender Violence and Reproductive Health’ in Panos Briefing No. 27.

March 1998).

OHT 10.6

The Semiotics of Domestic Violence
Signs_ of violence
Symptoms of violence____________
Sensations and/or pains that women manifest

k

that can often be attributed to violence :

•

Minor or severe trauma that produces noticeable

•

dispirited

bruises on the body, especially around the

eyes and face

Women who are anxious, fearful, sad,

•

Women who are aggressive without

apparent cause

•

Injuries produced by blows or by sharp objects

•

Loss of teeth, often associated with maternity

•

Prematurely-aged women

or malnutrition, can also be caused by kicks

•

Dejected, humble women who express

•

or blows to the mouth

worthlessness or refer to themselves as

Deformation of the nose produced by fractures

stupid or incapable

of the bridge, even when the result of earlier

•

•

•

•

Women who complain of unspecified

injuries often permits a diagnosis of current

pains, muscle contractions, numbness,

violence
Frequent nosebleeds, for which women seek

•

intestinal or pelvic pains
Women with frequent headaches or insomnia

treatment, can in fact be produced by

•

Women who complain of pain or

aggressions
Leucorrhoea, or vaginal secretions, caused by

experience no pleasure during sex or

trichomoniasis or other STDs, can frequently

as the following are typical of women

be signs of sexual violence

subjected to frequent violence :”He uses

X^ginal haemorrhages produced by mistreatment

me”. "He relieves himself with me”. "This

of women, whether or not pregnant

is the cross you bear in marriage". "It’s a

consider it a sacrifice. Expressions such

woman’s martyrdom”.

226

OHT 10.7

Do’s and Dont’s Related to Gender-Based Violence
Do nt’s :

Do’s :

ask

•

judge or blame

express concerr

•

wait for her to come to you

listen and validate

•

pressure her

offer help

«

give advice

support her decisions

•

place conditions on your support

OHT 10.8
Safety Plan
1.

Practice getting out of your home safely. Identify which window, or door would

be best.
2.

Whenever you believe that you are in danger, leave your home and take your

children, no matter what hour of the day it is. Go to a friend or relative’s house

or a domestic violence shelter.
3.

Devise a code word to use with your children, family, friends and neighbours
when you need the police.

4.

Plan where you will go if you have to leave home, even if you think you will not need to.

5.

Have a packed bag ready and keep it in a secret but accessible place so that

you can leave quickly.
6.

Identify neighbours you can tell about the violence and ask them to call the
■■■

:

•

police if they hear any disturbance coming from your home.
7.
i

8. Call for help, scream loudly and continuously. You have nothing to be ashamed

i
i

I

When an attack has begun, escape if you can.

of - the batterer does.
9.

During an argument stay close to an exit and avoid being near the kitchen or
anywhere near weapons.

O ’’a/
1s Wt.
. ..
;

'

I

10. Defend and protect yourself. Seek medical assistance for your injuries.

£

11. Trustyour own instincts and judgment. Whatever you need to do to survive, is

I

B

the right choice. You have the right to protect yourself.

227

Chapter 11

Training for Documentation and Recording

The counsellors at the Information and Counselling Centre are required to keep a set of records.

The purpose of these records is to (a) assess the work load and to see the trends in utilisation of
the services (b) assess patient satisfaction (c) use the information generated from these records

for training purposes, for example, unusual case studies can be used for training of student
medical officers and other health care providers in the Continuing Medical Education sessions.
■r

The following section describes each record and format and its use.

Recording tools used at the Centre include
1.

Client Card

2.

Records Register

3.

Monthly report

Client Card

A Client Card is maintained for each client coming to the Centre for counselling. This is updated at

each visit and provides a quick summary of the proceedings till date and enables the counsellor to

identify those who fail to keep appointments and ensure a quick follow-up at their residences. However,
a quick follow-up may not always be feasible and should be done considering the time factor and
available human resources. Review of these cards over a period of time also contributes to assessment

of the case handling/management as well as the usefulness of the services offered by the Centre.
Cards may be maintained for at least three years as patients may come back. The format of the card is

presented in Handout 8.5.

