1. Family Planning Counseling
Session II:

2. FP Counseling: Beliefs and Attitudes
Be aware of your beliefs and attitudes
Clients may not return if they feel judged or pushed
Remain neutral and nonjudgmental
Respect the rights of your clients
Practice helps
It’s important to be aware of our own beliefs and attitudes and how they may influence how we counsel our clients.
Clients may not return for services if they feel they have been judged or pushed. Remaining neutral and nonjudgmental toward a client is an important skill in counseling. This means managing what we feel and say so that we do not let our beliefs and attitudes interfere with our counseling.
Everyone has their own beliefs and value system. Often, these attitudes may come in conflict with different clients that you see. It is important to respect an individual’s beliefs. Clients have the right to be treated with respect.
However, while remaining respectful, it is also important to challenge client beliefs that might be harmful to that individual or to others. As you engage in family planning work, it is equally important to challenge your own values and beliefs.

3. Communication and Counseling Skills
Success of FP counseling depends on ability to establish and maintain a good connection:
Builds trust
Helps client relax
Helps client communicate openly
Good communication and counseling skills are keys for maintaining good connection throughout the counseling session
The success and effectiveness of the counseling session depend on your ability to establish and keep a good, warm connection with the client, so that you build trust with the client and help them to relax, which helps them to communicate openly with you. What are some things that you do when greeting a client to establish a good connection? <allow participants to respond; affirm or build upon their responses to make the following points> Yes, you greet them using a warm tone of voice, use eye contact if appropriate, call them by name, and ensure that they are seated comfortably.
What are some things that you do to maintain this connection? <allow participants to respond; affirm correct responses>
All of the communication and counseling skills that you have learned up to this point will help you to establish and maintain a good connection.
As we begin to learn and practice each stage of the counseling process, it is good to keep in mind the importance of using these and other skills to maintain a good connection with your client throughout the counseling session.
We have a Competency Based Skills Checklist for Counseling that will remind you of the tasks and skills needed for establishing and maintaining a good connection that you can use on the job. <display the job aid and distribute it to participants> Let’s look at this now.
References:
1. Knebel E. The use of manual job aids by health care providers: What do we know? Issue Paper Volume 1. Baltimore, MD: Quality Assurance Project, 2000.
2. Tumlinson K; Hubacher D; Wesson J; Lasway C. Measuring the usefulness of family planning job aids following distribution at training workshops. Journal of Biosocial Science, Sep;42(5):695-8.
Reference:
1.Johnson SL, Kim YM, Church K. Towards client-centered counseling: Development and testing of the WHO decision-making tool. Patient education and counseling, :

4. Communicating Effectively and Maintaining Rapport
Show respect
Be relaxed, friendly and attentive
Use simple, clear language
Use open-ended and probing questions appropriately
Listen carefully to client
Ask client about feelings
Encourage client participation
Explain what will occur during visit and procedures
Ensure client understanding and correct misunderstandings
Use job aids appropriately
Correctly record information on data-collection forms
Ask a trainee to read the slide out loud. Note the list of skills and tasks. Note how all the items on this section of the Competency Based Checklist are important for establishing and maintaining rapport and are also used or done throughout the session or more than once during the session. Ask trainees to recall how they practiced these skills in previous exercises.
Ask trainees if they have used Competency Based Checklists in the past. Note that this checklist can make it easier to carry out tasks by providing quick access to needed information. Such as the steps and tasks of FP counseling. Even the most experienced providers can benefit from checklists.
Leave the slide in place and tell trainees that they can refer to the slide during their practice exercises when they are learning the stages of the FP counseling process. Inform trainees that you will demonstrate most of these tasks and skills when demonstrating the first stage of counseling.

