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Background and Resources for Module 3 Session Objective: Learn methods and develop attitudes that help to improve interpersonal relations between providers and users, and to respect users' rights and identities in sexual and reproductive health services. Specific Objectives: Identify and reinforce skills and practices that promote quality care in health services. Become familiar with personal attitudes and interpersonal dynamics that promote quality care. Learn new criteria and techniques for more effective and efficient services. Key Concepts: Quality care in sexual and reproductive health services Quality in human relationships Technical quality Tools for improving health services Activities: Appreciating our abilities The quality care philosophy Practices and techniques of quality care Human and technical quality in health care interactions Time: 4 hours Activity 1: Appreciating Our Abilities Objective: Identify and reinforce skills, abilities and practices that promote quality care in sexual and reproductive health. Procedures: Each participant identifies three abilities, skills or practices that make a positive contribution in his/her work. Try to focus on abilities that help us to recognize and respect differences, establish equitable and constructive work relationships, share knowledge and power, and strengthen users and colleagues' skills. Participants write each ability on a card, providing a concrete example of each. Deposit all cards in a box. When all the cards are in the box, each participant draws three, which s/he reads aloud and writes on the poster paper. Participants have a group discussion and analyze the different practices and abilities that promote compassionate quality health care and gender sensitivity. Time: 30 minutes Materials: - Index cards Activity 2: The Quality Care Philosophy Objectives: Introduce the philosophy of quality care. Relate the abilities and skills identified in the preceding activity to the practice of gender-sensitive quality care. Procedures: Guide a discussion using the concept card on quality care. Different participants can read consecutive sections of the concept card, pausing to discuss alternative interpretations and applications of the ideas presented in each section. Conclude with a discussion about tangible attitudes and actions that participants can take to offer better quality care in their work. Refer to the poster paper that records the positive abilities identified in Activity 1 to see how these can be strengthened and institutionalized to guarantee quality care. Activity guide: Facilitators should have read beforehand the section on the conceptual framework that presents quality care, and be prepared to refer to it in discussion. Invite the participants to relate their own abilities presented in Activity 1 to the goal of developing and implementing quality care at an institutional level. Time: 45 minutes Materials: Concept card: Quality care Activity 3: Practices and Techniques of Quality Care Objectives: Observe the practice of key techniques for quality care in sexual and reproductive health. Analyze cases in which different methods that contribute to quality care are practiced. Procedures: One at a time, watch each of the three cases presented in the video "Hablemos con Confianza," produced by The Johns Hopkins University, plus the case presented in the video "Quality Care in Reproductive Health," produced by the Flora Tristan Center for Peruvian Women. After each case, stop the video and spend 10 minutes discussing what was seen using the discussion guides provided below. Facilitators can enrich the discussions with the summary of techniques for improving gender-sensitive quality care included in the support resources for this session. First Case: "We were all 18 ..." This case emphasizes the importance of respecting the user's age, culture and way of thinking in health care interactions. Discussion guide: What message does this story convey? What challenges did the provider face in her efforts to put herself in the user's place? How well did the provider carry out her role? Which aspects did she handle well, and where could her approach be improved? What sexual and reproductive rights come into play in this case? What obstacles impede the user from making her own informed decision? Second Case: "Step by step" The GATHER method lays out steps to follow that help to ensure better communication with users. This method is not rigid and can be adapted to the needs of each situation and each user (Rhinehart et al. 1998). Discussion guide: What message does this story convey? How is the couple's relationship presented? What rights does the woman exercise? What rights does the man exercise? What sexual and reproductive rights does the provider promote? What did the provider do well? What could we have done differently? Use poster paper to write out the steps of the GATHER method. Discuss each step of the method in light of participants' experiences. How can we apply each of these steps in our own work? What are the advantages and the drawbacks of the GATHER method? Third Case: "We all have doubts" This case demonstrates techniques for listening, respecting users' silences and respecting the users' perspectives as a means of improving communication. Discussion guide: What is this case about? What is the personal situation of the user? Of the provider? What feelings and fears does each experience? What expectations does the user bring to the consultation? Identify positive attitudes and practices manifested by the provider. How would we act in this situation? In this consultation, was the right to obtain comprehensive information respected? On poster paper note the nonverbal techniques (gestures, looks, facial expressions) and the verbal techniques (phrases of interest, listening, open questions, closed questions, reflection questions) that are employed. Identify an example of each of these techniques in