• Communication skills
• Communication
  • Advising mothers
    • Summary of steps taught in training activities
  • A good question
  • Practical exercise for training courses
  • What is communication?
  • Active listening
  • Repeating and interpreting
  • Story-telling
  • Plain language is best
  • Putting it into practice
    • Table of observed behaviour
    • Table of health workers advice reported by mothers
  • Quality consultations
• Resources and letters
  • HealthCorn
  • On the boil
  • Singing the praises of ORT
  • Oxfam support

DDOnline Dialogue on Diarrhoea Online Issue no. 58 September-November 1994 Page 1 2

Communication skills

Greeting a mother and showing interest in her child's well-being are essential to effective communication. To be effective, health workers need to know the right facts about how to prevent ill health and treat illness. But just as importantly, they also need to be able to communicate these facts and help people to improve their families' health.

Good communication is a two-way sharing of information. It involves finding out people's views. listening carefully to what they say and understanding their situation. It includes being observant and appreciating the constraints people face at home. Attitudes are as important as what is said. Effective communication starts with welcoming a mother when she comes to see you with a child who has diarrhoea, respecting her views and recognising that she has valuable experience of looking after her child's health. Giving advice is a key part of health worker communication. But finding out information and gaining people's trust has to come first. Unless you have gained people's confidence by communicating well with them, then that advice may not be followed. Articles inside explain how to select key messages to give people, how to explain points clearly in appropriate language and how to check if people have understood what you have said. This issue also provides ideas and examples for training others in communication skills. Finally, enthusiasm for your message is vital. If you believe in your message and want to share the information, this makes communication come alive! William Cutting and Katherine Elliott

• How to ask the right questions Page 3
• Listening skills training activities Page 5
• Are you using appropriate language? Page 6

DDOnline Dialogue on Diarrhoea Online Issue no. 58 September-November 1994 1 Page 2 3

Advising mothers Cathy Wolfheim describes a new WHO training initiative aimed at improving the way health workers advise mothers on how to manage diarrhoea at home.

Good communication can ensure that mothers return to health facilities if problems arise. Some health interventions depend mainly upon adequate supplies of drugs and equipment and health workers' skills to deliver the right treatment. However, good management of diarrhoea also relies on mothers being able to treat their children's diarrhoea at home.

How well mothers care for children with diarrhoea depends largely on how messages have been communicated by health workers. There are three main guidelines for home management of diarrhoea:

• give the child more to drink than usual
• continue usual feeding, including breastfeeding if the child is being breastfed
• take the child to a health facility if danger signs appear.

Mothers and other care givers need to know these rules so that they can apply them when their children are ill. People who have heard the rules before may need to be reminded. One of the most effective means of communication is two individuals talking, sometimes called 'face-to-face' or 'one-to-one' communication. It allows an immediate exchange of information and ideas. Health care workers often do face-to-face communication. They are usually respected as good sources of information, and they are in regular contact with many parents through their day-to-day work. However they may need help in improving their communication skills. Integration with clinical training WHO has recently developed a training guide called 'Advising mothers' which aims to teach health workers to communicate more effectively using the simple process - ask, praise, advise, check (see bottom). The training activities in the guide are designed to be included in courses on clinical management of diarrhoea so that communication skills are given the same importance as clinical skills such as diagnosis or treatment. Alternatively, the training activities can be run as a separate 11/ 2 day course for health workers who have already been trained in clinical management of diarrhoea. Rather than attempting to produce communication 'experts', the training aims to teach a few essential communication skills to health workers. The training guide emphasises the value of practising new skills. Practice helps participants to become familiar with listening and giving advice, and convinces them that the process works. In the same way that practice is important when learning to do new things such as driving a car or diagnosing illness, it is also important when learning how to talk to mothers more effectively, and how to use visual aids. In the training activities some skills are first practised as exercises (see pages="#page3">3 and 6). then participants are given the opportunity to practise the skills in a real life situation with mothers whose children have diarrhoea. Cathy Wolfheim, CDD, WHO, CH-1211 Geneva 27, Switzerland.

