Counselling is a key component of an IEC programme. In the best of circumstances, a good counsellor is compassionate and non-judgmental, is aware of verbal and non-verbal communication skills, is knowledgeable concerning RH issues, and is respectful of the needs and rights of the users. In a refugee situation, there is often a poor counsellor-to-client ratio, emergencies are common and the local environment is not conducive to counselling. However, at a minimum, counsellors should strive to ensure that every service user has the right to the following:

Information:
to learn about the benefits and availability of the services.

Access:
to obtain services regardless of gender, creed, colour, marital status or location.

Choice:
to understand and be able to apply all pertinent information to be able to make an informed choice, ask questions freely, and be answered in an honest, clear and comprehensive manner.

Safety:
a safe and effective service.

Privacy:
to have a private environment during counselling or services.

Confidentiality:
to be assured that any personal information will remain confidential.

Dignity:
to be treated with courtesy, consideration and attentiveness.

Comfort:
to feel comfortable when receiving services.

Continuity:
to receive services and supplies for as long as needed.

Opinion:
to express views on the services offered.

The Role of the Counsellor

The counsellor's role is to provide accurate and complete information to help the user make her/ his own decision about which, if any, part of the services (s) he will use. The role of the counsellor is not to offer advice or decide on the service to be used. For example, the counsellor will explain the available family planning methods, their side effects and for whom they are considered most suitable. The user then makes a decision, based on the information given, about which method she/ he wishes to use.

Effective counselling requires understanding one's own values and not unduly influencing the user's by imposing, promoting or displaying them, particularly in cases where the provider's and the user's values are different.

Be careful never to assume that you know what refugees need or want in their lives or from your projects.

To plan effective interventions, you must find out what refugees think and know about various issues, including their ideas about: what causes sickness and disease and what maintains health, health care, traditional medicine, and reproductive health. It is important to build a relationship of trust and mutual respect in order to get accurate and complete information about sensitive issues such as sexual and reproductive matters.

It is usually necessary to use multiple methods in undertaking a thorough needs assessment. Focus groups, individual interviews or Knowledge, Attitude, Behaviour and Practice (KABP) surveys can be valuable ways to gather information and help develop systems, activities, materials or messages to support RH interventions. Only after there is an accurate picture of the refugee community's knowledge, attitudes, behaviours, expectations and aspirations surrounding reproductive health can you determine what programme and messages might be best suited to its needs.

RH interventions and IEC activities and materials should be based on relevant research conducted through the use of quantitative (how many) and qualitative (what, why and how) methods. Research and discussions should be seen as an integral and ongoing part of planning and implementation.

Quantitative:

• Use available incidence or prevalence rates of targeted problems.

• Knowledge, Attitude, Behaviour and Practice (KABP) Surveys use a series of closed-and open-ended questions to determine what people in a community know, think, believe or do in relation to their reproductive health. Findings are presented in the form of percentages of people who think or do a certain thing. These surveys require many respondents that are randomly selected from the community. Interviewers are needed to implement the survey and they must be trained. This is generally considered an expensive and time-consuming method. Also, this kind of survey does not usually gather information about what inhibits or promotes certain behaviours, since those factors may arise from the context in which people live and not from their knowledge and attitudes.
  

Qualitative:

• Individual interviews allow the researcher to get deeper insights into a person's thoughts and feelings. Using an interview guide, interviewer and respondent talk at length about the respondent's feelings about a specific service or issue. If trust is established and confidentiality ensured, the interviewer can often get very valuable information about the interviewee and the community, information that might not otherwise be revealed.

• Focus Groups are in-depth discussions, usually of one to two hours in length, with a small group of people. Members of the Focus Group should have something in common with each other (age, sex, and experience) in the expectation that this will make it easier for them to talk together. They are representatives of the target group in that they are deliberately chosen. The intention is to make sure different groups within the community are represented within the Focus Group, or that several Focus Groups are held with members drawn from various sectors within the community. Discussions are lead by a facilitator who follows a prepared guide that allows for probing into the thoughts and feelings of group members. This method is often considered cost-effective, as many people are gathered together at one time to express their opinions. Findings are presented in the form of comments or extracts from interviews, which illustrate what people are thinking about certain topics, or why they engage in a particular activity.
  

