Objectives

Training frontline providers to effectively:

  • Define referrals as part of service provision
  • Understand general barriers in accessing health care and abortion in particular
  • Describe at least six barriers that a local woman or girl might face in accessing such care
  • Describe the consequences of delays in access for women’s health
  • Describe and demonstrate best practices for thorough referrals
  • Gain familiarity with the components of a referral system (procedures & content)
  • Increase knowledge about, and opposition to, centers that misinform or manipulate women with unintended pregnancy
  • Take pride in perceiving themselves as able to help women be safe

Duration

85 minutes, including:

  • 40 minutes: Activity: Barriers and Humans
  • 10 minutes: Activity: Be a STAR
  • 20 minutes: Activity: Role-Play of Thorough Referral-Making
  • 15 minutes: Activity: Systems!

Materials Needed

Barriers and Humans

(40 minutes)

Participants use a checklist to weigh how specific barriers affect access to various reproductive health services.

Materials: Flipchart/markers; ‘Barriers and Humans’ worksheets; Sets of post-it pads or colored dots in 9 different colors (about one set of 9 pads per participant) or multi-colored magic marks in 9 different colors (about one set of markers for each group); Teens State Handout; State Abortion Providers Handout; State Financial Assistance Resources Handout.

To Prepare: To effectively facilitate discussion, review the studies on restricted access to abortion in the Training Guide. Review the instructions below carefully.

On a flipchart, prepare a color code that participants can refer to for ‘transcribing’ their worksheets onto the flipcharts: Divide the sheet into 9 cells and label each with a different barrier from the Barriers & Humans worksheet. In each cell, stick on a different color Post-It notes, colored sticky dots, or Magic Markers—these colors should match the Post-Its or colored dots that you will be handing out to participants. [See an example below.]

Image of flipchart

Note

Trainers may wish to use magic markers instead of Post-It notes or colored dots to prevent either from falling off the flipchart paper.

Instructions

  1. Ask the meaning of service provision; ask if making referrals is part of the care they offer.
  2. Ask the group to name (then write on a flipchart) different reproductive health services that women seek, until these are on the list: Prenatal, STI tests, Abortion, Cancer screening (Pap/Breast Cancer), Contraception, and Infertility. If abortion is not mentioned, probe for “health services related to unintended pregnancy.”
  3. Briefly discuss the barriers that patients/clients face when trying to access reproductive health care, giving examples for each barrier. [Use the corresponding PPT]
  1. Transportation / Distance
  1. People without access to a car or without easy access to public transportation
  1. Finances
  1. Lack of insurance coverage for abortion, infertility care
  1. Immigration Status
  1. Fear of accessing services or traveling to service because of immigration status
  1. Language(s)
  1. Health care providers may not speak the same language as the patient
  1. Lack of knowledge
  1. What, where, and how to access care
  2. Lack of understanding of the US health care system
  1. Legal Obstacles
  1. Lack of coverage for services
  2. Legal obstacles that delay access to care
  1. Age
  1. Teens need parental consent to access some health care
  1. Fear of lack of privacy
  1. People in the community may discover that person is accessing care
  1. Scorn, intimidation, coercion, threats
  1. Negative consequences for the person accessing care
  1. Discrimination
  1. Based on economic status, race, gender, age, religion, nationality, sexual orientation, physical disability, etc.
  1. Have the group form pairs (when presenting to larger audiences trainers may need to form larger groups). Give each pair a ‘Barriers & Humans’ worksheet. Ask them to consider each health service, going down the list of potential barriers and putting a check mark [✔] wherever the barrier applies. (For example, looking at the second cell, if they consider finances a fairly common barrier to prenatal care, they should enter a check mark.) They should enter two check marks for: (a) barriers that they think are very common (affecting many, many women or girls), or (b) barriers that can carry particularly serious consequences. Make sure they understand the instructions.
  2. Put up the Color-Code Flipchart. Explain that after they finish their worksheet, they will transcribe their results onto flipcharts, according to the instruction on their sheet, and using the color-code flipchart.
  3. WHILE PARTICIPANTS ARE WORKING: Put up the five flipchart sheets, and label each with one of the reproductive health care services across the top of the worksheet [Prenatal / Infertility Services /Abortion /Contraception /STI & HIV Testing]. (Be sure to put the flipchart sheets in the same order as they are listed on the ‘Barriers & Humans’ worksheet.) Keep an eye on how the worksheet group is progressing.
  4. As they finish up, have them take their completed worksheets around to each Reproductive Health Service flipchart and use their colored Post-Its or colored dots to “transcribe” the barriers they identified for that service. For barriers that have two checkmarks, they should use two Post-Its or colored dots. [These instructions are also on the worksheet, but show an example.]
  • Alternately, when training a large group it may save time to ask groups to bring the completed ‘Barriers & Humans’ worksheet to a co-trainer who will then place sticky notes, dots or marks using colored markers on the flipchart paper.
  1. Once everyone is back in their seat, ask the following questions. [Focus on barriers, not solutions—the next activity will address solutions.]
  • For accessing reproductive health care in general, which barriers (which Post-It/dot colors) seem to be the most common?
  • What were some of the different types of discrimination people identified (Probe for: based on economic status, race, gender, age, gender identity, religion, nationality, sexual orientation, physical disability, etc.)
  • Which reproductive health services do women have the greatest difficulty accessing? (which flipchart has the most Post-Its/dots?)
  • Trainers may wish to highlight patterns that emerge from this exercise, e.g. lack of transportation in rural areas, disproportionate impact on low-income patients and clients.

