Counseling

By:Abraham Tamirat (BSc,MPH)
11/23/15 1

Lecture outlines
Counselling Vs Advice
Patient education
Home visits
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Learning objectives
At the end of the session students will be able to;
Describe the overview of concept of counselling
Explain patient education
Discuss different types of health care errors
Identify the importance of home visit
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Counselling
Counseling is one of the approaches most frequently used
in health education to help individualsand families.
When it isapplied in health mattersit’sHealth counselling
Concept/definition
Counseling is helping process by which, we first
understand the problem, and then help the people to
understand their problem, and then we need to work
together with them to find solution that is appropriate to
their situation.
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…these situations of counselling include
Situationsmay beinterpersonal, decisional or emotional ;
Situations for which best recommended action is not available.
(clear alternativesmay exist)….but specific to events.
In situations/conditions when the best of the clear alternatives are
specific to individualsdecision/preference. e.g FP
In specific situations for which no clear alternatives are available
but theparticipation/helping processmake alternativesemanate.
Urgent situationsoccur that elicit seeking or providing help
e.g: Crying from HIV+ test result
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Counseling…
It is a process of helping a person/people learn how to solve
certain interpersonal, emotional and decisional problems.
A counselor'sroleisto help theclient help himself or herself.
A counselor also help clients avoid the pre-existing premature
decision.
A counselor may assume a role of checking maturity of a
decision at any timefrom start to just beforeleaving aroom.
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Counseling…
Counseling IS …
 Client-centered — specific to the needs, issues, circumstances
of each individual client
Counseling IS NOT…
 Telling or directing
 Giving advice
 A conversation
 praying
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• Counseling isahelping processand it isachoice.
However, advice is…………………
• an opinion given for someone by experts as to what to do and how
to do something.
• an opinion recommended or offered asworthy to befollowed.
• Isaproposal for appropriatecourseof action
• In advice, the decision is made by thehealthworkerand the clients
are expected to follow the decision made by the health workers.
But, in counseling thedecision aremadeby theclients themselves.
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Advice is not appropriate in counseling fortwo reasons
1st
: if the advice is right the person may become dependent
on thecounselor for solving all theproblems.
(you arenot investing)
2nd:
if the advice turns out to be wrong the person will be
angry and no longer trust thecounselor.
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Characteristics of good advice
Still if thereisaneed to advicetheclients, it should bemeet the
following characteristics.
Meetsafelt needs& Realistic.
Epidemiologically correct
Easy to understand (usematerialsaids)
Culturally acceptable
Affordable
Requiresminimum time/ effort
Advicemay beused in p/education when actionsarenot optional
1011/23/15

Rules for(principles) counseling
A) Good relationship (show concern and acaring attitude).
 build rapport
B) Feelings: counselor should develop empathy (understanding
and acceptance) for peoplefeelingsnot sympathy (sorrow or
pity)
C) Participation: counselor should work with theclients
towardsthesolution.
A counselor should never try to persuadepeopleto accept
his/her advice.
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D) Privacy and confidentiality: the information must
be kept secret from all other people, even from the
clients’ relatives.
E) Provide Information: although counselors do not
give advice they should share information and ideas
on resources which the clients need in order to make a
sound decision.
F) Normalize situations: provide existence of similar
situation if any or explain it is a possible event at a
point in life(if you fail to havesimilar event before)