5. Stages of FP Counseling1 2 3 4
Establish rapport and assess client’s needs and concerns
Provide information to address client’s needs and concerns
In this section of the training we will review the stages of counseling during a client visit and how we can use the counseling tool to help guide our discussion with the client. There are four stages of the family planning counseling session. The title of each stage describes the primary task or tasks of that stage:
In Stage 1, you establish rapport and assess the client’s needs and concerns. In Stage 2, you provide information to address the client’s needs and concerns.
In Stage 3, you help the client make an informed decision or decisions about FP or help them decide how to address a problem. And, in Stage 4, you help carry out the client’s decision.
The communication and counseling skills that you have learned and practiced are important in all of these stages. Though we will discuss each of these stages separately, in actual practice the stages flow one into the other and the boundaries between them are not distinct. To give you an idea of how a family planning counseling session works, I will demonstrate a counseling session that moves through all of these stages. Watch and see if you can identify when I am in each of these stages. I will stop the demonstration at certain points and ask you what stage you think I am in.
Conduct a brief FP counseling session demonstration using Roleplay Scenario 1 in the Facilitator’s Guide. Ideally, arrange for two co-facilitators to conduct the demonstration so you may comment on the interaction. If necessary, conduct the demonstration with your co-facilitator. Stop the demonstration at several points to give participants the opportunity to identify each stage, correcting their responses as needed. Note the use of the counseling tool and other job aids used during the demonstration that participants will be using at their workplace, (i.e., Balanced Counseling Strategy method cards, or a method selection sheet) and inform participants that they will use these during practice role plays. Inform participants that next they will review the counseling tool.
Distribute a counseling flip chart of counseling tool used in the country or The Community Health Worker Tool for Family Planning , which is one of the handouts in this module. If no local tool is available use WHO’s Counseling Tool for FP Clients and Providers or WHO’s A Guide to Family Planning for Community Health Worker’s and Their Clients (also a handout) or the Population Council’s Balanced Counseling Tool. If none are Available, use the Fact Sheets for each FP method. * Note, links to these tools can be found on the Training Resource Package Website.
Help client make an informed decision or address a problem
Help carry out client’s decision

6. Counseling Tool for Family Planning
The purpose of this activity is for participants to become familiar with using counseling tool, so they can more easily absorb information about the stages of the FP counseling process during the activities that follow. Adapt this overview and the activities for the tool that the participants will be using during FP counseling.
Begin by asking participants, Recalling the demonstration, what do you think is the benefit of using a counseling tool during FP counseling? Allow participants to answer and discuss. Use responses to highlight these points: A counseling tool helps guide decision-making for the client and also organizes the counseling for the provider. A tool can help a client clarify what she wants in a method and consider benefits and limitations of method options, and how these might affect her or his life. It encourages client participation and helps a client feel confident in her decision-making. A counseling tool helps a provider give accurate and complete information and reduces the need to memorize information. Because of these features, a counseling tool supports and facilitates informed decision-making.
Ask trainees to open their counseling tools , look at the first few pages and become familiar with them. To conclude the activity, demonstrate how to hold the counseling tool so the provider and the client can see it, and how to point to information. Ask participants to practice showing pages of the counseling tool to each other.

7. Assess Client’s Needs and Concerns1
Assess Client’s Needs and Concerns
Greet client appropriately
Ensure privacy, confidentiality, and client comfort
Ask about reason for visit
Ask about partner(s), home life, family, health, sexual behavior, HIV status
Ask about plans to have children, desire for FP
Explore STI risk and what client does to avoid STIs
Suggested script:
The first stage of FP counseling has three main purposes: 1) To establish a good connection with the client, 2) to find out why the client has come to see you, and 3) to gather basic information about the client’s situation so you can help them. To do this, you will complete these six tasks during this stage of counseling. Look at page 2 of your job aid to see these steps.
<read list of tasks on slide; click the mouse to reveal each bullet>
As we saw in the roleplay, it is very important to establish a good connection with the client at the beginning of the visit by greeting them appropriately. Make sure that you are in a private space where others cannot see you or overhear your conversation, and assure the client that everything he or she says will be kept confidential. Also make sure that the client is seated comfortably.
After greeting your client, ask “How may I help you today?” What is another way to ask about the reason for the visit? <allow participants to answer> <give an example, such as “What do you hope that I can do for you today”>
Then gather information about these areas of the client’s life: home life, ideal family size, health, partner or partners, sexual behavior and HIV status. Ask a brief series of questions to gather this information. The amount of detail discussed at this point depends on the client’s needs and whether or not the client is new or is a returning client. Ask about a client’s plans to have children and desire for family planning—to delay or prevent pregnancy, or to become pregnant.
Next, help the client consider their STI risk. When assessing STI risk, ask questions and then listen closely to the client. Respond in a way that helps them explore their own risk and decide for themselves if they are at risk. You should not tell them that they are at risk, even if you think they are. The information gathered at this stage should be used to tailor the rest of the counseling session to the client’s individual needs. Each session will be different.