Summary of steps taught in training activities ASK what was done for the child before coming to the health centre and listen carefully. Were drinks given? What sort? How much? Was the child given food? What food? How much? Any other treatment? PRAISE the mother's helpful actions. Every mother bringing a child for care has done something right, even if it is only the fact that she has sought medical help. ADVISE the mother about other things she can do to help her child. Even if a mother has taken most of the correct steps, she is likely to welcome further advice such as danger signs to watch out for if the child gets worse, or advice on preventing further episodes of diarrhoea. Make sure you do not overload her with information - choose the most important points. CHECK that the mother has understood. Ask her to describe what she will do when she returns home. This is better than asking: 'Do you understand? ' She would probably answer 'yes', because she may be too embarrassed to say no. If possible, ask her to demonstrate what she will do, e. g. preparing an oral rehydration fluid.

Editors' note: In this issue of DD we refer to advising mothers since mothers usually bring children to clinics. However, other people often look after sick children - grandmothers, fathers, older children and other family members. The same skills should also be used to communicate with them.

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A good question The way health workers ask questions is very important. Good questioning will allow a real exchange of information between you and a mother. Questions can be used for several purposes: finding out basic information, getting more information about something a mother has said, finding out what a mother already knows, and checking whether she understands and remembers what you have told her. There are two basic types of questions: Closed questions

These are questions that need only yes or no as an answer. For example, 'Did you prepare ORS solution'? ' 'Have you continued feeding your daughter? ' Closed questions often begin with the words: have, has, did, do, are or will. These sorts of questions are useful when you need to find out simple information, such as whether a mother prepared ORS solution or continued feeding a child. However, closed questions are very limited. If a health worker only asks closed questions, a mother will have little opportunity to say anything apart from yes or no. The chance to find out other important information will have been missed. Closed questions can also lead a mother to answer what she thinks the questioner wants to hear. For example, if you ask: 'Did you give your child ORS solution? ' then she might say yes because she thinks that is the correct answer. If you ask instead 'What did you do for your child with diarrhoea? ' it is more likely that she will describe what she actually did. since she has not been prompted to remember ORS. Open questions These are questions that require a mother to say much more than just yes or no. Such questions encourage her to describe what she did, explain why she did it, or outline what she understands about managing childhood diarrhoea. Open questions often begin with: What? When? Why? How? Examples: What did you do when you realised your child had diarrhoea?
How much has your child had to drink?
How do you prepare ORS solution? When finding out what home care the child has received, it is useful to use a combination of closed and open questions as the following example shows. HEALTH WORKER: Has your child been drinking lots of liquids'?
MOTHER: No.
HEALTH WORKER: What seems to be the problem?
MOTHER: She was vomiting as well as having diarrhoea, so I thought if I gave her something to drink it would increase her vomiting.

What is communication? Communication is the exchange of information. In health programmes, the aims of this exchange are to reach a common understanding and to change or reinforce certain behaviours that promote health. The word 'exchange' is vital. Think about how two people hold a conversation. First, one person talks and the other listens. Then, based on what the first person has said, the second person responds. Information and ideas are exchanged between the two. The course on advising mothers is also based around exchanging ideas. It starts with a health worker asking a mother key questions; then praising the mother, so the mother knows she is being listened to; then the health worker giving the mother advice based on what the mother already knows and does.

Practical exercise for training courses This exercise aims to help you think about different ways of asking questions. Please change each closed question into an open question. Example CLOSED: Do you know about the importance of giving more fluids to a child with diarrhoea?
OPEN: How much will you give your child to drink? Exercise

1. CLOSED: Do you understand what you should do at home now?
   OPEN: ....................................................................................................................................................
   ..................................................................................................................................................................
   
2. CLOSED: Do you have a one litre container at home to measure water for mixing ORS?
   OPEN: ....................................................................................................................................................
   ..................................................................................................................................................................
   
3. CLOSED: Do you know when to bring your child back to the health centre?
   OPEN: ....................................................................................................................................................
   ..................................................................................................................................................................
   

