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Welcome to the Integrated Condom Training Resource 3.1 Barrier methods & Dual protection Learning objectives. By the end of this module participants should be able to: Explain the terms Dual Protection and Barrier Methods in simple language. Understand and explain the various strategies against unintended pregnancy and STIs/HIV. Resource 3.1- Dual Protection

Dual protection Definition: A contraception method that can be used to prevent both pregnancy and STI/HIV infections Examples: Male condoms Female condoms Resource 3.1- Dual Protection How condoms work

A condom creates a physical barrier that prevents semen or vaginal fluids and microorganisms (e.g. those causing gonorrhea, herpes or HIV) from passing from one partner to the other during sex. The condom also prevents contact with any genital sores on the penis or vagina. Resource 3.1 - Dual Protection DUAL PROTECTION Against unintended pregnancy and STIs / HIV Various strategies: Male or female condom use Using two methods (e.g. condom + any other contraceptive

method) Avoiding all forms of penetrative sexual relationships Being faithful and using a contraceptive method to prevent pregnancy Do it yourself (self-stimulation) Abstinence Dual Protection messages may differ in different situations. Resource 3.1 - Dual Protection Resource 4.1 Sexual & Reproductive Health Rights Learning objectives. By the end of this module participants should be able to:

Explain what is meant by SRH rights. State basic sexual and reproductive health rights. Identify when rights are violated. Argue the case for a womans right to practice dual protection, and refute arguments against this right. Resource 4.1- Sexual and Reproductive Health and Rights Resource 5.2 Values clarification Learning objectives. By the end of this module participants should be able to: Explain the terms Dual Protection and Barrier Methods in simple language.

Understand and explain the various strategies against unintended pregnancy and STIs/HIV. Resource 5.2- Values Clarification Values Clarification Learning objectives: To allow participants to reflect on their values, beliefs and attitudes. To reflect on personal values and recognize how they impact on interaction with clients. To separate personal values from professional values when interacting with clients. Resource 5.2 Values Clarification

Definition of Values Clarification A process of exploring our values, behaviours, prejudices, attitudes and beliefs when dealing with clients on a daily basis. Resource 5.2 Values Clarification Why do we need Values Clarification?

To explore our own personal and professional values. To explore how values impact on quality of services. To identify factors that may cause barriers to effective provision of comprehensive RH Services. To reinforce the importance of distinguishing between personal and professional views in health care service provision. To increase confidence to talk about sex and sexuality. Resource 5.2 Values Clarification Values

Moral principle / ones accepted standard. What a person thinks is important. That which directs our lives and gives meaning to ones life. Something of worth, that is held dear by a person. They form a basis for behaviour. Resource 5.2 Values Clarification

Believes Opinion/religious faith. Influenced by culture. A principle accepted as true, not necessarily with proof. Different information/experience may change beliefs. Resource 5.2 Values Clarification

Attitudes Personally held feelings towards someone / something. Shaped by values or beliefs. Influence behaviour. Influence reaction to client presenting with SRH issue because there is a conflict with the service providers own value system.

Resource 5.2 Values Clarification Helping others to examine their values Respect the values of others. Dont impose our values on others. Accept that people are free to change and update their values.

Assist clients to recognize values, beliefs and attitudes that are placing them at risk of being infected with HIV/STIs. Be able to convince clients that risky behaviours can be changed however difficult. Resource 5.2 Values Clarification Helping others to examine their values (continued)

Do not get angry or frustrated with clients who refuse to change risky behaviours. Accept that some clients will take longer then others to change behaviour. Accept that only when an individual has consciously accepted the risk and has made the decision to change, he or she may change. Clients need continuous counseling and support without judgment. Resource 5.2 Values Clarification Personal reflection

How do your beliefs, values and attitudes affect your communication with clients, colleagues and others? How far do your beliefs/values create barriers between clients and effective service or quality of care? Resource 5.2 Values Clarification Personal reflection (continued)

Health and other service providers need to revisit own value systems to be able to serve clients with objectivity without imposing own values. Service providers who are self-aware are better able to maintain a clear client-focus and respond to their needs, feelings and concerns. Resource 5.2 Values Clarification Resource 6.1

Gender & HIV/AIDS Learning objectives. By the end of this module participants should be able to: Explain the concept of gender. Describe how gender affects vulnerability to STIs including HIV. Describe how gender issues can influence condom promotion. Resource 6.1- Gender & HIV/AIDS Resource 7.2 Factors contributing to the Spread of STIs/ HIV

Learning objectives. By the end of this module participants should be able to: Discuss the biological, social, cultural and economic factors that contribute to the spread of STIs including HIV/AIDS in men, women and children including infants. Discuss service-related reasons for failure to reduce the spread of STIs. Explain the importance of partner management and how it can be achieved. Resource 7.2 Factors contributing to the spread of STIs/HIV Title

Resource 7.2 Factors contributing to the spread of STIs/HIV Resource 8.1 Risk Assessment Learning objectives. By the end of this module participants should be able to: Define risky behavior. Perform risk assessment with clients. Train other health care providers to perform risk assessment with clients. Resource 8.1 Risk Assessment Risk Assessment

Learning objectives: define risk assessment. perform risk assessment with clients. Resource 8.1 Risk Assessment Factors for STI Risk Assessment - Unprotected Sexual Intercourse - Behaviour: Serial monogamy. Sexual networking. Casual sex. Dry sex. Number of partners. Partners with multiple partners.

New partners. Lack of condom use. Incorrect or inconsistent condom use. Low awareness of STI/HIV risks. Inability to influence partner to use condoms. Type of work. Gender issues. Resource 8.1 Risk Assessment Factors for STI Risk Assessment (continued) - Clinical: History of STIs. Treatment of STIs.

Completion of treatment. Treatment of partners. Living with HIV. Quality of the service provided. Resource 8.1 Risk Assessment Risk Behaviour Assessment What is risky behaviour? Any behaviour that predisposes clients to possible STI/HIV infection or unintended pregnancies. Resource 8.1 Risk Assessment

Factors that influence development of behaviour Genetic make up. Culture.

Religion. Life style and work. Personal factors. Family and community. Economics. Physical environment. Peers. Media. Resource 8.1 Risk Assessment What is risk assessment

A process. Identification of risk factors. Counseling. Client identifies her/his problem. Client makes own informed decision. Resource 8.1 Risk Assessment Risk Behaviour Reduction

Behaviour/s are difficult to change. Behaviour change is a process. Each client is unique. Resource 8.1 Risk Assessment Reasons for clients not wanting to change behaviour

Lack of information. Lack of understanding. Lack of motivation. Resistance to change. Underestimating risks. Personal circumstances. Lack of support to sustain change. Attitude of service providers. Resource 8.1 Risk Assessment Copy of handout 8B:

Process for assessing a clients risk Assess client risk level. Counsel and inform client of risk. Identify barriers to change and discuss course of action. Give information on dual protection. Discuss options for behaviour change. Encourage Voluntary Counseling and Testing.

Resource 8.1 Risk Assessment Resource 9.1: Stages of behaviour change Learning objectives. By the end of this module participants should be able to: Describe a range of different stages in the process of behaviour change. Demonstrate understanding of the process of behaviour change. Demonstrate how to help clients change their behaviour.

Resource 9.1 Stages of Behaviour Change Steps towards Behaviour Change (handout 9A) Resource 9.1 Stages of Behaviour Change Stages of Behaviour Change Seek to establish where the client is.

Encourage movement from knowledge to motivation. Provide support for trying new behaviour. Help evaluate the benefits of the new behaviour. Encourage sustained behaviour change knowledge, attitude and skills. Resource 9.1 Stages of Behaviour Change The Behaviour Change Cycle Adapt counseling to stage of each client Resource 9.1 Stages of Behaviour Change

Resource 10.1: Communication Skills Learning objectives. By the end of this module participants should be able to: Explain the importance of effective two-way communication in service delivery. Understand the difficulty many people experience in talking about sex and sexuality. Describe barriers to communication and factors that enhance communication. Engage more effectively in interpersonal communication. Distinguish between passive, aggressive and assertive styles of communication. Monitor their own styles of communication and improve them.

Train, coach or mentor clients so as to help them communicate more effectively. Resource 10.1 Communication Skills Communication Learning objectives: To define communication. To discuss the role of effective communication in service delivery. To discuss the different kinds of communication. Resource 10.1 Communication Communication

One way. Two way. Verbal. Non Verbal. Resource 10.1 Communication Types of communication in sexual and reproductive health

Motivational. Promotional. Information. Counseling. Resource 10.1 Communication Effective communication

Give full attention. Be aware of body language. Listen carefully. Acknowledge clients feelings and concerns. Keep silent sometimes. Paraphrase and clarify. Be careful with the why? word. Reassure the client. Resource 10.1 Communication

Resource 11.1: Counseling Learning objectives. By the end of this module participants should be able to: Explain key principles of counseling. State the rights of a client seeking FP/Dual Protection services. Demonstrate good counseling techniques. Resource 11.1 Counseling Counseling Objectives:

Define counseling. Demonstrate the principles and techniques of counseling. To assist providers to act as advocates for clients by facilitating free informed choices. Resource 11.1 Counseling Principles for counseling Respectful.

Non-judgmental. Genuine. Warm. Resource 11.1 Counseling Criteria for effective counseling

Individualization. Purposeful expression of feelings. Controlled emotional environment. Non-judgmental attitude. Client self determination. Acceptance. Confidentially. Counseling environment. Dress code. Resource 11.1 Counseling The Soler Principle

S O L E R - Sit squarely facing client

Open posture Lean forward Eye contact Relax Resource 11.1 Counseling Counseling norms

G A T H E R - Greet Ask / Assess Tell Help Explain Return visit

Resource 11.1 Counseling Free and informed choice Give correct information. Suggest options/choices. Allow client to make an informed choice (clients rights). Allow client to give an informed consent.

Resource 11.1 Counseling Resource 12.1 Introduction to FC2 Female Condom Learning objectives. By the end of this module participants should be able to: Locate and describe the main female reproductive organs. Have an understanding of FC2 Female Condom. Describe the characteristics and advantages of FC2 and who can use it. Resource 12.1 Introduction to FC2 Female Condom

External female reproductive organs Mons pubis Clitoris Vaginal opening Urinary opening Hymen Labia majora Labia minora Anus Resource 12.1 Introduction to FC2 Female Condom

Internal female reproductive organs Ovary Fallopian tube Cervical opening Uterus Bladder Vagina Resource 12.1 Introduction to FC2 Female Condom

Resource 12.2 Introduction to FC2 female condom Resource 12.2 Introduction to FC2 female condom What is FC2 female condom?

FC2 is inserted into the vagina before sex and holds the mans sperm after ejaculation. FC2 is a strong, soft, nitrile sheath or pouch of 17 cm (6.5 inches- the same size as the male condom) in length. Nitrile polymer forms an effective barrier against pregnancy and sexually transmitted infections (STIs), including HIV. Nitrile polymer (non-latex) is thin and strong and warms up to body temperature. Nitrile polymer is non-allergenic. Each FC2 is tested electronically to assure its quality. FC2 can be inserted prior to sex since it is worn by the woman and the man doesnt need to be erect. FC2 cannot be used simultaneously with a male condom.

FC2 contains a silicone-based lubricant on the inside of the condom, but additional lubrication can be used for extra pleasure. FC2 does not contain spermicide. Resource 12.2 Introduction to FC2 female condom How FC2 works (1) FC2 has a flexible ring at the closed end of the pouch with a slightly larger ring at

the open end. At the closed end of the sheath, the flexible ring is inserted into the vagina to keep the female condom in place. At the open end of the sheath, the ring stays outside the vulva at the entrance of the vagina. Resource 12.2 Introduction to FC2 female condom How FC2 works (2) The outer ring:

Acts as a guide during penis penetration. Prevents the sheath from bunching up inside the vagina. Covers the genitalia and base of the penis and adds extra protection against transmission of STIs. Resource 12.2 Introduction to FC2 female condom Who can use FC2? All women and men who want to prevent unintended pregnancies and protect themselves against STIs, including HIV.