Records Register
The records register is maintained for the purpose of compilation of records. This register also serves
as a data gathering tool and will be useful for generating a data bank regarding counselling needs

related to gynaecological conditions and strategies that work and those that do not. The structure of
)

the register is presented in Handout 11.1.

I

I
I

Monthly Report Format
A reporting format is developed for submitting the monthly report to the Medical Superintendent of the
hospital and the Medical Officerof Health, in charge of the ward, where the Centre is located. Monthly

I

compilation of data, analysis and drawing conclusions for implementation at their level also serves as

a capacity building exercise for) the staff at the Centre (Handout 11.2).

Process
A Client Card ( Handout 8.5) is prepared for every new patient referred to the Centre for counselling

and information purposes. After the counselling session, relevant information from the card is copied
to the register (Handout 11.1). If a patient is asked to come for a follow up, all subsequent visits are
marked on the register Cards are arranged in the box files according to the serial numbers.

A monthly summary report (Handout 11.2) is submitted to the Medical Superintendent of the
hospital and the Medical Officer of Health.

Module Objectives

I

At the end of the session participants will

•

describe each record/format and will be able to fill the same

•

state the purpose of the format, when to fill it, how to analyse the data yielded by
each format periodically, and how to interpret and use the data for corrective

•

action at their own levels
write reports based on the analysis, including suggestions for future action.

Learning Objectives

At the end of the session participants will be able to
•

explain the purpose of filling the record sheets

•

fill the records and analyse the information

Time

1 hour

Resources

Copies of three recording sheets (Handout 8.5,11.1 and 11.2)

Methodology
1. The facilitator distributes the three recording sheets to the participants and asks

them to read these.

2.

Each item on the record sheet and its purpose is then discussed.

3.

Participants fill the client card and social history form based on the data gathered

in session 3 in the gynaecology chapter and reflect on it.
4.

230

Questions regarding the filling of the forms are discussed and clarified.

<5°

■xSS

<x6>

I

Handout 11.1
Case Record
1. Description of Social Problem

Code No

I
I

&

GJ

Case Paper Number

Case Serial Number

^ason for see <ing counselling :
Date

Description

Date

Desciption

0)

"S

0)
Qj
■o

u.

c

I

QJ

£

8
□
u.

(D

C
CQ
C
0)

E

o
u

5
o

Xj

Q
(0

3
O

<0

o
3

V)

i
C

•2?

G
c:

•-Sc
0)

o

a
Q

CN

232

11

1
■

—

3. Details of Referral
Date

Reason for referral

Refferal Centre

Specific information Needs Expressed by the Client, Client’s Husband and Relative
Queries asked

Remarks

Discussion with Clinicians if any

Skills used

r*

I
Problems faced by the guide

I

I

J

I

I

Handout 11.2
Monthly Reporting Format
Month :

Name of the hospital:

1.

Distribution of new and old patients regarding conditions for which counselling is

sought
.

... ---------------------------------------------- f

Conditions'for which counselling

1st contact

OPD visit

I is sought

with counsellor

No.

2.

Repeat visit with

OPD

counsellor

visit No.

4

Distribution of new patients by source of referral

Sr. No.

Referred by

1

Health Posts

I2

Dispensaries

3

V N Desai Gynaecology OPD

4

V N Desai Other OPDs

5

Self referred

6

Other

j'!

No.

h
in
111
I
in
r
if

Total

234

rb® /b®

Zb®

Zb®

o^>

3.

Details about patients who failed to keep a pre-determined appointment

a. Reasons for referral to centre
. No.
i-

: Reasons

b. Number of house visits

c. Number of patients contacted at home visits

d. Reasons for failing to keep the appointment

!

Reasons

No.

i_____
I

J

I

e. Willingness to come to the Centre

Willing to come to Centre

No.