Suggested answers are on page 7

Source: CDD, WHO, 1993. Advising mothers. CDD/ 93.2 Copies of the 'Advising mothers' training guide are available to trainers and managers of health care providers. Write to CDD, WHO, CH-121 1 Geneva 27, Switzerland.

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Active listening Good communication is a two-way process with both health workers and mothers listening to one another, respecting each other's viewpoints and learning from one another. Unfortunately, we have probably all seen examples of one-way communication where health workers 'talk down' to mothers, lecture them, or criticise them. These mothers are likely to go away feeling misunderstood and humiliated. As a result, many of them will be unwilling to visit a health centre again. Listening is a particularly important skill. Many of us might think we do this every day and do not need training in it. But do we listen with our full attention and really try to understand, rather than just hearing the words and reaching our own conclusions? Very few of us could claim to be perfect listeners. But with training, many of us can improve our listening skills. Active listening involves:

• giving our full attention to the person speaking
• concentrating on what the person is saying
• respecting the speaker's viewpoint
• checking that we have understood what the speaker is saying.

It does not involve:

• carrying out another task at the same time
• switching off and thinking about other things
• interrupting the speaker
• telling the person that they are wrong.

Active listening builds relationships by showing the other person that we take what they say seriously and accept them. It helps to avoid misunderstandings. It encourages people to speak fully and frankly because they know their ideas will be listened to. Much of active listening is common sense. The following points may help you to focus on how to listen more actively.

• Give the speaker your attention and make time for them. Different cultures have different ways of showing this. For example, in some cultures it may involve looking at the person, making eye contact and nodding.
  
• Be ready to summarise what the person has said. This helps to check your understanding and to demonstrate it to the other person. You may like to use expressions like: 'Are you saying .....?'
  
• If you do not understand, ask. It is better to ask: 'I'm not sure I understand the point about . . . . . Can you explain it again, ' than to ignore what the person is saying.
  
• Encourage the speaker if he or she seems uncertain. This may take the form of asking open-ended questions such as: 'And what happened next?'. or making supportive comments or gestures. Sometimes silence can be a way of encouraging - you do not have to say something.
  
• Try not to respond until it is clear that the speaker has finished.

Two-way communication takes more time and effort than giving instructions, but it is time well spent when it results in improved care of children. Source: The Open University; 1991. Managing Yourself,: Block 1 Book 2, Managing Voluntary and Non-Profit Enterprises. EXAMPLES OF TRAINING ACTIVITIES Repeating and interpreting

Ask participants on the training course to form groups of 3-5 people. Give each group a copy of this discussion between a mother and health worker. Ask the groups to choose two people to act out the parts of the mother and health worker. MOTHER: I'm not breastfeeding much now. My milk's no good.
HEALTH WORKER: Your milk's no good?
MOTHER: No. I work hard and we don't have much money. I don't eat well.
HEALTH WORKER: It seems that things are difficult for you. It sounds like you feel that since you work hard and don't eat well, that maybe it makes your milk bad? (The health worker pauses - looking and waiting for the mother's response.) MOTHER: Yeah. My sister told me that if I don't eat good food then my milk will be too thin.
HEALTH WORKER: OK. let's talk about that .. (They discuss the woman's diet and how it could be improved without spending a lot more money. Then the health worker explains that a poor diet will not make breastmilk bad. The woman decides she wants to breastfeed more.) Ask the groups to discuss and write down:

• how well the health worker listened
• where the health worker showed signs of active listening.

After 15 minutes discussion, bring all the groups together and ask a spokesperson from each group to report on the group's discussion. Afterwards you may like to summarise some of the issues involved. The health worker used a combination of active listening skills to better understand how the mother felt, show her how important her feelings were, and decide what specific things to discuss with the mother on this visit. As a result, the mother would have left with a better understanding of her own nutritional needs and felt more confident to breastfeed. The health worker took these specific steps to listen well:

1. she repeated what she had heard, using the mother's words
2. she watched for feelings on the mother's face and in her tone of voice
3. she interpreted what was happening, based on what the mother said, what the health worker saw, and what the health worker already knew about the mother's situation, to fully understand what the mother was saying
4. she checked if this interpretation was correct.