the video. Fourth Case: "Quality care in reproductive health" This video demonstrates a user's fears about negative power relations with health providers, revealing numerous tensions and anxieties that need to be discussed and dealt with to obtain quality care. Discussion guide: What is this story about? What aspects of interpersonal relations in health care are brought into question here? How can one describe the first contact that the user has with the health care center? What type of power relations are manifested in the different provider-user interactions depicted during the video? Do the imagined stories have any basis in reality? Have participants observed or heard of any similar experiences? What rights are not respected in the imaginary visits? Time: 2 hours Materials: - Videos Discussion: It is important to emphasize that the techniques presented here do not dictate uniform approaches to all interactions with users. The methods and techniques reflect a range of possibilities that should be selected and applied according to the personal style of each provider and the needs and identities of each user. Expected results for participants: Learn how to apply for personal use certain techniques that help to improve the quality of human interactions in health care. Understand that gender identities, relations and considerations constantly influence health care interactions, among men, among women, or between men and women. Embrace analytical approaches that promote reflection, critique and improvement of one's own daily work. Activity 4: Human and Technical Quality in Health Care Interactions Objectives: Identify concrete strategies to improve our daily work. Apply methods to improve the quality of care in sexual and reproductive health services and make those services more sensitive to gender realities and relations. Procedures: Form groups. Each group selects one technique or method for gender-sensitive quality care, as presented in the videos. Develop skits that demonstrate the application of the chosen technique in a familiar health care setting and situation. Members of each group prepare to act out the skit. Each group presents its simulation of a health service situation in which gender sensitivity and quality care techniques are used.
Time: 45 minutes Discussion: The methods and techniques presented in the videos help providers put themselves in the place of users and, thereby, empathize with their health situations and decisions. This effort requires sensitivity to the cultural, gender and generational identity of the user, as well as sensitivity to his or her unique feelings, fears, doubts and needs. Background and Resources for Module 3 Concept Card: Quality Care Quality care is a philosophy of comprehensive and compassionate health care oriented toward the satisfaction of users. It facilitates improvements in services offered to men and women through changes in personal communication and interaction, as well as through changes in administrative and technical practices. Quality care strengthens users' responsibility, knowledge and autonomy, self-esteem and dignity and the exercise of their rights. Quality is different not only for men and women, but also for persons of different cultures, ethnic groups, social classes and ages. In other words, everyone has his or her own definition of quality. So then, who evaluates quality care? Since the philosophy of quality care is oriented toward the satisfaction of users, it is they who should evaluate the quality of services. Basic principles help us to obtain quality care: a focus on the comprehensive well-being and satisfaction of diverse users; the active and equitable participation of all personas involved in health care; the practice of offering options from which users may select, such as different contraceptive methods or birthing positions (Finger and Hardee 1993); the empowerment of users to make free and informed decisions about their own health; and the equitable treatment of women and men, people of different ages, social classes and ethnic backgrounds. Quality care has three interrelated dimensions: quality in administration and management; quality in human interactions and technical quality. Quality in administration and management An institution's philosophy transmits ideas, values and attitudes to employees as well as to users (Araujo and Matamala 1995). Quality management encourages a work environment and a health care environment free from discrimination and abuse of power. The key here is the existence or absence of mechanisms that promote the participation of personnel and users in the improvement of the service. These might include posted policies promoting users' rights or prohibiting discrimination; the use of suggestion boxes; and the organization of participatory and democratic meetings between administration and staff, and between the latter two representatives of the user population. To improve quality of care, we must begin with a philosophy that places priority on user satisfaction (Finger and Hardee 1993). This philosophy will then be manifested in a facility's infrastructure, menu of information and services offered, labor practices and relations, staff treatment and labor policies, guarantee of confidentiality and privacy during provider-user visits and even in the hours of service. If the institution does not take quality care into account as a matter of policy, it is improbable that staff will be able to provide the kind of services that satisfy users. Each institution expresses its gender perspective in the relations it establishes with the public, from the assignation of resources to different groups of users to the distribution of tasks and responsibilities within that institution. A gender perspective is key to understanding different groups, ensuring that services do not favor some and discriminate against others and making sure that programs do not reinforce existing inequalities. For example, better gender balance and more