Yes

No

f. Number of those followed up at home who came to the Centre

&
4

----- --------------------------------------------------------------------------------------- - ----------- f-----------

1____

235

4. Details of patients referred

Reasons

Referral Centres
Total

Total

5. Details of counselling to husbands / other family members :

Reason for counselling

236

Husband

Other relative

*1

Annexure I
Task analysis of Staff at Gynaecology OPD
&

GynMeoZo D T X
X7oZ.X Z

w

iS ““ in,° A ln,Oma"°n GiV,na 8' C0U"M* C L“

7 7

and Records Keeping Pieese not. rha, the technic,, role

I

£
£

t
£

Ce”8'!"i"S B'’*

S“n9

'

_______ _______ ROLE

doctors and nurses

KNOWLEDGE

the gynaecology OPD Is no, Included

this ana,ysis

ATTITUDES

A. Information Giving

•

To answer all the queries of those who
approach the Booth.

About physical set up of the hospital-

•

Names of Doctors, No. of departments.
-

Facilities available

-

Procedures for admissions, discharge,

working of departments and timings,

<

respective OPDs specific days and
timings

-

List and location of Health Posts and

facilities and staff (medical and
paramedical) available at the Health Post.

N>

->»"-■ 0 Tuning CHVs

SKILLS

1. ANMs and MPWs

case papers, cost for taking treatment,

&

™ " «»

’s

•

Clarifying doubts

•

Helpfulness

•

Clear Speech

•

Patience

•

Listening

•

Dignity and worth of
every Individual

•

Respecting every
individual

*

N)
CO
00

ROLE

KNOWLEDGE

SKILLS

ATTITUDES

(a) Self referred patients

•

To identify the problem if the person comes

Knowledge of technical and social aspects

Exploring

Helpfulness

directly to the Booth before visiting the

of gynaecological conditions

Asking open-ended

Patience

doctor i.e. - self referral.

Knowledge about the hospital set up

questions

Respect for another’s

Clarifying doubts

dignity

Listening
Paraphrasing

•

To guide the person — with reference —

Knowledge of technical and social

to their problem

aspects of gynaecological conditions

Communication skills

Patience

Readiness to explain in
simple and local language

•

•

•

To give information about her gynaecolo

Technical knowledge of Gynaecological

Communication skills -

Readiness to explain in

gical problem / condition.

problems /conditions, Family Planning

Verbal

simple

To guide the person about consultation

methods, ANC, PNC, Nutrition, treatment

Non-verbal (e.g. interpret

language.

with the doctor during the current visit or

and related procedures.

silence and pauses of

Helpfulness
Patience

when to come again, for example, end of

•

Principles of effective communication

women)

her next menstrual period for the insertion

•

Knowledge about the surrounding health

Observe body language

ofCU-T

posts / dispensaries, their functioning,

Active listening

To suggest alternatives for getting

timings and so on.

Reading in- between the

Thorough knowledge of timings and

lines

Dispensaries.

locations of various OPDs, and

Using audio-visual material

To guide the person to visit on appropriate

procedures the woman would be required

forgiving information.

days, timings and units. E.g. ANC women

to complete at these OPDs

consultations at the Health Post /

•

•

•

and patients from other units.

A

and

local

Mar

M

ROLE

KNOWLEDGE

SKILLS

ATTITUDES

(b) Referred by doctors in the gynaecology OPD

•

J

•

To look into the social problems related to

•

To look into the social problems related to

•

Rapport building

the gynaecological condition of the patient

•

Acceptance

the gynaecological condition of the patient

•

Enabling

and explore these in detail.

•

Non-judgmental attitude

and explore these in detail.

•

Empathy

•

Empathy

To explain regarding operations and

•

Ventilation

•

Dignity and worth

procedures.

•

Communication and

•

Individuality

Counselling skills

•

Gender sensitivity

•

Sensitivity towards need for

To explain regarding operations and

•

procedures.

■

•

To discuss about options available in

•

treatment which are suggested by the

—. doctors.

•

•

Explaining and preparing the patient for

MTP/Family Planning

•

privacy and confidentiality

•

To help patients who cannot make decisions

s

•

•

treatment, examination and investigations.

background of patients.

•

To have knowledge of different cultures and

•

Gender factors affecting health

•

•

Problems

of

Poverty

and

moralistic in relation to
under

world countries;effects of social and
economic policies on the lives of poor

w
CD

Understanding need to be

non-judgmental and non

development and the politics of the third

bo

Sensitivity to the social,

economic and cultural

social condition of the patients

&

etc.

examination

explaining/giving information about
treatment, examination and investigations.

fear

associated with internal

To refer the patient back to the doctor after

explaining/giving information about

To refer the patient back to the doctor after

Sensitivity to feelings of
shyness,

of MTP/Family Planning methods.

methods.

•

Explaining and preparing the patient for

internal examination.

To help patients who cannot make

decisions of

£

ment which are suggested by the doctors.
•

internal examination.

To discuss about options available in treat

sexual issues

•

Sensitivity to difficulties of

women in taking decisions
regarding use of FP

O

ROLE

________ KNOWLEDGE

•

SKILLS

Technical knowledge of -Gynaecological

methods, MTPs , no. of

problems /conditions, Family Planning

children

methods, ANC, PNC, Nutrition, treatment

I

•

&

•

Believing in women's ability

and related procedures.

and right to understand and

Family planning policies and programmes

ta\e informed decisions

of the state

•

ATTITUDES

•

Politics of contraception and gender

Patience to deal with non
literate and rural patients

(c) Patients rejected by Doctors (in rare cases)
•

•

Patients failing to keep the appointments

Rapport building

given by the doctors.

Active listening

Patients who have refused MTP/IUDs

Empathy

&

•

Woman Centeredness-seeing
things from woman's perspective

•

Self-esteem

Exploring facts for non-

Self respect

compliance

Informed decision making

(d) Follow-up visits

•
&
•

&

Technical knowledge of the related Communication skills -

Acceptance

on procedures like hydrotubation

disease conditions, Family Planning

Verbal

Readiness to explain in

To check whether the patient has brought

methods, ANC, PNC, Nutrition, Treatment •

Non-verbal (e.g. interpret

simple and local language

all the required reports of investigations

and related procedures.

silence and pauses of women)

To guide the person and provide information

advised by the doctors in the first visit.

•

•

Principles of effective communication

•

Observe body language

•

Active listening

•

Reading in-between the lines

•

Using audio-visual material

forgiving information.

■r

____________ ROLE

; i

KNOWLEDGE

SKILLS

ATTITUDES

B. Counselling

0
■i

i

F

•

Principles and Values in Counselling

•

Active Listening

•

Unconditional acceptance

Knowledge about different theories of

Ventilation

•

Individuality

counselling

Empathy

•

Non-judgmental

Enabling

•

Dignity and worth of an

•

I

Reflecting

&

s

individual

Paraphrasing

Self-determination

Summarising

Confidentiality

Focusing

Warmth and Genuineness

Ability to challenge and

Sense of humour

confront

£

Goal setting
Involving patient in decisio i

&

making
Self awareness

C. Link between the patient and the Doctor
•

V
•

&

ro
■U

Information gathering - facts from patients

Information gathering - facts from patients

Interviewing skills

Acceptance

about their condition and findings from the

about their condition and findings from the

•

Attending

Non-judgmental

doctor, and then to communicate to the

doctor, and then to communicate to the

•

Exploring

Individuality

patients.

patients.

•

Listening

Self-determination

Sensitising doctors about socio-economic

Sensitising doctors about socio-economic

•

Observing

Dignity and worth

and cultural situation of the patients and

and cultural situation of the patients and

•

Reflecting

Patience

encourage doctors to act accordingIy.

encourage doctors to act accordingly.

•

Empathy

Helpfulness

ho
bo

____________ ROLE

I
I

_________

________ KNOWLEDGE

________ SKILLS

•

•

Case presentation to doctors in regular CMEs.

Case presentation to doctors in regular

•

Psychologically preparing patient and

CMEs.

patient’s family for operation and •
procedures

Psychologically preparing patient and

•

•

•

Presentation skills
Logical flow while

Commitment to explain
things in different ways

presenting

for hospitalisation.

Clear speech.

