• Summary
• Credits

1. Promoting Dialogue
2. Supporting the Client’s Role
• Box: Client-Centered Counseling
3. Improving Providers’ Performance
• Table: Activities to Improve CPI
• Box: Supervisors Can Improve CPI
4. Best Practices in Training
• Curricula Cover Process, Tailoring
• Adopt Proven Training Methods
• Many Contribute to Transfer of Learning
5. Evaluating the Quality of CPI
• Box: Evaluating Training Programs
6. Moving Beyond Family Planning
7. Bibliography

• INFO Project
• Order
• Online Reports
• Upcoming Reports
• POPLINE

This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.

Published by the Information & Knowledge for Optimal Health (INFO) Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Proven training methods increase the effectiveness of any type of training, including training on CPI.

• Microskills training breaks counseling down into specific interpersonal communication skills, such as body position, asking questions, reflection of feeling, summarizing, and feedback (35, 61). After trainees master individual skills, they integrate them during practice.
• Modeling uses live or videotaped demonstrations of good counseling to help trainees develop essential skills, appreciate different counseling styles, and develop a sense of self-efficacy (81, 89).
• Supervised practice, beginning with role plays and followed by sessions with real clients, gives trainees the opportunity to practice in situations as close to reality as possible and to receive feedback. Positive feedback from trainers can strengthen providers’ self-efficacy (89), and constructive feedback from peers can help build new group norms regarding good CPI and attitudes towards clients.
• Experiential learning starts with a group activity or exercise that enables participants to experience a situation relevant to their work. Then they reflect together on their reactions, identify lessons learned, and apply their insights by planning specific changes in their behavior (108).

Training outside the classroom may reach more providers than classroom training. Family planning and reproductive health projects have successfully tested a variety of alternative CPI training approaches (31, 84, 97). In Nepal, for example, distance education via radio proved as effective or slightly more effective than conventional workshops at improving providers’ communication skills (153). In Ghana self-directed learning (127) with print materials helped midwives improve their CPI performance with adolescents (109). In Zimbabwe interactive computer instruction (83) allowed students at a school of midwifery to proceed at their own pace and increased their knowledge of technical and communication topics (21).

Knowledge does not always translate into behavior (94, 110). Ensuring that health care workers apply newly learned knowledge and skills on the job requires the active cooperation of the trainee, the trainer, the on-site supervisor, and coworkers (122). The process ideally begins before training, when providers and supervisors create an action plan for applying newly learned skills, coworkers discuss the need for and potential benefits of training, and trainers design activities, training materials, and job aids that connect formal learning to providers’ daily tasks.

Some of the most important activities take place after a course ends (122). If training is not supported and reinforced when providers return to the job—a common situation—there is little sustained change in providers’ behavior. In Indonesia, for example, analysis of audiotaped family planning consultations found that the quality of providers’ communication increased immediately after training, but without reinforcement the newly acquired skills eroded over the next four months (77).

Supervisors play a key role (36). Ideally, they observe or participate in the training themselves so that they can act as coaches and role models when providers return to work. Trainers also can help providers overcome difficulties in applying new skills on the job if they continue to advise trainees after the course ends (122). Even coworkers can contribute to the transfer of learning by encouraging providers to demonstrate and apply their new skills.

Studies have tested several reinforcement strategies following CPI training workshops, including supervision, self-assessment, peer review, and refresher courses (16, 32, 68, 77). In Turkey specially trained three-member teams used an observation checklist to rate providers’ communication and clinical skills during a series of five follow-up clinic visits. They offered feedback, coaching, demonstrations, and role-playing to refresh providers’ skills (114). In a social marketing program in Pakistan, trainers made annual visits to providers, during which they conducted a semi-structured monitoring interview, reminded providers of good practice, and invited them to refresher training (116). In Indonesia providers conducted weekly self-assessment exercises, rating their own interpersonal communication skills during a selected consultation; some also attended peer review meetings (77). Regardless of the approach, regular reinforcement improved providers’ on-the-job performance of CPI skills.

Transfer of learning may pose an even greater challenge after preservice education than after in-service training because there may be little correspondence between the academic environment and the worksite. Nevertheless, many of the same strategies apply. Preservice curricula, training activities, and training materials should be based on current policies and service delivery guidelines that promote CPI, and they should address the realities of the jobs that students will fill upon graduation (136). Well-supervised internships and practica during preservice education can give students the opportunity to put new knowledge, skills, and attitudes into action in real-life settings, with immediate feedback from instructors. After graduation, new health care workers may need extra coaching and reinforcement from supervisors until they become proficient at their jobs.

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