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Who shall be counselors
Qualities of good counselor:
Respect for dignity of others
Open or non-judgmental
Activelistener
Empathetic and caring
Knowledgeable (readily equipped by counselling facts)
Honest, sensitiveand self-discipline.
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Pitfall forcounseling:
 Directing and leading theideasof theclients.
 Minimizing theclient’sproblem
 Using wordssuch as“should”and“must”
 Not accepting theclientsfeelings
 Pushing or threatening theclient
 Encouraging dependency
 Advising theclient
 Taking responsibility for theclient’sproblem and decisions
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Approaches to counseling
TheGATHERapproach to counseling
G-Greet the individuals/clients by name: show respect and trust,
tell thediscussion isconfidential
A-Ask about his/her problem, measures he/she took to solve the
problem and how he/shebelievesyou can help theclient.
T-Tell any relevant information he/sheneedsto know.
H-Help them to makedecision: guidethem to look at the various
alternatives, and help them to choose solution/s which will
best fit for their circumstances.
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Approaches…
E-Explain any misunderstandings. Ask questions to check
understanding of important key points and repeat the key
pointsby their own words.
R-Returnto follow-up on them: makearrangement for follow up
visit or referral to other agencies.
If follow-up visit is not necessary give the name of someone
they can contact if they need help.
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Note: Counselingcanbedonewithanindividualor
withcouples orfamilies.
Exercise:
if youareproviding PIHTservice inOPD &
someone becomeunexpectedlyHIV+ &
emotional, howdoyoumanagethecase.
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Terms
Patient: capable of waiting or preserving: able to
endure waiting, delay, or provocation without
becoming annoyed or upset
It implies a sort of submissiveness/dependency on
health care providers (to whom treatment is given)
Client: someone (active) using professional service
Customer: some one to whom services are
provided or sold… it implies marketing
perspective
(Microsoft Encarta® , 2009)
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Patient education
Health education may occur in any setting as school,
prison, worksites, health care setting etc
In health care setting education/communication is
inevitable in the process of health care service
provision that encompasses patient education.
It happens in the continuum from diagnosis of
illness, informing illness, providing recommended
action/treatment for effective sick role behaviors.
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…Patient education
It is matters of health information in the provider-
patient relationship in clinical care.
It is education of patients, using methods & materials,
involving information on;
Diagnosis or nature of the problem
Nature of recommended treatment, side effects etc.
The two main recommended regimens for patients
health benefits are drug/device & lifestyle for self care
(e.g; SNAP-smoking,nutrition,alcohol&physical exercise
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…patient education
The ultimate purpose of patient education is;
To enhance patient health behavior like sick role
behavior that best restore Health (secondary & tertiary
HE)
Patient education aims on priority behaviors in
relation to disease & regimen using priority P,R & E
inventory of the behavior.
 In HCF strategic patient education will be conducted
on priority health problem, priority behavior & priority
factors affecting a behavior.
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…Patient education is targeted to;
motivate for complying the regimens (drugs & lifestyle)
Provide skills, help diagnose & solve barrier situations in
self care (e.g remember the case study as method )
Provide a intervention on enabling factors (e.g inability
to fill regimen) via systemic referral to third
parties/agencies to help deal with such situation.
Allow appointment to identify problem & reinforce
adherence of self care
The effectiveness of PE (avoiding errors) involves
participation of patients & commitment of providers for
patients’ better health.
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The capitals/opportunities in HCF
Health care workers are powerful instigators for many of
specific behavioral & even lifestyle change.
They play a supporting non-trivial role with out which
many patients will not start the process of change.
The following are opportunities in HCF to that change
Clinical credibility-authoritative source of h/information
Access to teachable moment- patients receptivity + flow
Public interest: the recent shift in general public to
actively seek counselling/education for health directed
behaviors or to cope with h/threat.
Readiness of clinical practitioners; ready to help
patients/devote for preventive medicine as b/r change.????
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Missed opportunities
The ideal opportunities that may be missed include;
Discouraged to implement preventive practice b/c;
Leaving little room for preventive medicine/HP.
Perceiving patients as non compliant to advice
Real/perceived lack of skill to influence behavior change
Underestimation of patients knowledge & skills
Limited space & tight clinic schedules
Economic disincentives etc
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Epidemiology of Health care errors
In the process of service provision in HCF different levels
of errors happen that affect patient health.
The errors even partly involve the lack/inadequacy of
patient education & again partly need patient education
as intervention strategy.
These errors may be related to either or both of patients
& providers
These errors may be broadly categorized as
Errors of omission
Errors of commission
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…errors
An error Omission:
occurs when a patient fails to receive or apply to
clinically important medication/procedures as needed.
An error of commission:
Occurs when a patient misuses a prescribed
therapeutic/preventive regimen or uses a drug
prescribed for another patient/illness OR
Occurs when a provider prescribes a wrong drug or
therapy. (lacks standard/ inefficient/in
appropriateness)
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Illness/condition
/risk present (A)
Contact with
health provider
(B)
Drug is
prescribed
Drug is
received
Few or no
drug error
Drug is used
(C)
Failure to contact
health provider
Undiagnosed(A1)
No drug/ appropriate
regimen is prescribed
Non-user (B1)
Drug is not received
Non-user (B2)
Drug not used
Non-user (B3)
Significant
error /misuse
(C2)
Using others
illness/patients
regimen +
pregnant risky
behavior C1