To confirm whether the patient has •

To confirm whether the patient has

Soft and convincing tone of

understood doctor’s instructions regarding

understood doctor’s instructions regarding

voice

medicines, treatment and instructions given

medicines, treatment and instructions given

Convince the patient and

on sensitive issues like sexual problems.

on sensitive issues like sexual problems.

explain the importance of

Work with patient’s husband if recommended

the treatment, and the

by the doctor.

procedure.

•

How to ask open-ended questions.

Counselling skills

•

Howto probe and explore questions.

•

Knowledge of cultural and social condition of

patient’s

husband

if •

the patient

•

To be clear about objectives, complete
knowledge of the case.

•

Knowledge about the family, and also about
interpersonal relations in the family.

•

and over again

patient’s family for operation and procedures

Convincing the patient and patient's family

Work with

P itience

Willingness to explain over

Convincing the patient and patient’s family •
for hospitalisation.

recommended by the doctor.

£

Building relationships.

ATTITUDES

Knowledge of the disease condition and also
about their family culture and status in the

society.

____________ ROLE______________

KNOWLEDGE

SKILLS

ATTITUDES

D Training the CHVs_______

•

To do follow- up in the community.

•

To identify women/couples needing •

To identify women/couples needing counselling

counselling and/or information and refer to

and/or information and refer to Health Post,

Health Post, NGOs, hospitals etc.

NGOs, hospitals etc.

•

I

•

Exploring

facts

about

•

family •

To do follow- up in the community.

•

Participatory T raining

Skills.

•

Sharing of knowledge and
skills is important for

empowerment of others.

Exploring facts about family conditions.(socio-

conditions.(socio-economic-cultural)

economic-cultural)

Explore facts about husband - wife relations •
if required.

Explore facts about husband - wife relations if

required.

•

Principles of adult learning

E. Documentation and Record Keeping

•

Maintain daily diaries.

•

Maintain daily diaries.

•

Case records.

•

Case records.

Monthly reports.

•

Monthly reports.

Prepare case studies for training purpose •

and CMEs.
&

•

•

•

Prepare case studies for training purpose and •
CMEs.

Skills of writing neatly and

Commitment to meticulous

completely

and authentic recording

Analytical skills

Woman

centeredness

Skills of abstraction.

(seeing

things

woman’s perspective)

Knowledge of general administration: to keep
and maintain records, regularity and

consistency in keeping records

•

ho
•u
co

Know the objective of maintaining records.

from

*i

£

N)
A

____________ ROLE____________________

KNOWLEDGE

SKILLS

ATTITUDES

2. Doctors in the gynaecology OPD

•

History taking

•

Preparing for internal examination

•

Information provision on all aspects.

•

Referring to the Booth
♦

*

♦

*

*
&

*

*

*

T

•

Socio-economic factors affecting

Communication skills

Acceptance

reproductive and sexual health

Eye contact

Non-judgmental attitude

•

Sexuality and reproductive health

Understanding Verbal and

Empathy

•

Gender analysis of health system,

Non-verbal

Dignity and worth

In case the patient or the doctor needs to

policies, programmes and services

nication (interpreting

Individuality

discuss sensitive issues like sexual problems •

Problems of Poverty and under

silences, pauses)

Gender sensitivity

In case women not willing or not

development and the politics of the third

Observing body language

Sensitivity towards need

cooperating for the examination

world countries; effects of social and

Active listening

for

In case patient expresses inability to

economic policies on the lives of poor

Probing for knowing the

confidentiality

follow the instructions or line of treatment •

Family

reality and facts

Sensitivity to feelings of

In case patient has failed to follow up on

programmes of the state

Use of simple and local

shyness, fear and so on

the date advised/ or to understand •

Politics of contraception and gender

language

associated with internal

reasons behind non-compliance

Socio-economic , cultural , gender

Maintaining verbal and

examination

In case of MTP or FP methods—

issues affecting women’s reproductive

non-verbal privacy in the

Sensitivity to the social,

patients unable to decide

and sexual health

available

resources;

economic and cultural

Preparing patients for procedures and

Functioning of the HP and the

talking softly during

background of patients.