The Reproductive Health for Refugees Consortium (1) has field-tested and finalised five RH needs assessment tools. These are

• Refugee Leader Questions
  

• Group Discussion Questions
  

• Survey for Analysis by Computer
  

• Survey for Analysis by Hand
  

• Health Facility Questionnaire and Checklist
  

The purpose of these tools is to assist relief workers in refugee/ displaced person settings in gathering information to assess attitudes toward RH practices and local medical practices/ policies, the extent of needed services and the degree to which current services provide what is needed.

It is important to note that not all tools will be appropriate for all refugee situations. The order in which the tools are used may also vary. In general, refugee leaders are consulted before any information is gathered from the larger population. This is often followed by group discussions, key informant interviews and facilities review. In some situations, a survey may be conducted but this is often dependent upon resources, time, skills of available staff and whether or not the level of effort required by a quantitative survey is warranted. A clear needs assessment objective will help field workers decide which tools are appropriate for their particular situation.

The information provided by the tools must be reviewed in the context of the broader objective of the needs assessment. Any tool used should be adapted to the local situation and resources available. Judgement is required by those applying the tools. In many cases, other resources may exist to support the needs assessment and these should be used. Examples of additional strategies for collecting information include: camp registration records (information on women's ages, marital status, and sometimes pregnancy); clinic, health centre and/ or traditional birth attendant records; in-depth interviews with representatives from UNHCR, UNFPA, Ministry of Health and NGO staff; camp health coordinating committees and NGO logistics officers; and structured observation at different times of the day and night in the refugee community.

1. The RHR Consortium comprises American Refugee Committee, CARE, Center for Population and Family Health, Columbia University's Mailman School of Public Health, The International Rescue Committee, JSI Research and Training Institute, Marie Stopes International and the Women's Commission for Refugee Women and Children.

The information gathered through the needs assessment provides the framework for the development of suitable IEC activities. Any activities and materials must always be culturally sensitive and appropriate. These are the major steps you should follow when designing an IEC activity:

• Conduct a needs assessment.
  

• Set the goal. This is a broad statement of what you would like to see accomplished with the target audience in the end.
  

• Establish behavioural objectives that will contribute to achieving the goal.
  

• Develop the IEC activities and involve as many other partners as possible. After their successful implementation, you should be able to have a significant impact on achieving the behavioural objectives.
  

• Identify potential barriers and ways of overcoming them.
  

• Identify potential partners, resources, and other forms of support for your activities and gain their sustained commitment.
  

• Establish an evaluation plan.
  

The indicators should determine the level of achievement of the behavioural objectives. Having such specific indicators makes evaluating and monitoring the progress and impact of the activities much easier. Additionally, process indicators could be established to track to what extent and how well the planned activities have been carried out.

An objective must be SMART:
S	pecific (what and who)
M	easurable (something you can see, hear or touch – usually expressed with an action verb)
A	rea specific (where)
R	ealistic (achievable)
T	ime-bound (when)

IEC Messages

• Develop IEC messages. A good message is short, accurate and relevant. It will make, at the most, 3 points. It should be disseminated in the language of the target audience and should use vocabulary appropriate for that audience. The message tone may be humorous, didactic, authoritative, rational or emotionally appealing. It may be intended as a one-time appeal or as repetitive reinforcement. It is often necessary to develop several versions of a message depending on the audience to whom it is directed. For example, differing information about contraceptive services will be relevant to women who already have three or four children already, from that which would be appropriate for adolescents who are just beginning to be sexually active. Their needs and priorities are different, so the IEC materials used with each group must also differ. Find out if materials already exist in the host country or country of origin, and if appropriate, use these instead of developing new ones.