Women/men who dont want to use the male condom. People who are allergic/sensitive to latex. People who are HIV positive. Women who are menstruating. Women who have recently given birth.

Women who have a retroverted uterus. Women who have had a hysterectomy. Women who are (peri and post) menopausal. Resource 12.2 Introduction to FC2 female condom How effective is FC2? Over 17 years of study have shown the female condom is an effective barrier against many

common STIs, including HIV. It is estimated that correct and consistent use of the female condom for one year with an HIV+ partner could reduce a womans risk of acquiring HIV by 90%. Studies in the U.S. and internationally have found that the prevalence of STIs decline and the rate of protected sex acts increase when female condoms are made available alongside the male condom. Resource 12.2 Introduction to FC2 female condom FC2 Regulatory approvals

In March 2009, FC2 was approved by the United States Food and Drug Administration (USFDA). FC2 is the only female condom that is FDA approved. In 2006, WHO judged FC2 to be acceptable for purchase by UN agencies. In 2005, FC2 received the CE mark in Europe. Registration in approximately 120 countries. Resource 12.2 Introduction to FC2 female condom

Why FC2 is important? Female condoms work to prevent pregnancy and STIs, including HIV, by lining the inside of the vagina, preventing skin touching skin. They collect pre-cum and semen when a man ejaculates, keeping sperm from entering the vagina and thereby preventing pregnancy and reducing the risk of STIs. Women have options available to them to increase

protected sex acts and decrease the transmission of STIs and unintended pregnancy. Providers play an important role in presenting all the options of protection to their clients. Resource 12.2 Introduction to FC2 female condom Advantages of FC2 (1)

Prevents pregnancy, STIs and HIV infection. Provides pleasure for both men and women (double pleasure rings). It feels natural because it quickly warms up to body temperature. The female condom isnt tight around the penis and gives the man a natural sensation. Female and male can initiate use. Facilitates communication, instills confidence and assertiveness in women. Provides another option for women and men. Lubrication makes sex more pleasurable for (peri and post) menopausal women.

Resource 12.2 Introduction to FC2 female condom Advantages of FC2 (2) Can be inserted in advance and does not require immediate removal after ejaculation. Option for women and men who are allergic to latex. Can be used during menstruation.

Covers external genitalia partially in women, giving a wider protection area. A woman can urinate with the condom in the vagina. Resource 12.2 Introduction to FC2 female condom Noted issues

Insertion requires practice. Inner ring may cause discomfort. Penis may miss entry into sheath . Awkward in some sexual positions. Relatively expensive compared to male condom. Where to discard? Perceived by some people as unattractive. Resource 12.2 Introduction to FC2 female condom Helpful hints

Issues related to insertion, noise and discomfort can be solved by practice, insertion some time before sexual intercourse and additional lubrication. Reluctance to try FC2 can be overcome by shared experiences, practice and increased awareness of the advantages of FC2. Developing good communication and negotiation skills can help increase use of both male and female condoms.

Resource 12.2 Introduction to FC2 female condom Examples of FC2 promotional materials Resource 12.2 Introduction to FC2 female condom Resource 13.1 Using and promoting FC2 Female Condom Learning objectives. By the end of this module participants should be able to: Demonstrate correct use of the female condom. Explain the use of the female condom to clients. Be familiar with myths and fears regarding the female condom.