Note

A given training group may highlight high barriers for other reproductive health care services. Trainers may want to acknowledge that high barriers can exist for other services but, at this training, the focus will be on the barriers for abortion services.

  1. Summarize by saying that women experience barriers for accessing various kinds of health services, but research shows that barriers can be particularly high for abortion. [Use the corresponding PPT]
  1. Clarify that abortion clients must navigate barriers in a constrained time frame, early in pregnancy. Discuss some of the specific barriers that patients/clients might face when trying to access abortion.
  2. Legal Barriers
  1. Explain that abortion is legal in the United States and has been since 1973 after Roe v. Wade was decided.
  2. Explain that since that time states have enacted laws which regulate abortion care, including mandatory waiting periods, mandatory ultrasound, bans on insurance coverage of abortion. Discuss some of the relevant state barriers that trainees may want to be aware of when making referrals. [For trainer reference only and not for distribution see Module 2 Resource – State Fact Sheets on Abortion]

Note

It is important for trainers to avoid getting into a back and forth with participants about the validity of legal obstacles to accessing abortion care imposed by states. These obstacles should be presented barriers that will impact patients/clients seeking abortion care. For that reason, it is important that health care and social service providers offering abortion referrals be aware of those barriers. For example, does the state require two trips to the clinic or have a mandatory waiting period before obtaining abortion care? If so, patients/clients must plan their visit accordingly. Similarly, if the patient/client does not have insurance that will cover abortion, the referring health care provider may want to raise, with the patient/client, that funds exist to help women access abortion care.

  1. Discuss Barriers for Teens
  1. Explain that in most states, teens cannot obtain an abortion without either notifying the parent/guardian or obtaining the consent of the parent/guardian. Handout Teens State. [Trainer note: Refer to “Parental Involvement in Minors’ Abortion” for specifics on the law of each state.]
  2. Explain that there is a procedure called a judicial bypass; judicial bypass is a legal procedure where a teen can ask a judge for approval for an abortion instead of obtaining parental consent. Explain that most teens talk through obtaining an abortion with their parents or guardians. However, a teen may seek a judicial bypass for a number of reasons, including maturity, the threat of violence in the home, or if the pregnancy is a result of rape or incest. The judicial bypass process involves the teen filing a request with a local court for a confidential hearing before a judge.
  3. Explain that if trainees are working with a teen who wishes to obtain judicial bypass instead of obtaining parental consent or notice, contacting the abortion provider is the best first step. The clinic can help the minor navigate the judicial system and find an attorney.

Note

It is important for trainers to clarify that trainees need not understand the parental notice/consent/ judicial bypass system. Trainees solely need to know how to refer to the abortion provider who can help a teen navigate the system.

  1. Mention Crisis Pregnancy Centers. [Refer to the Resource on CPCs for useful language to discuss these centers.]
  1. Explain that high quality referrals direct patients/clients to providers who will share unbiased information. Note that Provide does not advocate referring to any organization that offers biased information.
  2. CPCs may offer services to women who are sure they want to continue their pregnancy, especially those planning to parent, but it is important to note that they do not offer unbiased counseling on abortion care. Some reports suggest that CPCs may employ coercive tactics to dissuade women from obtaining abortions. Coercion is in direction opposition to women’s right to information about their options when determining how to proceed with an unintended pregnancy.
  3. How do you avoid a Crisis Pregnancy Center?
  • Do your research. Don’t refer a client/patient or schedule an appointment for an abortion unless you are sure you are referring to an abortion provider or a counseling center that will offer unbiased pregnancy options counseling. Prior to making a referrals, consider looking at the CPC’s website to determine if they offer unbiased information about all pregnancy options.
  • Ask colleagues, other health care providers, counselors, or other people you trust for the name of a trusted health center.
  • Use the Referrals List for Abortion Providers.