operations

Dispensaries and the role of outreach

internal examination, and

Understanding need to be

In case they identify social problem

worker

giving information,

non-judgmental and non-

•

planning

policies

and

commu-

privacy

and

related to the condition

moralistic in relation to

Indicate on the case paper if the booth

sexual issues

staff should talk to her family members

Sensitivity to difficulties

including husband

of women in taking

to •

-

JI

!-

____________ ROLE

•

I
•

J

•
&

•

•

•

_______________

ATTITUDES

instructions about sexual

decisions regarding use of

regarding patient’s socio-economic, cultural

relations and issues

FP methods, MTPs , no.

background if it is relevant for managing

Making

of children

the case

comfortable ( use of

Believing in women’s

Share information regarding patient’s

bedside manners)

ability

conditions/admission with the booth staff

Training skills

understand

the

patient

and

right

to

and take

Understand the socio-economic, cultural

informed decisions

barriers for treatment, and plan alternative

Patience to deal with non

action along with the booth staff

literate and rural patients

Indicate which patients could be referred

Willingness and openess

to the HP/Dispensary for follow-up

to

Attend case presentations made by the

experiences of the booth

booth staff and discuss difficulties they

and the outreach staff

had in dealing with patient’s problems

Sharing of knowledge and

e.g.related to information, compliance etc.

skills is important for

Train the booth staff in technical matters

empowerment of others

(knowledge about conditions, referrals,

and

procedures and admission , investigations

multidisciplinary approach

preparing the resource material e g. case
studies)

cn

SKILLS_______

Checking for referral from the booth staff,

and discharge procedures and help in

bO

KNOWLEDGE

learn

from

helps

the

in

N)
O)

R0LE

KNOWLEDGE

SKILLS

3. Nurse in the gynaecology OPD

•

Answer all queries

•

-•—Guidance regarding procedures,

•

Communication skills

•

Acceptance

Eye contact

•

Non-judgmental attitude

affecting women’s reproductive and sexual

investigations, working of the hospital

I

Socio-economic, cultural, gender issues

ATTITUDES

health

Understanding Verbal and

•

Information-giving

•

Empathy

•

Sexuality and reproductive health

Non verbal corapmunication

•

Directing patients for follow-up visits and

•

Dignity and worth

•

Gender analysis of health system, policies,

(interpreting silences,

•

Individuality

programmes and services

pauses)

•

Gender sensitivity

•

Sensitivity towards need for

for consulting the doctor

•

•

•

Checking whether patient has completed

•

Problems of Poverty and under development

-

Body language

all the required investigations

and the politics of third world countries; effects

-

Active listening

Management of logistics - Curtains and

of social and economic policies on the lives

Probing for knowing the

draw sheet for

of poor

reality and facts

shyness, fear and so on

Use of simple and local

associated with internal

language

examination

privacy

Be present at the time of internal

•

examination , give instructions and make
the patient comfortable

•

Family planning policies and programmes of

-

the state

•

Politics of contraception and gender

-

Attend to patients referred by the doctors
for explanations regarding operations,

procedures

•

Maintaining verbal and

•

•

•

Sensitivity to feelings of

Sensitivity to the social

nonverbal privacy in the

and cultural sanctions to

available resources (talking

sexual issues

softly during internal

Discuss treatment options with the patient

privacy and confidentiality

•

Sensitivity to inability of

examination and giving

women in taking decisions

information, instructions

regarding use of FP

about sexual relations

methods, MTPs , no. of

and issues

children and so on

Making the patient comfor
table (use of bed-side manners)

•

Patience to deal with non

literate and rural patients

Annexure II

Design of the 4- day Counselling Workshop for ANMs and MPWs
Objectives
To familiarise the participant health care providers to the principles of counselling and skills

•

required for counselling

Time

Contents

Session Topic

Methodology

Day 1

1.

30 minutes

Ice breaker exercises

Ice breaker and

games

introduction

2.

Pre-test ques-

Ice breakers and

•

Pre-test questionnaire

30 minutes

Questionnaire

Gender and Sex

2 hours

Pictures of gender

tionnaire

3.

