UNFPAReproductive Health in Refugee Situations: An Interagency Field Manual
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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL
APPENDIX ONE
Information, Education and Communication (IEC) Programmes


Contents:

Reproductive health in refugee situations
Photos
An inter-agency field manual

Foreword

Preface

Acknowledgments
 

Chapters


1. Fundamental Principles

2. Minimum Initial Service Package (MISP)

3. Safe Motherhood

4. Sexual and Gender-based violence

5. Sexually Transmitted Diseases, including HIV/AIDS

6. Family Planning

7. Other Reproductive Health concerns

8. Young People

9. Surveillance and Monitoring
 

Appendices


a1. Information, Education, Communication

a2. Legal Considerations

a3. Glossary of Terms

a4. Reference Addresses


design


©1999 United Nations High Commissioner for Refugees

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged.


design


Good communication skills
could include the following:

  • effective, "active" listening in which the provider gives small verbal or non-verbal feedback that indicates to the client that (s)he is being heard and understood;

  • rephrasing what the client has said to make sure it is correctly understood;

  • asking open-ended questions, asking the client to answer questions with more than one word answers;

  • making eye contact;

  • providing complete attention;

  • not being curt or showing a condescending attitude toward the client.

 

The essentials of IEC

Information, education and communication (IEC) combines strategies, approaches and methods that enable individuals, families, groups, organisations and communities to play active roles in achieving, protecting and sustaining their own health. Embodied in IEC is the process of learning that empowers people to make decisions, modify behaviours and change social conditions. Activities are developed based upon needs assessments, sound educational principles, and periodic evaluation using a clear set of goals and objectives. IEC activities should never be developed or implemented independently from a broader reproductive health programme that is being designed and executed in the country. IEC activities not only need to have an appropriate context in which they are shaped, but it is crucial that health services providers be prepared to respond to any demand that may be created as a result of effective IEC activities. The influence of underlying social, cultural, economic and environmental conditions on health are also taken into consideration in the IEC processes. Identifying and promoting specific behaviours that are desirable are usually the objectives of IEC efforts. Behaviours are usually affected by many factors including the most urgent needs of the target population and the risks people perceive in continuing their current behaviours or in changing to different behaviours.

Health information can be communicated through many channels to increase awareness and assess the knowledge of different populations about various issues, products and behaviours. Channels might include interpersonal communication (such as individual discussions, counselling sessions or group discussions and community meetings and events) or mass media communication (such as radio, television and other forms of one-way communication, such as brochures, leaflets and posters, visual and audio visual presentations and some forms of electronic communication).

Good communication between users and providers of any service is essential; but it is especially important when providing RH services, given the sensitive nature of some of the issues that are addressed (such as sexual violence, female genital mutilation, and providing contraceptives to adolescents). Accordingly, IEC approaches must be carefully and appropriately designed and selected.

Although good "one-to-one" communication at the point of service provision is essential for transmitting information and building trust with the client, communication with other individuals and groups within the community is also vital. It is through such communication networks that service providers can obtain information about users' needs, priorities and concerns. Such informal information gathering is the first step in assessing needs (which can be supplemented by other more formal means – see section below). It also helps providers better understand the specific setting and context in which they are working, which will be useful in the later development of IEC approaches, messages and materials.

These types of conversations, or passing on information by "word-of-mouth", has been shown to be one of the most effective communication channels for acquiring knowledge and promoting desired changes in behaviour. Evidence of this is the speed with which rumours spread and the force of their impact. Field staff should not ignore these informal opportunities to educate the public through casual conversation with people in the community.

Once a refugee situation stabilises, it becomes appropriate to consider the development of more elaborate and formal IEC strategies. This requires serious thought and significant allocation of time and resources. The steps involved in the development of IEC are outlined here, but this is not intended to be an exhaustive guide. More in-depth information and details can be found in the items listed in Further Reading. Whatever materials and formal programmes are developed, it is important to ensure that the different aspects are coordinated, and that the content of any messages and the media used to convey those messages are complementary. It is also vital to ensure that people are provided with the necessary support and resources to act in the manner advised.


Communication

Communication can be both verbal and non-verbal.

In verbal communication, the tone of voice can communicate feelings and emotions that are as significant as the words being spoken. Accordingly, it is important to choose words that do not offend in any way and that are easily understood. One should avoid using trigger words, jargon, medical or other sophisticated terms. The use of particular languages may be important in reaching all sections of a community (women may speak fewer languages than men, for example).

In non-verbal communication, body position, gestures and facial expression, often referred to as "body language", can communicate as much as words. It is often through such body language that we express our attitudes towards an issue, a person or a person's behaviour. Service providers must become skilled in interpreting the body language of users as this may assist them in understanding users' needs and concerns more fully. Service providers must also be aware of their own body language and the signals they may be unknowingly sending to users (e. g., movements or expressions that indicate fatigue, boredom, fear, frustration, indecision). It is important that the attitude conveyed by the service provider be compassionate and non-judgmental.


Service Users

Good communication skills are necessary to ensure that good-quality services are provided and that service users are satisfied. It is through communication that trust and rapport are established between the provider and user of a service. Emotional support and the communication of concern and understanding by health staff are often as crucial in providing quality services as is clinical care. If there is a strong provider-user relationship established in this way, it becomes easier to move towards open dialogue on more sensitive aspects of reproductive health.


Other Individuals and Community Groups

Beyond communication with service users, it is necessary to open a dialogue with influential individuals and groups within the community. Such individuals and groups will need to be identified as early as possible. The nature and intention of services should be explained to them and their concerns and priorities discovered and understood. This will not only help make the services more appropriate to the clientele being served, but it will help garner family and community support for the client in the reproductive health behaviour being promoted. The following are some pointers for identifying such individuals and groups:

  • Familiarise yourself with the community with the help of someone who lives in the environment of the refugees and who provides them with some service, advice or protection.

  • Identify individuals who are most important in the social structure of the community with which you are working. They can be existing formal leaders (elected or appointed), but, more often than not, they are informal leaders. This can be done by asking many people in the community. As certain individuals are named repeatedly, it will become clear that they are the true leaders.

  • Identify individuals who have some influence within the community, people whose opinions are respected. They will make suggestions about how to approach people and work with them effectively. They can also serve as role models for desired behaviours and actions.

  • Provide these individuals with very clear information about what your intentions are, what you plan to do, and how they can contribute as partners. Be specific about what they will gain from working with you and allowing you access to the community.

  • Provide them with input about your plans before you proceed, and secure their willingness to participate and to support your efforts.
     

  Counselling

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.


Undertaking a Needs Assessment

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.


Field Tools for Conducting RH Needs Assessments

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.


Although the GATHER method of counselling may appear simplistic, it is complete and thorough:
 

G
 

reet users
 

A
 

sk users about themselves
 

T
 

ell users about the service(s) available
 

H
 

elp users choose the service(s) they wish to use
 

E
 

xplain how to use the service(s)
 

R
 

eturn for follow-up
 


Steps in Developing IEC Activities

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


Links to Providing Services, Support and Follow-up

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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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL