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CLOSE THIS BOOKOral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)
Module Four: Working with the health system
VIEW THE DOCUMENT(introduction...)
Session 10 - National health policy and programs for controlling diarrheal diseases
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTTrainer Attachment 10A: National health policy and oral rehydration therapy
Session 11 - Encouraging collaboration among services for treatment, control and prevention of diarrhea
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTHandout 11A: Coordinating activities
VIEW THE DOCUMENTTrainer Attachment 11A: Discussion guidelines on collaboration
VIEW THE DOCUMENTTrainer Attachment 11B: Examples of services and organizations with which volunteers and counterparts can collaborate
VIEW THE DOCUMENTTrainer Attachment 11C: Case studies
Session 12 - Monitoring and follow up for controlling diarrheal diseases
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTHandout 12B: Monitoring worksheet
VIEW THE DOCUMENTHandout 12C: Ways to do monitoring
VIEW THE DOCUMENTHandout 12D: Steps in problem solving
VIEW THE DOCUMENTHandout 12E: Problem situations
VIEW THE DOCUMENTTrainer Attachment 12A: Examples of items to monitor
VIEW THE DOCUMENTTrainer Attachment 12B: Home visits
VIEW THE DOCUMENTTrainer Attachment 12C: Useful tool: diary
VIEW THE DOCUMENTTrainer Attachment 12D: Suggestions for a diary on ORT/CDD
VIEW THE DOCUMENTTrainer Attachment 12E: Sample problem solution

Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)

Module Four: Working with the health system

OVERVIEW

This module addresses practical issues in coordinating Volunteers' project efforts with programs in the host country. Session 10 provides an overview of policies and programs on ORT as a part of CDD in the country. Session 11 focuses on pros and cons of collaboration between agencies and projects focused on ORT. Session 12 examines the national CDD surveillance system and ways Volunteers and Counterparts can contribute to that system.

OBJECTIVES

At the end of this module the participants will be able to:

· Explain the Host Country National's recommendations for the use of ORS packets and homemade oral rehydration solutions in the treatment of diarrhea and dehydration that were stated in Session 10.

· List two areas identified in Session 11 in which Peace Corps Volunteers can collaborate with Host Country Nationals and/or other international organizations in the implementation of CDD programs.

· Describe the Host Country National Diarrheal disease surveillance system as explained in Session 12.

Cross reference with the Technical Health Training Manual:

Session 6 Health Care Delivery System
Session 9 Monitoring

Session 10 - National health policy and programs for controlling diarrheal diseases

TOTAL TIME

2 hours

OVERVIEW

To work effectively on ORT and related projects in the community, participants need to know where ORT fits within the health care Delivery system. To avoid teaching ORT messages that differ from those of national health workers, it is also essential to be familiar with government health policy regarding standards and program goals for ORT within CDD.

In this session participants explore national health policy and programs for ORT in a panel discussion with visitors from the Ministry of Health. They look at CDD activities in relation to an organizational chart of the health system and discuss where and how Volunteers and Counterparts could contribute to ORT and related projects. They also examine the referral system for severe cases of diarrhea and dehydration. In an open forum discussion with the visitors, they discuss concerns and issues about their roles in promoting oral rehydration therapy.

OBJECTIVES

· To explain national health policy on CDD and describe the standards and programs for ORT.
(Step 2)

· To describe the organization, lines of authority and Diarrheal case referral system within the national health system.
(Step 2)

· To identify the tasks and levels of the health system with which participants can work on ORT and related projects.
(Step 3)

RESOURCES

The Role of the Volunteer in Development bureaucratic Efficiency and Working with Counterparts

Handouts:

- 10A National CDD Policy (to be prepared by the Trainer
- 10B Organizational Chart of the National Health System (to be prepared by the Trainer

Trainer Attachment:

- 10A National Health Policy and Oral rehydration Therapy

MATERIALS

Newsprint and markers; any special materials requested by the panelists.

PROCEDURE

Trainer Note

This session will vary considerably depending on the locale of the training, the state of the ORT program in the country, availability of Ministry of Health officials, health problems or issues related to CDD in your country, etc.

Invite people from the Ministry of Healthworking on CDD programs. Describe the session objectives and format and ask each person to prepare a ten minute, nontechnical talk, giving an overview on one of the following topics:

- National health policy regarding ORT as a part of CDD. If there is no formal policy, ask them to describe CDD programs.