equitable participation could improve the quality of many maternal-child health and family planning programs by questioning and changing current services and information that are oriented exclusively to women; reinforcing stereotypes that give women sole responsibility for their families' health; and denying the fundamental importance of men's participation. Quality in human relationships Quality of interactions encompasses the empathy expressed by providers, time dedicated to each user, sharing of knowledge and respect for each user's opinions and decisions. It also implies respect for differences among people: A woman in native dress deserves the same understanding and respect as a woman in modern dress; a disheveled adolescent boy deserves the same service as a professional man. In addition to changes in attitude on the part of personnel, quality care requires that users themselves exercise more responsibility and initiative. Providers can facilitate this change by sharing knowledge about health, offering options for treatments and methods and supporting users in their decision-making process. Services should offer complete information that permits users to care for their own sexual and reproductive health, and to take preventative actions that help them to achieve a sustained state of physical, mental and emotional well-being. Technical quality Technical competence concerns adequate equipment and supplies and requires that providers apply current and appropriate knowledge, skills and technology. Indicators for this type of quality include the existence of clear operational norms and procedures and demonstration of the skill and accuracy necessary in diagnosis, treatment and follow-up of users. Technical quality includes having the necessary equipment, supplies and medicines needed to fulfill standards (Güezmes 1997), together with maintenance of conditions, fulfillment of protocols and availability of competent personnel (Finger and Hardee 1993). Quality equipment and supplies also refer to the general infrastructure of the center (water, plumbing, lighting, garbage disposal) and the conditions, comfort and cleanliness of the waiting and consulting rooms. A crucial aspect of technical quality is the existence of programs for continuous professional improvement for men and women personnel, which cover medical techniques as well as techniques for patient care and communication. Quality care and gender Health providers often reproduce and reinforce gender inequities in the relationships that they develop with users and with co-workers. In many cases, health professionals tend to overvalue medical knowledge, give privilege to masculine-scientific discourse and reject other ways of knowing, thinking and talking as expressed by patients. Often the prejudices and values of providers and institutions are expressed through doubt, criticism, rejection and even sarcasm toward the way patients understand things, especially female patients and those who come from lower socioeconomic classes and marginalized ethnic groups. In social environments in which certain groups of women assume subordinate positions in most of the relationships in which they engage, these women tend to relate to providers in the same way, thus, undermining their potential power as health care clients. In their relationships with health providers, many Bolivian women feel constrained by their fears, shame and timidity; by guilt and moralistic norms; by insecurities about their own knowledge; and by their experiences of physical, psychological and sexual violence. These constraints are coupled by gender-related economic and operational difficulties that must be overcome in order to seek health care. Men also approach health care from their own gender experiences and are restricted by normative models of masculinity. In Bolivian contexts, these can include pressure for "real men" to resist pain, refuse to seek or accept help and appear strong, physically and emotionally invulnerable. These aspects of "being a man" in Bolivian society impede men's access to health care. Pressure to demonstrate stereotyped masculine behaviors is especially strong for young men, many of whom do not take preventative measures, nor seek medical care until they are extremely ill. In considering quality care, providers should recognize these gender norms and stereotypes, their impact on users' health and their influence both on provider-patient interaction and on user follow-up. Providers are capable of forging new gender visions and possibilities, and of changing their own behaviors and attitudes, through their professional action. They can, for example, encourage and support women users to make strong decisions in favor of their own well-being and to assume new responsibilities for their health and sexuality. They can encourage men to admit that they hurt, to seek and accept help and advice, and to participate in the health care of their children and partners. Better understanding and respect for others, together with improved communication between people from different backgrounds, cannot help but improve relations and processes of diagnosis, treatment and education, and thereby contribute to improvements in the population's health. Summary of Techniques to Improve Gender-sensitive Quality Care The video "Hablemos con Confianza," from The Johns Hopkins University, presents three health service stories, and the video "Calidad de Atención en Salud Reproductiva," from the Flora Tristan Center for Peruvian Women presents another health care story. Each of these 10-minute stories presents a series of gender-sensitive techniques and methods designed to improve interaction and communication between providers and users. Watching and discussing these videos motivates us to reflect on our everyday practices and think about ways in which we can improve. Here we provide a brief discussion of each video. -- "Hablemos con Confianza"
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