…errors
Based on targets (for intervention) these errors can
be
Professional errors
Patients errors
Special groups errors within patient error of
commission
For errors of omission two broad classes of patients
The undiagnosed/unscreened (A1)
Non users (B1, B2,B3 groups)
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…errors
Errors of commission include
Professional errors:
A diagnosis applied with out adequate confirmation
In appropriate/inefficient drugs e.g drugs in lieu of style
Drug-drug interaction not evaluated
Wrong dose of right drug.
 So what is your intervention here>>>> professional
media communication, quality assurance/continued
education.
NB: many of these errors result in pts errors of
omission.11/23/15 30

…errors
Patient error of commissions
significant errors of misuse (C2) due to
Misunderstanding procedures
Inadequacy of information need etc
So, what intervention??? >>>> satisfying information
need via IEC materials, work on professionals the role of
information/communication in health impact etc
Special groups (pregnant + users other
illness/patients)
C1)11/23/15 31

Systems thinking ‘many but whys’ ’
It is basically aimed for behavioral diagnosis.
It is a technique of understanding reasons or factors
behind any behavior or health outcomes
It is creating a logical systems picture quite simply by
asking, at each juncture, “but why?”
The systems level thinking helps planners identify &
isolate concrete behavioral events that enable them to
be more precise in targeting program strategies.
In HCF, to understand why unhealthy behaviors
happen, system thinking is important.
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…systems thinking
It also assists to identify reasons of some behaviors in
some context of non behavioral/environmental
factors
This is because “health behavior is best understood a
part of ecological system.”
E.g ‘Taking a prescribed medication’ …many why?
Medical care seeking
Obtaining a prescription medication
 Rejecting a prescription
Past personal or others history related to medication,11/23/15 34

…system thinking
 “A broken-appointment cycle” in which clients decide
to stop attending follow up is a good example of
systems view of keeping appointments i.e
Appointments are not being kept…but why?...b/c
Patients are dissatisfied…but why? ….b/c
Poor relationship or long waiting time…but why?...b/c
Decreased time with physician & over schedulling….why
In efficient use of staff time
Now get system of actions & reactions, decisions/choices
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11/23/15 36
In
adequate
medication
Decreased time
with physician

The role of clear HC in patient education
& health care errors
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First identify common problems in provider-
patient communication
What basic problems are there on Provider & Patients?
Use systems thinking to identify the problems
For example;
Client side: embarrassed to ask, know, etc for better
health, low health literacy
Provider side: fail to know what to emphasis on,
undermining the role of patients health literacy in health
outcomes, attitude on importance of risk b/r information
& belief patients acceptance of advice
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…problem scope of low health literacy
 Health literacy is the ability to read, understand and act
on health information.
 Older patients, people with chronic dses and those with
low socioeconomic status are especially vulnerable to low
health literacy
 Adults with low health literacy, as literatures depict:
– Are often less likely to comply with prescribed Rx and self-
care regimens (C2 error)
– Make more medication or treatment errors , fail to seek
preventive care (C1, A1 errors)
– Are at a higher risk for hospitalization & remain in hospital
nearly 2 days longer (externalities of errors)
–11/23/15 39

Under-utilization of preventive services
Over-utilization of health services & Unnecessary
health care expenditures
Poor Health Outcomes/ limited effectiveness of
treatment & needless patient suffering
Higher patient dissatisfaction &
Higher provider frustration
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Best Opportunity for Immediate Impact
Enhance Patient-Provider Communication
Focus on Clear Health Communication
What Needs to Be Done
Improve the Patient-Provider Relationship
Best Way to Do It
11/23/15 41