- National and regional incidence of Diarrheal diseases and

- Priority health problems associated with diarrhea in the country.

- The place of CDD and ORT within the organization of the Health Care Delivery system .

- Standards regarding health education messages on ORT, especially instructions and measures for preparing ORT solutions.

- ORT projects in the country, including any collaboration with other agencies.

- The referral system for severe cases of diarrhea and dehydration.

Ask all the visitors to begin their presentation with a brief description of their role in CDD efforts in the country. Encourage them to show visual aids developed in their program and to bring any health education materials on ORT that they can distribute to the participants for use in the community.

Ask one of the participants with sufficient skill in the local language to act as moderator for the discussion. The moderator can take over the session after the introduction, or in Step 3 when the general discussion begins.

Another alternative is to invite one person from the Ministry of Health CDD division or Peace Corps Health Staff to present a lecturette addressing all the topics.

In settings where Trainees expect an opening ceremony for a training program, this session can easily serve that purpose. It also provides a means to involve host country health personnel in the training program and to encourage ongoing collaboration in ORT health education activities.

You may want to combine this session with Session 21 (Resources for Health Education on Controlling Diarrheal Diseases) by inviting guests from other organizations, arranging a display of resources, and increasing the time for the session.

Step 1 (15 min.)

Guest Panel and Participant introduction,

Introduce the panelists to the group and ask participants to introduce themselves and mention the programs and regions where they work.

Step 2 (50 min.)

Panelists' Presentations

Ask each panelist to give his or her presentation.

Trainer Note

Be sure everyone understands that there will be ample time for general questions after the presentations. Ask for one or two very specific questions after each presentation.

Step 3 (45 min)

Open Forum Discussion

After all panelists have finished their presentations, ask the moderator to lead an open forum for questions and answers.

Trainer Note

Ask the moderator to keep the pace moving during this discussion and to guard against any one panelist being called upon too much or too little.

Optional Step (30 min)

Informal Panelist Discussion

Have the moderator close the session by thanking the panelists and inviting them to continue exchanging ideas and perspectives informally over refreshments. Trainer Note

If you schedule the panel discussion late in the afternoon, you can close the session with a reception for the guests. This informal discussion time gives participants a chance to ask questions comfortably and develop further rapport with Ministry of Health officials.

Trainer Attachment 10A: National health policy and oral rehydration therapy

MR. ROBERT HOGAN
Diarrhoeal Disease Control Program
World Health Organization
Geneva, Switzerland

The advisability of oral rehydration therapy in the treatment of diarrhea is no longer a controversial issue in many places. When compared with other competitive uses of health resources, the potential cost effectiveness of ORT, including the complete formula ORS, seems equally certain. Studies such as those described by Dr. Shepard document the economic advantages that this therapy bungs to particular countries These studies should also serve to influence the health policies and goals of countries.

Nearly all countries already have health policies and goals, however, and these can affect, either favorably or unfavorably, the likelihood that the advantages of ORT will actually be realized. 5 would like to describe briefly five policies, currently already accepted by large numbers of countries, which seem to me to imply the rapid acceptance and large- scale use of ORT. Next, I would like to mention two policy decisions which need to be made if ORT is to bring about the economic and social benefits which we all feel it promises. Third, I would like to indicate the elements which the World Health Organization feels should be included in a country's plan of operations.

Most developing countries, in their planning, documents, in their presentations at the World Health Assembly, and elsewhere, have adopted the following policies, among others: (a) emphasis on primary health care, (b) priority attention to child health, (c) greater community involvement in determining health goals and plans and in implementing health programs, (d) self-sufficiency, and (e) appropriate technology Rather than dismiss these as empty words or slogans, I feel these can be carefully enough defined so as to be meaningful policies, that is, guides to action.

If a country chooses to pursue primary health care as a matter of policy I take it that this means, among other things, that they have decided that health services should be given at the lowest organizational level possible. WHO and UNICEF, in their recently issued joint statement have suggested that ORT to prevent dehydration be given by family members themselves and that oral rehydration solution for the treatment of dehydration be given at first-level facilities. A policy to emphasize primary health care in a country with a serious diarrhea problem implies that ORT will be a part of such care

Many countries have decided that giving priority to the health problems of children is a desirable policy. While one might question whether such a priority, together with emphasis on the health of mothers, is advisable if it implies a certain neglect of the health of working-age men, this policy is widely accepted and implies that attention be given to those conditions which most seriously affect children. That diarrhea is a leading cause of childhood morbidity in every developing country of the world, and in most is the first or second cause of childhood mortality suggests that an emphasis on child health mean greater emphasis on diarrheal disease control and ORT.

