The impact of communication skills training in the management of paediatric HIV : examining the process of designing, implementing and evaluating a communication skills training programme for adherence counsellors in the South African context.
Date
2010-11-15
Authors
Evans, Melanie
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Abstract
This study examines the design, implementation and evaluation of a communication skills training programme for
adherence counsellors in a paediatric HIV clinic. Effective communication is a pre-requisite skill for any counselling
interaction. For both prevention and treatment, counselling is a critical component of the healthcare team response to
the HIV epidemic. Given the shortages of healthcare workers in sub-Saharan Africa, task-shifting of the counselling
role to less-trained cadres of workers is commonplace. In the multilingual, multicultural South African context, taskshifting
coupled with the complexity of the message in paediatric HIV presents enormous challenges. In-service
support for counsellors is lacking. Counsellor burn-out and fatigue is commonplace affecting the quality of
counselling interactions.
Measuring the quality of communication in a multilingual context poses ethical and methodological challenges and is
a neglected area of research. Traditional communication and counselling assessments appear to be largely taxonomic;
lack cultural and linguistic sensitivity; and fail to acknowledge communication as a dynamic, two-way process.
Mindful of these issues, this study utilized a non-taxonomic approach.
Verbal and non-verbal communication was analysed before and after the implementation of in-service training which
was tailored to the specific research context. The training comprised a two day multidisciplinary team workshop
followed by individual training. This consisted of video feedback and analysis of counsellors’ own sessions and was
attended by four counsellors. Results were recorded over an eighteen month period. Twenty-two consultations
between counsellors and caregivers were video-recorded, transcribed verbatim and analysed using a hybridized form
of linguistic analysis. Findings that demonstrated consensus, substantiation and cross-consultation occurrence were
triangulated with thematically analysed interview data, patient questionnaires and researcher reflections. These
methods are more sensitive to process than checklist approaches and individualised, complex dynamics emerged.
Communication barriers and facilitators were identified before training. Variations in communicative competence
between counsellors appeared to be unrelated to prior training. After training, counsellors asked more open-ended
questions, encouraged caregivers more, provided simpler explanations of treatment regimens and checked
understanding more effectively. In response, caregivers initiated more questions. These findings suggest that
communication training improves treatment literacy and results in interactions that are more patient-centered. Despite
this evidence, the results suggest limitations to the impact of communication training given the lack of agency of
women in South Africa. Interactions included frank and open discussion about cultural beliefs. However, this benefit
may be lost due to poor healthcare team cohesion. In their roles as mothers and caregivers themselves, counsellors are
effective patient advocates and bring their own lifeworld experience to the counselling interaction. These shared
stories are testimonies to the resilience of women living in poverty. Whilst allowing for greater exploration of
patients’ cultural beliefs and explanatory models, communication training has limited impact in assisting counsellors
with dealing with issues such as disclosure, non-adherence and scepticism about biomedicine. Results indicate conflict
between patient-centeredness and perceived desired medical outcomes. Caregivers and counsellors appeared to engage
in ritualistic dialogue when discussing certain topics suggesting that a shared lifeworld between caregiver and
counsellor is insufficient to overcome barriers from the meso (institutional) and macro (broader socio-political)
context.
An awareness of the impact of context is critical to our understanding of communication in a clinical setting. The
results from this research have implications for the role of the counsellor within a multidisciplinary team and establish
a need for communication specialists to work in a clinical setting within the HIV epidemic.
Description
Keywords
Counsellors, Communication, Caregivers, Paediatric HIV, Communication training, Adherence counselling, Intervention evaluation