Note

Some trainees have experiences with CPCs in their community, including participants who have had both positive and negative experiences with CPCs. It is important to honor the experiences of those participants. Conversations about CPCs should not be not be framed as “gotcha” moments, nor as opportunities to rally opposition to CPCs. Instead, trainers should provide balanced info about CPCs and hold the tension that exists regarding CPCs. CPCs may offer useful services for women who choose to parent, but they are often coercive and do not offer unbiased information about abortion.

  1. Refer back to the earlier session about the participants’ power/responsibility to save women’s health and lives by helping them overcome barriers with thorough, timely referrals to ALL services.

How You Can Help: The STAR Model

(10 minutes)

Participants learn the STAR model, and apply it to the scenarios from the previous activity.

Materials: PowerPoint of STAR model (optional); Are you Being a STAR? Handouts; STAR worksheets (one per small group); scenarios for making STAR referrals (one per small group).

To Prepare: Decide if you will show the STAR model on Power Point; cut the scenarios for referral into small slips of paper.

  1. Ask: Given the identified obstacles, what are all the ways that the person making the referral can help? Brainstorm a list. Then have them look at “Are you being a Star?” handout. Congratulate the participants for having identified most/all elements of the Supportive, Thorough, Active, Referral (STAR) model. (Also show the model on Power Point if available).
  2. Form small groups of 2-3, and give each group a scenario for making STAR referrals.
  3. Ask the groups to apply the STAR model to the situation and write down on the STAR worksheet what could be done under S, T, A, and R to assure a quality referral. Allow five minutes. Let them know the content will be translated into a role-play in the next activity.
  4. Process by reminding the group that referrals are too often hit-and-miss in quality, but that effective and systematic referrals are a critical link in women’s actual health and well-being. Remind them that the STAR model can help them be sure they are doing a quality referral.

Role-Play of STAR Referrals

(20 minutes)

In this activity, participants enact the scenarios as client and referral-maker.

Materials: Scenarios for making STAR referrals; Are you being a STAR handout (no need to hand this out again, ask trainees to refer to the handout distributed in the previous activity); magnets.

  1. Participants can remain in their same small group.
  2. Tell the groups that one person takes the role of the client, one takes the role of referral-maker, and any other members are observers/ mentors (who should use the STAR model to assess the enacted referral). Allow them to role-play as if on the phone, if they are likely to do that at work. Ask them to rehearse the role-play and get feedback from the observer(s) in their group: Was every aspect of the STAR model considered?
  3. Choosing a group with one of the abortion stories, ask them to demonstrate their model referral role-play in front of the whole group. [Where participants seem stuck, ask if they need help and be ready to respond with model language. Ask participants: What went well? Not so well? Offer feedback as needed, referring to the STAR model.] Then repeat with another (abortion or non-abortion) scenario.

Note

If trainees are reluctant to volunteer for the role-play, trainers may want to model a role play and then ask for volunteers.

  1. Wrap up by acknowledging how much knowledge frontline providers manage in order to help women be safe, and that Everyone Has a Role. Pass out Provide magnets.

Systems!

(15 minutes)

In this brief activity, participants learn about adequate referral systems and resources, then assess needs at their workplace for strengthening the referral system.

Materials: PowerPoint (Assessing Your Referral System); State Abortion Providers Handout; State Financial Assistance Resources Handout.

  1. Explain that the training has focused on individual knowledge, attitudes, and skills—but that workplaces have an important role in ensuring effective referrals. Take as an example one type of referral that participants identified as involving a lot of obstacles, e.g., abortion. Mention that this is an aspect of referrals that you have some expertise in and discuss the role of participants in helping to ensure that their workplace supports STAR referrals.
  2. Show the PowerPoint slide (Assessing your referral system). Trainers should read (or have participants take turns reading) the different elements of a good referral system for abortion.
  3. Then ask:
  1. Which elements of abortion referral do you feel the staff here generally do well with?
  2. What needs to improve?
  3. And how can we help?
  1. Pass out the list of local abortion providers and resources for financial assistance to everyone.
  2. If participants are from the same workplace: identify 2-3 priorities to strengthen the referral system.

Note

If trainees work at different sites or within different systems trainers may need to tailor this activity by asking general questions about how to strengthen referrals in any workplace.