…solutions to the P-PC problems
For example;
Inform & Encourage patients to ask main essential
questions that impact their better health.
Help providers to give attention to health literacy of
patients, identify what to do & inform, identify local
health beliefs & use them.
The change agent produce important material aids
So, Creating partnership among patients, providers &
intervening agent with shared responsibility for clear
HC plays a pivotal role in alleviating the problem
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For example the partnership for a
shared responsibility named with;
11/23/15 43

Promotes three simple, but essential, questions
and answers for every healthcare interaction:
Why Is It
Important for Me
to Do This?
Context
What Do I
Need to Do?
Treatment
What Is My
Main Problem?
Diagnosis
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Provides a consistent approach to patient-provider dialogue
Allows patients to get information they need to manage their
health
Time-efficient for providers to reinforce healthcare
instructions
11/23/15 45

Patients Should Not Be Anxious About Asking
Their Health Care Provider the 3 Questions!
Health information can be confusing at times
Everyone wants help with health information
Asking questions helps patients understand
how to prevent or manage illness
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ProviderPatient
All they can about their condition/medication
Why this advice/treatment is important for good
health
Steps to take to prevent a condition or keep it under
control
Thus, health Care Providers Want Patients to Know :
11/23/15 47

What should the provider do for CHC?
Bear in mind!!!
The 3 Qs that need answer in any health care interaction.
That many people have trouble understanding medical
terms. (but often, common words, an example/visuals )
That chances are there /high that patients with poor
health literacy skills are in your care who:
 are often ashamed to admit they have difficulty
understanding information and instructions
 use well-practiced coping mechanisms that effectively
mask their problem (may be sources of errors)
11/23/15 48

Benign Harmless
Chronic Happens again & again; does not end
Cardiac Heart
Edema Swelling; build up of fluid
Fatigue Tired
Screening Test
Intake What you eat or drink
Adverse events Side effects
Consider Using
This One Instead
Instead of
Using This Word
1. Avoid/decrease the Use of Medical Jargon
11/23/15 49

What should the provider do for CHC?
2. Limit the amount of information provided but not little.
3. Slow down
4.Use IEC material aids (visuals, models, brochures,
posters etc) to explain important concepts
5. Assure understanding with the “show-me” technique
6. Encourage patients to ask questions
Note:
These things can alleviate B2, B3, C2 Health care errors
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What should third party/change agent do
Increase health literacy of clients, patients & the would
be patients. (Create health awareness & general
education)
Produce & distribute IEC materials
 To encourage patients to ask questions, seek medical care
To guide & motivate providers in h/care interaction
Note:
It reduces almost all errors A1, C1, C2, B2, B1, B3
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11/23/15 52
Examples of IEC materials
produced & used for patients &
providers

Element: Poster
Description:
Stimulates curiosity
about Ask Me 3
Informs patients and staff
about the program
Implementation (hang poster):
Hang anywhere where provider-
patient interaction takes place
Anywhere patients might see it!
 In waiting areas, In exam rooms
 On ceiling above the exam table
 On a door11/23/15 53

Element: Patient brochure
Description:
Educates patients about
the Ask Me 3 & Motivates
patients to ask their healthcare
provider questions
Implementation:
Display in waiting
rooms/registration area
Distribute to patients upon
arrival/sign-in
Distribute with any paperwork
11/23/15 54

Element: Provider brochure
Description:
Explains the scope and impact
of low health literacy
Offers communication tips
Emphasizes how effective
communication can positively
impact patient health outcomes
Implementation:
Distribute to all staff interacting
with patients through staff meetings
or mailings
Conduct in-service training on CHC
11/23/15 55

Home visit
• Home visit is one of the opportunities we have for counseling &
patient education.
• Home visit are important to understand the real back ground of
families, their living conditionsand theenvironment.
The purpose of home visit
• Establish rapport –keeping good relationship with families and
people.
• Encouragetheprevention of common diseases.
• Detecting and improving troublesomesituation early.
• Follow up of patients- checking theprogression of sick person
5611/23/15

…Home visit
Observe the environments and the behaviors that affect
thehealth of thefamily.
Educating thefamily on how to help asick person.
Identify barriers
Motivateadopters.
Providehealth education
Informing people about important community events in
which their participation isneeded.
More realistic and people feel free to talk with health
providerswhen they arein their home.
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11/23/15 58
For your practical solution on health care
errors during your service provision!

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