Repeating (the actual words) and interpreting (using what you hear, see and know, to fully understand what people consulting you think and want) are both important skills. Repeating shows people that you are paying attention and encourages them to talk more. Interpreting gives people a chance to expand on what they have said and correct any wrong assumptions you have made. Active listening will stop you from assuming you know what a person thinks, needs or wants just because you know 'other people like them'. No two people are the same. Valerie Uccellani, Academy for Educational Development (AED), 1255 23rd Street, NW, Washington DC 20037, USA.

DDOnline Dialogue on Diarrhoea Online Issue no. 58 September-November 1994 4 Page 5 6

EXAMPLES OF TRAINING ACTIVITIES Story-telling

Ask participants to form small groups as in the activity on="#page4">page 4. Give each group a copy of the following story for one group member to read aloud while the others listen carefully. Ana comes to the clinic with her very young baby. She has lost her health card and feels very frightened to tell the health worker. The health worker shouts at Ana: 'Where is your health card?' Ana whispers a response. The health worker shouts: 'If you cared more about this little baby you wouldn't forget to bring that card!' Ana looks down and hands over the child who is crying. The health worker weighs the child, shakes her head sadly, and writes information in her book without telling Ana what she is writing. Ana is frightened and worried. She thinks 'Is there something wrong with my daughter?' The health worker then speaks very quickly to Ana. 'Your daughter is underweight. Give her more food more often, especially fruits and vegetables. Breastfeed her frequently. That's all! Next time, bring your health card!' Ask participants to discuss and write down on a chart: (a) what did the health worker do that showed poor communication?
(b) what will Ana do as a result?
(c) suggest specific things the health worker could have done to ensure better communication. In the same way as before. ask a spokesperson from each group to report on the group's discussion. At the end. it may be worth suggesting some of these points if groups have not already mentioned them. (a) The health worker spoke quickly, wrote information without telling Ana, gave orders instead of information.
(b) Ana may worry, get discouraged, lose hope, forget the message, feel badly that she cannot buy enough fruit and vegetables, decide not to return the next time, tell her family and friends about the harsh person.
(c) The health worker could ask, listen to Ana, praise, advise, check. Source: Learning to listen to mothers. Nutrition Communication Project. Academy for Educational Development (for details about this training manual see page 8).

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Plain language is best Health workers learn about disease using very technical terms. When these terms become familiar it is easy to forget that other people may not understand them. Because of this, health workers often use terms that mothers may not understand when there are simpler ways of saying the same thing. For example, a health worker may advise a mother to prepare rice water using 50 grams of rice. If the mother does not know what grams are, or if she does not have a way to measure the rice, she may not know how to prepare it. It would be clearer to tell her to use one open handful of rice.

Information overload: it is better to emphasise a few essential, easily remembered points. This exercise can be used to practise changing difficult sentences into everyday language. You will need to decide which of the terms used in the sentence may be difficult for a mother to understand. You should then replace them with more common expressions.

Example: Diarrhoea can lead to dehydration, so you must give your child greater quantities of fluids than usual.

Simplification: Diarrhoea can make your child lose a lot of water from her body and become weak. So you should give her more to drink than usual. Explanation: The words dehydration, greater quantities and fluids, may not be familiar to the mother. It is simpler to say lose water and more to drink. For each of the following sentences, write the same thing in a simpler way. (Suggested answers are on page 7.)

1. Mix the contents of this ORS packet with 1,000ml of water and give your child 200ml each time she has loose motions.
   
   Simplification .......................................................................................................................................................
   
2. After the diarrhoea episode, your child needs increased nutrition.
   Simplification .......................................................................................................................................................
   

Source: CDD. WHO, 1993. Advising mothers.