8. Questions About the Client
Ideal family size
Home life
Partner(s)
Health
Sexual behavior
HIV status
The purpose of this exercise is for participants have fun while generating a list of questions they can use in the first stage of FP counseling.
Show slide with the categories of information to be gathered from clients. Remind participants that, at the start of a session with a new client, they need to gather information from the client about the client’s ideal family size, partners, home life, health, sexual behavior, and HIV status.
Ask the trainee’s to form small groups of no more than three to four trainees (Depending on the total number of participants, this may be three to five small groups.) Make sure each group has a blank piece of paper, pens or pencils and a place to write. Assign one or two categories from the flip chart to each group, so that all categories are covered and no two groups have the same category. Tell the groups to discuss and agree on what questions they would use to gather information about their assigned category. Tell them that each group will have just two minutes to discuss and write their questions and that they should create mostly open-ended questions, as appropriate. Tell them to write their assigned category or categories at the top of their blank sheet of paper, then signal the groups to begin.
At the end of the two minutes, tell the groups to stop writing. Instruct them to fold their papers into paper airplanes, demonstrating how to do this, if necessary. Tell each group to “fly” the airplane to the group next to them. After each group receives an airplane, they should unfold it carefully and examine the questions listed on this new sheet of paper. Give them about one or two minutes to add any questions to those on the list, or to suggest new ways to ask a question that is already listed. At the end of this time, instruct them to refold the papers into an airplane and “fly” it back to the group it received it from. Ask one representative from each group to read their list of questions aloud to the rest of the participants. Give feedback on the questions; write some of the best questions as examples on flip chart paper, and ask the group to suggest ways to improve other questions.

9. 2 Provide Information to Address Client’s Needs and Concerns
Part 1
No method in mind? We can discuss:
Protection from sexually transmitted infections (STIs) or HIV/AIDS
Your experiences with family planning
What you have heard about family planning methods
Your plans for having children
Your partner’s or family’s attitudes
Other needs and concerns
The second stage of FP counseling is about providing your client information and options to address their identified needs and concerns. <read the list of these tasks on the slide>
What you say to your client in this stage is based upon what you learned during the first stage, when you asked questions to find out about the client’s needs and situation, such as about their home life, partners and HIV status. For example, what did we learn about Sarah during my demonstration of Stage 1? <allow participants to answer, record responses on flip chart, summarize the information learned about the client and point at the relevant information on the flip chart> To summarize, we learned about Sarah that she is 21 and married, she is interested in injectables but also wants to learn about other FP methods, she is still breastfeeding her eight- month-old baby, her menses returned two months ago, her husband was treated for an STI recently, and she wants to delay pregnancy for at least several years.
<The information in this paragraph applies only if participants are community health workers.> If during Stage 1, or during any part of the counseling session, your client tells you about a need or concern that you have not been trained to respond to, it is important to tell them that you can not deal with that issue and refer them to the local health center or to a clinical provider. <give name of local health center or provider>
The first task in this stage is to advise the client how to prevent STIs, if the client believes he or she is at risk for STIs or HIV infection. This advice should flow naturally from your assessment of STI risk. Do you recall how I helped the client assess her STI risk at the end of Stage 1? What are the ways you can advise your clients to prevent STIs including HIV? <allow for several responses> <affirm and highlight correct answers; refer to any relevant pages of the counseling tool>
What do you say to your client at this point? <allow for several responses> Yes, that’s correct, what you say is based on the goals they described in Stage 1. If they said they want to become pregnant, you describe things they should do or consider when thinking about becoming pregnant. <review any relevant counseling tool pages> <continue on next slide>
Now let’s discuss how a method can meet your needs

10. Provide Information to Address Client’s Needs and Concerns2
Part 2
Inform client when needs or concerns are beyond provider’s capability
Advise on how to prevent STIs
Advise on how to have a healthy pregnancy (if client wants to become pregnant)