If a country has decided that the priorities as content of its health programs will be decided in consultation with individual communities, than the fact that ORT can be introduced into all communities, even those with the least developed formal health structures, makes it a particularly attractive vehicle for the implementation of such a policy.

The policy of "self-sufficiency" involves primarily economic considerations. It says, "We will offer those health services which can be paid for with our own resources" if Dr. Shepard and others are correct that ORT is an excellent choice from an economic point of view, then its extensive use is clearly consistent with a policy of self-sufficiency.

"Appropriate technology" can be defined as analogous to self-sufficiency, but without direct involving cost considerations. A country which has a policy of emphasizing appropriate technology says, "We will offer those health service that can be effectively delivered with our country's technological capability." Both in terms of the production of ORS and, most importantly, terms of the technology required to deliver ORS it may well be a country's most attractive choice if the country is committed to a policy of appropriate technology.

Since so many countries already have these five policies, all of which seem to be highly consistent with the extensive use of ORT, why has its use not been more widespread? There are many reasons, but one maybe that countries need to consider adopting a few additional policies. Policies are clearly not the whole problem; implementation is probably more important. To the extent that policies determine what is to be implemented, however, they can be important.) I would like to suggest two broad policies which may be worth consideration: (1) emphasis on coverage, and (2) prioritization of health services in terms of their potential contribution to decreasing morbidity and mortality.

Coverage. A policy or commitment to offer services to as high a percentage as possible of the susceptible population needing that service would do at least two things. First, it would establish a long-term goal from which specific targets could be rationally determined. Second, it would facilitate subsequent evaluation of the extent to which such targets have been achieved.

Prioritization. If it is a country's policy to give priority attention to those conditions which are the leading causes of morbidity and mortality and those conditions for which feasible control programs can best be developed, then programs such as diarrheal disease control and expanding immunization and interventions such as ORT could be given greater emphasis. The determination of priorities is obviously a decision for individual countries to make. The recognition that the purpose of health programs is to reduce morbidity and mortality and that a rational process can be followed in assigning priorities could lead to acceptance of the prioritization process as a critical national health policy.

Once countries have established a sound policy basis, WHO has suggested that a well-formulated plan of operations is an essential step in the development of a program.' Such plans will often be part of a more general planning document including a variety of primary health care interventions, or they may constitute a separate document. In either case, we believe that a well-formulated plan of operations will include the following elements:

1. Objectives and targets. What will the program accomplish in terms of reducing diarrhea mortality and morbidity? How many children will have access to oral rehydration solution? How many childhood cases of diarrhea will actually be treated with ORS? To what extent will other services be available and used? (Targets should be specific, quantified, measurable, and realistic)

2. Strategies. How much emphasis will be given to each of the tour strategies recommended by WHO: case management, maternal and child care practices, environmental health practices, and epidemic control? Which specific aspect of each strategy will be emphasized (for example, "breastfeeding" in maternal and child health)?

3. Delivery systems and personnel. How will services actually be delivered? What will be the role of each of the potential providers of services? How will the providers be trained (who, when, where, what, by whom)?

4. Activities. For each strategy, what are the specific activities that health providers will need to carry out? What will be the output of each of these activities? (For example, in carrying out the case management strategy, health facility staff will need ORS and production facility staff will have to produce ORS. The output for receipt of ORS would be "x,' packets for each health facility, and the output for production would be "y" packets per year) What are the times and sequences involved in carrying out all the activities?

5. Evaluation. How can data from routine information systems, sentinel information systems, and special studies be used to assess the achievements of program targets? In what way will activities be monitored?

6. Budget. What will be the annual cost of the program? To what extent are the necessary resources available from the national budget? What other sources of funding can be developed?

As Dr. Merson noted, fifty-five countries have thus far developed well-formulated plans. We hope this number will double by 1989.

Sound policies and well-formulated plans in themselves are obviously not enough. They need to be implemented and then evaluated But if they are not sufficient we feel they are essential conditions for the successful realization of the dramatic potential offered by oral rehydration therapy.