Gender

and

sexuality

4.

Sensitivity in
counselling and

•

Implications of gender in

stereotypes

terms of power and decision

Lecture and discussion

making framework

Gender analysis

Gender and health - RH

framework

Qualities desirable in a 1 hour

Exercise

counsellor

qualities of a
counsellor

e

5.

Self realisation

Self

evaluation

for 30 minutes

Questionnaire

openness, getting feedback

and sensitivity
f

6. Communication
skills

Verbal and non-verbal 30 minutes

Lecture

communication and skills

Role play

for effective

Discussion

required
K

I

communication

7.

8.

in 20 minutes

Errors in coun-

Do’s

selling

counselling in terms of

Discussion

principles and values

Lecture

Macro and micro

Macro and micro skills in 1 hour 15 minutes

Lecture

skills in counse-

counselling

Role play

and

Don’ts

Hing

Role play

Discussion

i

Exercise for conver-

ting close ended
questions to open-

i

ended questions
Day 2___________

9. High risk ANC and
hysterectomy

fyo

Technical aspects of high risk 2 hours

Question - answer

ANC and hysterectomy

Lecture

rb0

. 'IF

“(Jv

247

1

•

Methodology

Time

Contents

Session Topic

Gender and sexuality in
reference to high risk ANC

and hysterectomy

•

Men's role in ANC and
hysterectomy

•
10. Violence and •

health

•

Concept of violence

Violence as a health issue

Brain storming

1 hour 30 minutes

and its consequences

Groupwork

Skills required for counse

Presentation

lling of survivors of violence

11. Sexuality and

•

Sexuality

•

Relevance of sexual

health

Exercises on attitude

2 hours

practices in gynaecological

tcvods sexuality

conditions

Discussion
Presentation

Information needs of

12. Information

needs of clients

45 minutes

Exercise

3 hours 30 minutes

Practical experi

clients

Day 3

Skills

13. Practical

required

for

■

i

working

i

ence at various

counsellors

of

experience

1

departments of

with

hospital

clients visiting the

Group work

1 hour 30 minutes

gynaecology OPD

14. Effective use of •
IEC material in

Importance of use of IEC

Exercises

material in counselling

Demonstration

gynaecological

1 hour

counselling

15. Demonstration of

of condom use

I

Role play

l

Discussion

Verbal, non-verbal, macro

and micro skills

counselling skills

!

Day 4

I

16. MTPand contra •

ception

Technical aspects of MTP

2 hours

and contraception

•

Importance of informed choice

•

Gender and sexuality

•

Question/answer

•

Lecture
i

issues related to MTP and
17. Recording coun •

•

post-test
questionnaire

248

30 minutes

Demonstration of counse

•

Evaluation and post- test

Practice session

for filling in forms
2 hours

Role play

lling skills by trainees

counselling skills
19. Evaluation and

contraception__________
Documentation of counse
lling cases

selling cases

18. Practicing

i

30 minutes

Questionnaire

WCHP Team (2003)
Dr. Usha Ubale

Renu Khanna

Swati Pongurlekar

Korrie De Koning

Ashalata Rikar

Sneha Khandekar

Bharati Ghuie

Anagha Pradhan

Veena Savinkar

Pravina Kukade

Shailaja Ajgarm

Vidya Lad

Shubhangi Joshi

Rashmi Shinde

Dhananjay Gaikwad
Sweta Barve
Jayant Pawar

xy*

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Women Centred Health Project

Dy. Executive Health Officer

Family Welfare and Maternal and Child
Health First Floor, F South Ward Office

Bruhanmumbai Municipal Corporation
PareL Mumbai - 400 014

SAHAJ
Safiaj
1, Tejas Apartments
53 Haribhakti Colony
Old Padra Road
Vadodara - 390 007, INDIA
Telephone No: 91-265-2340223

Royal Tropical Institute (KIT)
MauAritskade 63
P.O.Box 95001
1090 HA Amsterdam
The Netherlands
Telephone No. 0031 -020-5688 239

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