• Pre-testing, by trying out the materials with small groups from your larger target audience, is an essential part of developing messages and educational materials. It is through pre-testing that you will ensure that people understand the message as intended. Pre-testing may need to be repeated frequently until you are sure your information is being conveyed as desired.

• Determine suitable methods and channels of action and communication. Once the target audience is identified and researched and the key messages have been chosen, it is time to decide which media and combinations of information channels will reach the target group. Both formal and informal groups can be targeted. Different channels do different jobs. Each has its own strengths and weaknesses, depending the role it will take in the communication programme. The choice of messages and media will be influenced by many factors: cost; literacy levels; artistic style within the community; familiarity with, and extent of penetration of a particular medium for both service providers and users; and availability of the medium in the target population's community.
  

The development and refinement of messages and the choice of the communication channel or medium are inseparable. Very different messages will be developed for different media, for example radio, stories, poems, songs, posters or flip charts, for the nature of the medium affects what messages can be successfully used. The skills of those using the materials must also be considered. It may be necessary to provide training to those staff expected to use the materials. For example, it is important to recognise that placing a picture or poster on a clinic wall at which people may or may not look is quite different from using a series of pictures in the form of a flip chart as an educational tool in a group setting.

The following are some suggestions for key messages on technical topics that may be shared. These are presented as examples only and are shown out of context. The choice of any message will, in reality, be context-specific; often a group of messages will be decided upon, rather than just one.

Sexual Violence:

• The importance for women to seek medical care as soon as possible
  

• Where to go for counselling if it is available
  

• How to prevent it, particularly in collaboration with others in the community
  

Safe Motherhood:

• The reasons why it is important for women to seek prenatal care
  

• The need to and how to identify obstetric complications and refer immediately
  

• The reasons it is important to breastfeed exclusively and the importance of maternal nutrition
  

Sexually Transmitted Diseases (STDs)/ HIV/ AIDS:

• How to use condoms and how to dispose of them safely
  

• How HIV is and is not transmitted
  

• Means of prevention
  

• Common signs and symptoms
  

• Where to receive counselling
  

• Where to receive treatment
  

• Where to go for support services
  

• Why it is important to inform and involve all sexual partners
  

Family Planning:

• How and where to obtain reproductive health services, including contraceptive supplies
  

• Where to get information or counselling
  

• How adequate birth spacing contributes to healthy families
  

Reproductive Health of Young People:

• How young people can protect themselves through safe sex
  

• Delay and patience is a positive value and that there are other ways to have fun
  

• Young people need to take responsibility for their own health
  

• High-risk behaviours may result in long term, unwanted consequences
  

For IEC of any kind to be effective it must be linked with the availability of support and resources so target audiences can act in the manner which is being recommended. It is therefore essential that the content of any IEC programme accurately reflect the nature and quality of the services provided. Logistical support must be adequate to ensure the necessary supplies (material and human) are consistently available and adequate training should be provided to health workers to support inter-personal communication and community follow-up. People must be able to act on the advice contained in the IEC messages and materials.

Further Readings

"A Tool Box for Building Health Communication Capacity", Healthcom, Academy for Educational Development, Washington, DC, 1995.

Debus M. Methodological Review: A Handbook for Excellence in Focus Group Research, Washington, DC, Academy for Educational Development, 1988.

"Developing Health and Family Planning Print Materials for Low-Literate Audiences: A Guide", Program for Appropriate Technology in Health, Seattle, PATH, 1989.

"Developing Health Promotion and Education Initiatives in Reproductive Health: A Framework for Action Planning", WHO, RHR, Geneva, 1998.

"Facts for Life", UNESCO/ UNICEF/ WHO. "Guide to Planning Health Promotion for AIDS Prevention and Control", WHO AIDS Series 5, Geneva, WHO, 1989.

"Refugee Reproductive Health Needs Assessment Field Tools", RHR Consortium, 1997.

"Tools for Project Evaluation: A Guide for Evaluating AIDS Prevention Interventions", Family Health International , AIDSTECH/ Family Health International, Durham, NC, 1992.
 

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