Session 11 - Encouraging collaboration among services for treatment, control and prevention of diarrhea

TOTAL TIME

2 hours

OVERVIEW

Two main points of contact between Volunteers or Counterparts working on CDD with the various governmental and private organizational projects in this area are referrals and health education. Both require good communication between the various services involved. This session offers two alternatives in training experiences for participants. In settings where agency workers are available to participate, a round table discussion format provides a basis for sharing project goals, experiences and ways to collaborate more effectively diarrhea case referrals and health education. Where this is not possible, participants work in small groups on case studies that require them to state clearly who must work with whom to resolve a particular health problem.

OBJECTIVES

· To list the advantages and problems encountered in collaboration between services on CDD projects.
(Step 1)

· To identify ways to collaborate with other services in CDD projects.
(Step 2)

RESOURCES

Handout:

- 11A Coordinating Activities

Trainer Attachment:

- 11A Discussion Guidelines on Collaboration

- 11B Examples of Services and Organizations with Which Volunteers and Counterparts Can Collaborate

- 11C Case Studies

MATERIALS

Newsprint and markers, four sets of 10 by 15 centimeter cards numbered 0-9.

PROCEDURE

Trainer Note

Where possible, well in advance, invite a range of professionals representing private organizations as well as government projects in CDD. where appropriate this should include persons working with traditional practitioners (traditional birth attendants, herbalists, spiritual healers etc.) as well as traditional practitioners. Explain to them the objectives of the session and the points to be discussed. Ask each visitor to prepare a five minute opening statement about the activities of his or her service related to CCCD. Consult with the Peace Corps Office and local health officials to determine the composition of the round table. The nature of the points of discussion about collaboration will depend on the country situation.

Where such representatives are not available or it is not appropriate to bring Volunteers and Counterparts together with them, you con use the second alternative activity for this session. In that case, adapt Trainer Attachment 11C (Case Studies) to fit problem situations commonly encountered in the host country.

Make sure that this session builds on what participants learned in Session 10 (National Health Policies and Programs in CDD)

Alternative 1

Step 1 (35 min)

Round table Discussion on Collaboration in the Control and Prevention of Diarrheal diseases

Welcome the speakers, introduce them and seat them around the table. Briefly review the objective of the round table discussion. Ask each visitor to give a five-minute opening statement about the CDD activities of their organization.

Give participants an opportunity to ask questions based on the introductions.

Step 2 (45 min.)

Small Group Discussion of Problems

Divide participants into small group so that there is one group for each visitor. Ask each group to talk with one visitor about the following questions;

- What kinds of collaboration have you done with other services? What were the advantages? What were the disadvantages?

- Have you encountered conflicting messages given to the public by other organizations about ORT!

- What can be done about such conflicting messages? What is the effect on the community!

- Have you encountered problems at any point in the referral system!

- What role can Volunteers and Counterparts play in facilitating collaboration at the community level?

Step 3 (30 min)

Sharing Smell Group Conclusions

Ask each group to briefly summarize their answers to these questions and discuss what practical steps can be taken to increase collaboration of services at the community level. Trainer Attachment 11A Discussion Guidelines on Collaboration) provides suggestions for facilitating this discussion. Close by thanking the visitors for participating in the session. Distribute Handout 11A (Coordinating Activities) as supplementary reading.

Trainer Note

You may want to schedule this activity so that you can serve refreshments for the visitors and allow additional time for participants to talk with them informally.

Alternative 2

Step 1 (20 min.)

Common Target Game

Ask four people to volunteer for this game. Have them sit in chairs at the front of the room. Give each person a set of cards numbered from 0-9. Make sure that the chairs are arranged so that they cannot see each other.

Explain that you will call out a number and the players should raise one of the numbered cards in their hand. You want the total of numbers on the cards that they raise to equal that number hut the players cannot look at each other or talk or consult with each other about what number to raise. If the total number raised corresponds to the number you requested, it is purely by chance.

Call out another number and tell the players that they can move their chairs so that they can see the cards that the others are raising.

Call out a third number and tell the players to move their chairs in a circle and discuss what numbers to raise, to cause the total asked for by the Trainer

Step 2 (30 min)

Processing the Common Target Game

Ask the game players to compare their experiences during the three times they raised numbers. How did they feel about working under the conditions required by the trainer? Which condition was easiest to work in and why?

Ask the observers of this game to comment on which conditions facilitated more efficient and effective action.

Use the game experience as a basis to discuss the advantages and disadvantages of collaboration between services for CDD projects, particularly in aspects of ORT.