Be able to address common questions, concerns and provide solutions for successful FC2 use. Resource 13.1 Using and Promoting FC2 Female Condom How to use FC2 Female Condom Before opening FC2 Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (1) Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (2)

Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (3) Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (4) Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (5) Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (6)

Resource 13.1 Using and Promoting FC2 Female Condom FC2 insertion (7) Resource 13.1 Using and Promoting FC2 Female Condom FC2 use during sex Resource 13.1 Using and Promoting FC2 Female Condom FC2 after use Resource 13.1 Using and Promoting FC2 Female Condom

FC2 failure problems (1) Resource 13.1 Using and Promoting FC2 Female Condom FC2 failure problems (2) Resource 13.1 Using and Promoting FC2 Female Condom Resource 13.2: Explaining the Female Condom to Potential Users

Discuss basic concepts Use simple language Maintain a non-judgmental attitude Encourage interaction Use humour, but carefully Remember: the female condom is not replacing the male condom. Resource 13.2 Using and Promoting FC2 Female Condom Specific issues on FC2

Timing of insertion Who inserts Position for insertion Sex positions Removal Disposal Practice

Re-use? NO. Use with male condom? NO. Resource 13.2 Using and Promoting FC2 Female Condom Barriers to promoting FC2 Size

Rings Appearance Lubrication Noise Handling Insertion Resource 13.2 Using and Promoting FC2 Female Condom Motivating clients to use FC2 female condom

Positive attitude Passionate about ones health Practice Patience Perseverance Perfect User Power Protected

Pleasurable Promote positively Resource 13.2 Using and Promoting FC2 Female Condom Resource 14.1 Male Condoms Learning objectives. By the end of this module participants should be able to: Demonstrate correct use of the male condom. Instruct others in correct use of the male condom; Dispel myths and misconceptions about the male condom.

Resource 14.1 Male Condoms Male reproductive organs Resource 14.1 Male Condoms Resource 14.2 The male condom Resource 14.2 Male Condoms Description of male condom

The male condom is a sheath made of very thin sensitive rubber latex. It is designed to cover the erect penis and prevent semen from entering the vagina. The condom is often lubricated to minimize loss of sensitivity during intercourse. Resource 14.2 Male Condoms Characteristics of the male condom Male controlled barrier method.

Protects against pregnancy and against STIs, including HIV. -> When used correctly and consistently Resource 14.2 Male Condoms Latex condoms

Made in different sizes, colours, textures and thickness. Fit tightly on the penis. Have pores that are so small they do not allow even the smallest viruses (like Hepatitis B, herpes simplex, or the HIV virus) to pass through. Some are lubricated with spermicide by the manufacturer. Can only be used with water-based lubrication. The integrity of condoms can be undermined (i.e. they can be damaged) by extremes of temperature. Resource 14.2 Male Condoms

Efficacy The male condom is about 98% effective in preventing pregnancy if used correctly and consistently Resource 14.2 Male Condoms Who can use the male condom?

People of all ages - except that: A very small percentage of people cannot use the latex condom because of sensitivity to latex (either partner). Some couples cannot use the male condom because the male partner has difficulty maintaining a complete erection. Resource 14.2 Male Condoms Advantages

Simple and easy to use with practice Widely available and does not require any medical prescription Can be used either as a short term or long term method Can be used to provide added protection (against STIs / HIV) with other family planning methods i.e. a dual method Only used during the times you have sex Promotes responsibility and accountability amongst users Allows partners to share responsibility

No systemic side-effects Can prolong sexual intercourse, particularly for men with premature ejaculation Resource 14.2 Male Condoms Disadvantages

Can reduce male sensation. Takes practice to use confidently and correctly. Breakage or slippage may occur especially amongst inexperienced or inconsistent users. Interrupts sexual intercourse unless incorporated into foreplay. Sometimes perceived as promoting promiscuity. If associated with STI/HIV prevention, may reduce the ability of some individuals/couples to negotiate its use. Some individuals may have occasional sensitivity to latex. General misperception of very high failure rates. Requires a full erection for correct use.

Resource 14.2 Male Condoms Common myths/misconceptions Condoms often break during sex. If the condom comes off or slips off it can travel inside the womans body. Use of condoms will weaken a man, causing impotence.