11. Provide Information to Address Client’s Needs and Concerns2
Part 3
Explain benefits of FP and healthy spacing
If client wants FP, help client identify methods suited to her needs
Give information on methods of interest
Respond to other client questions or concerns
For clients who are thinking about using family planning for the first time, the next step in Stage 2 is to describe the benefits of family planning. <display any relevant counseling tool pages and note the main points>
If your client says she wants to limit or delay childbearing, or stop childbearing, then ask her if she already has a method in mind. If she does, you would give her information about that specific method. If she does not have a specific FP method in mind, what do you say? <allow participants to respond>
You explain that there are many family planning methods to choose from, and then display the method selection job aid for the client. <display the method selection job aid(s) participants will be using> Then we come to the heart of Stage 2: Identifying methods that are suitable for the client’s situation. By asking four questions, you can quickly narrow down the list of available FP methods to those that best meet the client’s needs. After asking the method selection questions, there will usually be two to four methods remaining that are suitable for the client. At this point you describe for the client the main features of each of these methods.
All of the information that is important to give to the clients to help them choose a method are in your counseling tools. For example, let’s look at information on the Pill (or COCs). <show where this information is provided a counseling tool > What are the features of the Pill described here? <allow for several responses> Yes, how it works, the fact that it reduces menstrual bleeding and cramps, possible side effects, health benefits, it requires taking a pill every day, and that it is less effective if you miss a pill. You will learn more about the Pill and other methods in future training sessions, so it is not necessary that you learn how to explain this now. The important thing to remember is not to overload the client with too much information at this point. Just share with them the five to seven key facts about the method that are shown in counseling tools.
You would also respond to any other client concerns or questions. For instance, if the client wants FP and also wants help with discussing FP with her partner, you would tell her you can help her find approaches that will work, and that you will discuss this further after she has decided on a FP method. Do you have any questions about this stage so far? <allow participants to respond and answer questions as needed>
I will demonstrate how to ask the four questions and use <insert name of job aid> to eliminate methods. Please follow along using your counseling tools (or other job aids).

12. Provide Information to Address Client’s Needs and Concerns2
Part 4
Display the method-selection job aid(s) for your client
Ask these 4 questions to identify methods suited to client’s needs and goals:
Do you wish to have children in the future?
Are you breastfeeding an infant less than six months old?
Do you have the cooperation of your partner in FP?
Are there any methods that you do not want to use or have not tolerated in the past?
Display the appropriate method-selection job aid(s) and ensure that each participant has a copy. Depending on the cadre of the participants and the available resources, the job aid may be a method- selection sheet that includes images of all available methods, a set of Balanced Counseling Strategy (BCS) method cards (or printed copies of the fronts of the cards), or a method-selection page in the counseling tool. If using a method selection sheet or page, demonstrate asking the questions and instructing the client to cover up each method that has been eliminated by her answers to the questions.
If using the method cards, arrange them by type—permanent methods, temporary methods, and fertility awareness methods—and demonstrate how to ask the questions and eliminate methods, following the instructions in the document, Demonstrating Use of the BCS Method Cards. Adapt your instructions to fit the job aid you are using.
Review the questions on the slide. Explain that the questions help you rule out certain methods.
If a client answers yes to question 1, what methods should we set aside? (vasectomy and tubal ligation)
If a client answers yes to question 2 , what methods could we safely rule out (or set aside)? (The Pill/ COCs)
Question 3, what methods require partner involvement or cooperation? (Male and female condoms, and Standard Days Method)
Question 4, what does this question rule out (or set aside)? (Methods the client does not want or did not tolerate in the past)
Ask trainees if they have any questions, clarify any points as needed. Tell participants that you will now demonstrate counseling a client during Stage 2.
Reference:
1. León, Federico, Ricardo Vernon, Antonieta Martin, and Linda Bruce The Balanced Counseling Strategy: A Toolkit for Family Planning Service Providers. Washington, DC: Population Council.

13. How Clients Choose Methods
Effectiveness
How long client wants protection from pregnancy
Ease of use
Health benefits and possible side effects
Safety
During the next stage of counseling, new clients will choose an FP method. Before we discuss this stage in detail, let’s first talk about how clients choose a FP method. When members of your community are considering using a FP method, what features or characteristics of the methods do you think are important to them? What features are important to you? Why do people choose FP methods? <allow participants to respond; use their responses to highlight the following points>
Factors that women and couples often consider when they decide which contraceptive method to use include:
How effective a method is at preventing pregnancy is a very important consideration for most users. Turn to a counseling tool pages on method effectiveness . You can use these effectiveness charts to help describe and compare the effectiveness of the methods that your client is considering.
How long the client wants protection from pregnancy—whether for a year or less, two to three years, four years or more, or whether they want to stop childbearing altogether.
How easy it will be to use. Some methods do not require users to do anything—such as the IUD— while others require action at the time of intercourse or at specific time intervals. What are examples of method that require user actions? <allow for several responses> Yes, examples include using a condom with each act of sex, taking a pill every day, or getting an injection every three months.
Health benefits and possible side effects of the method are also important considerations. Some methods offer important health benefits that may be particularly appealing to some women. Side effects are different from method to method and knowing them in advance helps a woman decide what potential side effects she is willing to tolerate.
How safe the method is for them to use. However, few women of childbearing age have serious health conditions that may affect safe use of contraceptives.
What other factors are important when choosing a FP method? <allow for several responses; discuss> <possible responses may include: cost and access to resupply; previous experiences with a method; desire for STI/HIV protection; whether partner involvement is required>