Trainer Note

Trainer Attachments 11A Guidelines for Discussion on Collaboration) and 11B (Examples of Services and Organizations with which Volunteers and Counterparts can Collaborate) provide suggestions for guiding this discussion.

Step 3 (30 min.)

Case Study Activity

Divide participants into small groups. Use Trainer Attachment 11C (Case Studies to assign a different case study to each group. Explain that all of the cases require collaboration of one or more organizations or services. In each case the group should identify the problem in the case, the cause of the problem and decide who must work with whom to resolve the problem. They have 15 minutes to study their cases.

Step 4 (30 min)

Reports on Case Study Activity

Have each group report on its case. Summarize the information as shown in the Trainer Note. Close with a discussion of what was learned in the case study activity that can be applied in their work in the community. Distribute Handout 11A (Coordinating Activities) as supplementary reading.

Trainer Note

Fill out the following table on newsprint to summarize participants resorts:


Trainer Note

Handout 11A: Coordinating activities

Coordination is bringing activities or groups of activities into proper relation with each other to make certain that everything that needs to be done is done and that no two people are trying to do the same job.

Coordination is the means of:

- distributing authority
- providing channels of communication, and
- arranging the work so that the right things are done..(what) in the right place ..(where) at the right time ..(when) in the right way ..(how) by the right people ..(by whom)

When an activity is coordinated, everything works well. A coordinated activity is orderly, harmonious, efficient, and successful

When an activity is not coordinated, it is liable to fail in its objective. An uncoordinated activity is disorderly, discordant, inefficient, unsuccessful.

Using organizational principles

To make coordination effective, eight well-recognized principles of organization Oust be applied:

a) Objective

Each group of tasks must have an objective that contributes to the objectives of the organization as a whole.

b) Definition

Each group of tasks must be clearly defined so that everyone knows exactly what the tasks are.

c) Command

Each group of tasks must have one person in charge, and all concerned must know who this person is

d) Responsibility

The person in charge is responsible for the performance of the people in his group.

e) Authority

Each person in charge of a group of tasks must have authority equal to his responsibility.

f) Span of control

No person in charge of groups of tasks should be expected to control more than six to ten other people.

g) Balance

The person in charge of several groups must see that the groups balance. For instance, case finding must not be 90 extensive that more cases of a disease are found than can be treated.

A coordinating check-list

A health worker responsible for an action, any action, will find it useful to apply the following check-list:

What is to be done?


Where will this action take place?


When will this action take place?

coordinating

Which equipment is needed?

the

How will this action be arranged?

activities

Who will take part?

coordinating

Who will do what?

the

Who will lead?

people

Is all necessary information available?


Has the information been communicated?

communication

Example: Coordinating group-activity health education by using a coordinating check-list

1. What are the objectives of the group learning activity?

To encourage members of a community to participate in promoting health and health care, particularly regarding nutrition of pregnant women and young children. So follow up families who have attended the health centre and, with them, to organize a nutrition programme based on the use of local foods.

2. Information

The health centre serves five villages. She health markers, in consultation with village leaders, will identify one or two women in each village who will be responsible for inviting people to take pare in nutrition discussions and demonstrations.

3. WHEN will the groups meet?

Consult with the community to find out the most convenient time of day, when women are least busy. In the village of Bargong the women prefer the afternoon. The public health nurse-in-charge discusses the matter with the midwife and a rural health worker. They arrange to visit Bargong every Thursday afternoon for a month. Then they will organize similar meetings the following month in another village.

4. WHICH equipment and material is needed?

Transport: Provide bicycles for the midwife and the rural health worker. Local foods to be supplied by village group. Flannelgraph to supplement demonstration. Mercurochrome chloroquine - aspirin to treat minor ailments.

5 . HOW will the meeting be conducted?

Health workers will discuss child health problems with village women and invite suggestions regarding the content and conduct of the demonstrations.

The women will select the meeting place and between them will provide local foods and crooking utensils.

At the health centre the public health nurse will hold a 'mini-workshop' on nutrition each Monday afternoon with the midwife, the rural health worker, and others who are free to attend.

6. WHO will take part?

The women in the connrunity including the young girls; village leaders; and the primary health care worker if there is one in that village.

The public health nurse will support and help with the organization from the health centre (supplies, planinng the programme, etc.). The midwife will be in charge of the programme at the village, assisted by the rural health worker. The coordination in the village will be done by the leader of the women's group.