Putting it into practice Training in face-to-face communication was introduced into diarrhoeal disease control (CDD) courses in Vietnam in 1990. Health workers are taught how to: use simple language, ask checking questions, use printed materials effectively, and demonstrate preparation of ORS and rice water. Participants in the training are also given the chance to practise these skills. To find out how well the training has been put into practice, health workers' performance in six provinces has been monitored regularly, with observation visits from regional or national staff. Mothers and other care givers have also been questioned during household surveys about the advice they received from health workers. The results have been very positive, showing improved advice given to mothers. Observations of 103 health workers during the year after training showed that the majority were practising what they had learnt. When mothers and carers in two provinces were asked about advice given in 1990 (before training) and in 1992 (after training), it was found that more health workers were following the steps set out in the course for improving the way mothers are advised (see table below). Cathy Wolfheim, CDD, WHO and the National Institute of Hygiene and Epidemiology, Vietnam.

* Province A is Hai Phong.
* Province B is Thua Thien-Hue.

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Quality consultations The Quality Assurance Project describes a training course on communication skills that has proved successful in a number of settings. During the professional training of health workers, one-to-one communication skills are not often emphasised. Some training courses look at what advice health workers should give people who consult them, but few courses address how to find out information from people and how to give advice. The result is that many people who visit health facilities experience poor communication and do not receive the attention and information they need.* The Quality Assurance Project attempted to change this by developing a training course in one-to-one communication skills. The training is based on the idea that if people are better satisfied with the service they receive from health workers, they will be more likely to follow health workers' advice, leading to improved health. This is supported by studies conducted in the USA and Europe. First, a review was carried out of communication methods, and the following recommendations were drawn up, covering three main communication areas. 1. Good social skills

(These are ways to make people feel comfortable when they visit a health centre.)

• Greet the person warmly.
• Be welcoming in the way you talk and behave - gestures and the way you sit can communicate your attitude.
• Ask about the person's feelings.
• Reassure them that their feelings are normal.
• Praise the person's efforts.
• Encourage them to provide more information by repeating what they have said, and inviting them to say more.
• Show understanding.
• Show support.
• Help them not to worry by suggesting specific things they can do.

2. Problem solving skills

(These help health workers gather information and understand people's health needs.)

• Actively listen.
• Encourage dialogue by asking open questions.
• Avoid interruptions.
• Do not decide what the problem is before finding out the full story.
• Listen carefully before making clinical decisions.
• Probe for more information.
• Ask about causes, difficulties and worries related to the problem.

3. Counselling and education methods

(These are effective ways to explain health issues and treatment.)

• Find out the person's views on their (or their child's) illness.
• Correct any misunderstandings about the facts.
• Use appropriate language.
• Present information in a logical way.
• Check the person understands what you have told them about their illness.
• Be specific about what the person should do.
• Motivate them to follow the treatment recommended.
• Check whether they will follow the treatment
• Make sure they know when to come back.
• Ask if there is anything else they would like to know.

We then developed a training course to teach these skills to 26 health workers in Honduras in Central America treating four key diseases, including diarrhoea. Local trainers were involved from the beginning so that training could continue without the project's involvement. Course participants were given the opportunity to practise new skills by doing role-plays (acting out a visit to a health worker), and being tape-recorded during a real consultation with a patient. Participants discussed each other's performance in the role-plays and tape recordings and suggested ways to communicate better. The new communication skills were summarised in a pocket-size booklet given to all participants as a reminder of what they had learnt. In addition, everyone received a more detailed training manual. Participants' communication skills were evaluated before and after the training by interviewing people after they had consulted the health workers, studying tape-recordings, interviewing health workers themselves, and conducting follow-up home visits. The communication skills of the health workers who attended the training course were compared with a group of health workers (called a control group) who had not received communication training. Positive evaluation results

Initial results show that training resulted in a significant improvement in communication skills and a decrease in poor communication such as criticising people or interrupting them. Health workers in the control group asked to receive training, and the Ministry of Health expressed interest in incorporating the training course into its on-going staff training. The training course has now been adapted and run in Egypt and Trinidad, showing that the course can be adapted to suit different settings and cultures. Dr Berengere deNegri, Dr Orlando Hernandez, Dr Lilliana Dominquez, Dr Deborah Roter, Lori DiPrete Brown and Julia Rosenbaum, The Quality Assurance Project, URC/CHS, 7200 Wisconsin Avenue, Suite 600, Bethesda, MD 20814, USA. * In this article 'people' visiting health workers also refers to mothers of children with diarrhoea visiting health workers for advice about their sick children.