If your partner suggests condom use, it is a sign of unfaithfulness on their part. Condoms are only used with women from areas perceived as cheap and high risk. Condoms are only for use with sex workers. Resource 14.2 Male Condoms Resource 14.3 - Male Condom Use Resource 14.3 Male Condoms Resource 15.2 Emergency Contraception Learning objectives.

By the end of this module participants should be able to: State country policy on emergency contraception. Explain country guidelines on emergency contraceptives; Explain currently available emergency contraceptives to potential clients; Know what information to discuss with clients or users in the case of unprotected sex, condom slipping or breaking. Resource 15.2 Emergency Contraception Resource 16.1 Negotiating Safer Sex Learning objectives.

By the end of this module participants should be able to: Conduct productive negotiations for safe sex, and help others develop skills for doing so. Discuss ways in which condoms (male and female) can affect sexual pleasure, both positively and adversely. Use effective negotiation strategies in trying to deal with aggression or violent behaviour in a sexual partner, and help others develop skills for doing so. Resource 16.1 Negotiating Safer Sex What is negotiation for safer sex?

The process of negotiation involves at least two people with two different views on an issue, in this case, sexual behaviour. Each person tries to persuade the other party to support his/her view, a win situation, or at least to agree on a compromise or middle position, a win, win situation. The goal that each woman and man must have is to practice safer sex. Resource 16.1 Negotiating for safer sex

What is negotiation for safer sex? Safer sex depends on the ability to convince partners that it is in their mutual best interests to use a condom. However, negotiations for safer sex are not always easy. Because it may be difficult to discuss the subject, practicing safer sex may be very limited or just not done

Resource 16.1 Negotiating for safer sex Factors that enhance negotiation for safer sex Persuasion. Ability to assess the situation. Good listening skills.

Knowledge to express ones self. Appropriate timing. Observation of non verbal skills. Resource 16.1 Negotiating for safer sex Tips for communicating with your partner Choose a relaxing environment in a neutral location, preferably outside the bedroom, where

neither of you feel pressured. Do not wait until you or your partner are sexually aroused to discuss safer sex. In the heat of the moment, you and your partner may be unable to talk effectively. Use I statements when talking. For example, I would feel more comfortable if we used a condom Resource 16.1 Negotiating for safer sex Tips for communicating with your partner (continued)

Be a good listener. Let your partner know that you hear, understand, and care about what she/ he is saying and feeling. Be ask-able let your partner know that you are open to questions and that you wont jump on him/her or be offended by questions. Be patient and remain firm in your decision that talking is important. Resource 16.1 Negotiating for safer sex

Tips for communicating with your partner (continued) Recognize your limits. You dont have to know all the answers. Avoid making assumptions. Ask open-ended questions to discuss expectations, past and present sexual relationships, contraceptive use, HIV testing, etc. For example, What do you think about us both going for an HIV test?

Resource 16.1 Negotiating for safer sex Tips for communicating with your partner (continued) Ask questions to clarify what you believe you heard. For example, I think you said you want us to use condoms. Is that right? Avoid judging, labelling, blaming, threatening or bribing your partner. Dont let your partner judge, label, threaten, or bribe you

Resource 16.1 Negotiating for safer sex Resource 17.1 Planning Future Condom Training Learning objectives. By the end of this module participants should be able to: Identify the likely learning needs of people to whom they will pass on condom training in the future (outreach workers, community based organizations, colleagues within their own organizations or partner organizationsand so on). Identify the topics they will need to cover in their own future trainings. Select the most appropriate topics, activities and materials from this manual. Design appropriate condom training workshops to meet the

needs of people with whom they will work in the future. Resource 17.1 Planning Future Condom Training Resource 18.1 Evaluation & Closing Learning objectives. By the end of this module we will have: Obtained participants feedback on the training and shared ideas for improving future trainings. Completed the post-course questionnaire and compared results with the pre-course questionnaire. Administered and collected the participants workshop evaluation forms. Exchanged contact information. Presented certificates.

Thanked everyone involved in the training. Closed the workshop in a positive way/finished on a high note. Resource 18.1 Evaluation & Closing

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