14. 3 Help Client Make An Informed Decision
Ask client if she or he has any questions about methods you discussed
Ask client to choose a method
Use pregnancy checklist or method screening checklist to determine if client can use method
Agree on decision or plan in partnership with client
The purpose of the third stage of counseling is to help the client make an informed decision about a FP method or help them decide how to address a problem they want help with.
These are the tasks of this stage: <click the mouse to display each bullet in turn and read each one as it displays on the slide>
The first task is to ask the client if she has any questions about the methods that you discussed. Answer any questions, and then ask the client to choose the method that is most convenient for him or her.
Clients may ask the counselor their opinions of the remaining methods. However, it is important not to impose your opinion on a client. Remain neutral even if you favor or dislike a particular contraceptive method or believe that the client would do better with a different method. If your client is not clear about which method she prefers, how can you help her? <allow several participants to respond> You can review information about the two or three methods that she is considering, emphasizing the characteristics of each method that are important to the client, and using a counseling tool (or other job aids) to explain how the methods differ. These are the characteristics that we just discussed, such as effectiveness, ease of use, side effects and health benefits. For example: at the end of your Stage 2 practice, for the health workers who were counseling Amina, what methods were remaining? <allow participants to answer> Amina is considering injectables, implants, and the Pill. You would tell Amina about the effectiveness, side effects, and other features of these methods that are important to her. You should give information about all of the methods your client’s are considering.
The next task is to use a screening checklist, if needed, to determine if the client has any conditions that would make it unsafe for her to use the method.
The final task of this stage is to agree on a decision or plan in partnership with your client. This means summarizing the decisions that the client has made during this session and describing what comes next. For clients who have chosen a FP method, you would confirm the client’s choice. You may say something such as, “So you’ve decided that you definitely want to use injectables, is that right?” In addition, if the client chooses a method that you cannot provide, what would you say at this point? <allow participants to respond; affirm correct responses> Yes, you would say “I will give you a referral to the clinic for implants.”Ask participants whether they have any questions about this stage; answer questions and clarify points as needed.

15. What method are you using?
Vasectomy or Female Sterilization
Condoms (Male or Female)
Vaginal Methods
LAM
Fertility Awareness-Based Methods
IUD
The Pill
The Mini-Pill
Long-Acting Injectable
Monthly Injectable
Implants

16. Help Carry Out Client’s Decision4
Give FP method and condoms, if needed
Explain/demonstrate correct use
Ask client to explain/ demonstrate, reinforce understanding or correct demonstration
Remind client about side effects, reasons to return
Role-play or rehearse negotiation skills
Arrange follow-up, resupply, or referral, as needed
In the fourth and last stage of FP counseling, these are the steps: <click the mouse to display and read each bullet point on the slide>
First give the client their requested FP method—or, <if participants are CHWs>, a referral to get a method such as implants, plus condoms, if needed.
Then explain how to use the method using a counseling tool.
Next, check to make sure that the client understands how to use the method or methods by asking him or her to explain and or demonstrate correct use. Remind the client about any side effects she may experience, and signs of problems or complications for which she should return, using the appropriate pages in the counseling tool.
Do the next task, “Role-play negotiation skills” only if the client requested help in preparing to talk with their partner. At this time you help them to plan and rehearse the discussion. This may include discussing what they will say and when and where they will have the talk, helping them brainstorm possible responses and role-playing the conversation so they can rehearse responses, as you practiced previously. I will do this during my demonstration of this stage.
Invite the client to come back any time for any reason. If the client has chosen a method that you will provide on a regular basis, explain what will happen during future visits and schedule the next visit. Do you have any questions? <answer any questions as needed> Let’s see what this stage looks like.