Suggested answers to practical exercises on pages 3 and 6 Open questions

1. What will you do for your child when you return home?
2. What containers do you have at home for mixing ORS?
3. What signs would show that you need to bring your child back to the health centre?

Simple language

1. Mix the contents of this ORS packet with three soft-drink bottles of water. Then give your child a cupful every time she has diarrhoea.
2. After the diarrhoea is over; your child needs to eat more than usual. It is a good idea to give her snacks between meals or an extra meal each day.
   

DDOnline Dialogue on Diarrhoea Online Issue no. 58 September-November 1994 7 Page 8

HealthCom Single copies of the following resources are free to readers in developing countries. Write to HealthCom (address below) and explain how you will use them.

• Graeff, J A, et al., 1993. Communication for health and behavior change. San Francisco: Jossey-Bass.

Useful for planners of communication programmes, trainers and health educators. Price for readers in Europe, North America and Australasia: US$23.95. Paid copies should be ordered direct from Jossey -Bass Publishers. 350 Sansome Street, San Francisco. CA 94104,. USA.

• HealthCom/ PNG and FirstTake Productions, Making things clear.

A 13-minute videotape for training health workers in interpersonal communication skills. Available in English and Tok Pisin. Please specify the format (NTSC, PAL or SECAM) and the type of tape (VHS or BETA) required. Price for readers in Europe. North America and Australasia: US$10.

• Uccellani V, and Vella J, 1993. Learning to listen to mothers: a trainers' manual to strengthen communication skills of nutrition and growth promotion.

The manual outlines a two-day training workshop for community-level nutrition workers on how to communicate better with mothers. Aimed at trainers and supervisors of nutrition workers, this manual. developed by the Nutrition Communication Project, offers practical advice about organising training courses and examples of group activities that can be adapted to different settings. Price for readers in Europe, North America or Australasia: US$4. For all orders (except paid copies of the first book) write to: HealthCom,
Academy for Educational Development,
1255 23rd S& t, NW, Suite 400,
Washington, DC 20037, USA.

TALC

• Hubley, J, 1993. Communicating health: an action guide to health education and health promotion. London: Macmillan.

Contains practical guidelines on how to carry out effective communication in a wide range of settings including with families, communities, schools, health services and through the mass media. Price: £5.80 plus postage and packaging (check with TALC for details of p& p charges). Write to: TALC, PO Box 49, St Albans, Herts., AL1 4AX, UK .
On the boil

I would welcome other readers' ideas about the best ways of convincing people who do not have access to safe water that they need to boil water before drinking it. It can be hard to overcome the idea that 'this is how we have always done it' and there is no need for anything new. Father Eddie Brady, Missionaries of Africa, Nyakato, PO Box 1421, Mwanza, Tanzania.
Singing the praises of ORT A number of campaigns have been undertaken in Nigeria to take information about oral rehydration therapy (ORT) to people's doorsteps. The importance of ORT is communicated through posters, calendars, stickers, film shows, T-shirts, radio and television, and the establishment of ORT units in rural areas. Another communication method is a song in the local language about ORT and how to prepare it which is sung in hospitals and clinics every morning after prayers. Health workers need to demonstrate how to prepare ORT and parents need to practise following their instructions. It is also important that parents are shown examples of how ORT has helped children to recover from diarrhoea. A E E Okoro, State Approved School Sick Bay, Hill Top, Ngwo, Enugu State, Nigeria.

Change of address AHRTAG has moved offices. Please note the change of address (including telephone and fax numbers) as follows: AHRTAG
Farringdon Point, 29-35 Farringdon Road
London EC1M 3JB, UK
Telephone +44 171 242 0606
Fax+ 44 1712420041
E-mail="mailto:[email protected]">[email protected]
[email protected]

However, if you have written to us recently at our old address it will still reach us. All mail will be forwarded to our new address - though it may take a few days longer to reach us.

Oxfam support A special thank you to Oxfam's public health team for funding the distribution in Africa of the last issue of Dialogue on Diarrhoea on sanitation.