7. Communication

The village, woman leader will inform other villagers. The public health nurse will inform the midwife and the rural health worker about the organization and implementation of the programme and teach and support them as necessary. Other health workers will take part in discussions on the nutrition programme and be invited to suggest other topics for village group meetings. The district health service will be kept informed of the programme and its progress.


Figure

Trainer Attachment 11A: Discussion guidelines on collaboration

The discussion is likely to cover points such as the following:

The major problem is the lack of communication and coordination between fieldworkers from the different organizations.

Some of the advantages of coordinating activities between organizations include:

- combining resources to save time and money
- sharing information
- avoiding sending conflicting messages to the village
- avoiding project plans that conflict with one another
- designing projects that reinforce each other

Some of the factors which hinder cooperation between organization include:

- The headquarter of ministries or other institutions to which field workers are responsible may be unwilling to work together or unable because the lack organizational means to coordinate their efforts.

- Fieldworkers may be from different backgrounds and religions or different in age or sex. For example, other fieldworkers may be reluctant to take advice from someone who is younger or the opposite sex.

- Duration of Jobs at a post may be too short to develop a working relationship with other fieldworkers in the area.

- Fieldworkers may be overworked and feel that coordination seems to be a waste of time in relation to other tasks that have to be performed.

Trainer Attachment 11B: Examples of services and organizations with which volunteers and counterparts can collaborate

1. Primary Schools, Secondary Schools.
2. Veterinary Service
3. Agriculture Extension Service
4. Hygiene and Sanitation Service
5. Rural Engineering Service
6. Public Works
7. Religious Organizations
8. Administrative and Municipal Authorities
9. Social Affairs
10. Community Development
11. Private Institutions: Health Centers, Schools
12. Red Cross
13. Women's Groups
14. Traditional Midwives, Healers

Trainer Attachment 11C: Case studies

1. After a health education lesson, the women in your village say they are ready to take some of your advice: when their children have diarrhea they will continue feeding them and give them sugar-water solution diets. But, they don't have the means and are interested in a project which would help them earn some money. What can you do? What would be the possibilities of working with other services?

2. The primary school director and several teachers would like to develop a sanitation project in the community. The school children are available Thursday afternoons to help out. How are you going to get organized? Who would you call upon for help?

3. There is a CDD project in the region. The project team tries to make regular visits and provide supplies of ORS, but often there are problems: lack of communication between divisional headquarters and the villages to be visited, difficulties of transportation. Nonetheless, the people in your village worry about their children's health, and the rainy season is coming with increases in cases of diarrhea. What can be done?

4. One quarter of the village is noted for its poor hygiene. In addition, several from line agents have noticed that children from that area do not go to school. The front line agents would like to do something about these problems. How would you go about dealing with these problems?

5. During some home visits, nurses have noticed several malnourished children. What actions can be taken to help these children, and in collaboration with whom?

6. In a certain village, the Chief wants to improve the water points, but several surpass the technical skills of your personnel. How will you go about helping the chief get the help he need to fix up the water points?

7. A community development agent requests your assistance. A village where he works is quite far from a health center. Deaths from dehydration resulting from diarrhea is a serious problem. What do you propose?

Session 12 - Monitoring and follow up for controlling diarrheal diseases

TOTAL TIME

3 hours, 30 minutes

OVERVIEW

After health education activities on ORT, it is important to follow up with home visits to see if the mothers mix and use ORT correctly, and to assess the health status of the children who earlier had diarrhea. It is also important to keep records to monitor diarrhea cases. In this session health Volunteers and Counterparts discuss the national health data collection system and follow the path of a set of records from the village health post to the regional medical facility. They start a diarrhea diary which includes checklists of items to monitor, questions to ask, observations to make during home visits, and notes on how often to monitor.

OBJECTIVES

· To describe the National CDD Surveillance and Monitoring System.
(Step 1)

· To describe the tasks involved in monitoring.
(Steps 2-4)

· To develop a checklist for monitoring an ORT project in the community.
(Steps 4, 5, 7)

· To resolve problem situations identified through Monitoring
(Step 6)

RESOURCES

Handouts:

- 12A The National Monitoring and Surveillance System for CDD (to be prepared by the Trainer
- 12B Monitoring Worksheet
- 12C Ways to Do Monitoring
- 12D Steps in Problem Solving
- 12E Problem Situations

Trainer Attachments:

- 12A Examples of items to Monitor
- 12B Home Visits
- 12C Useful Tool: Diary
- 12D Suggestions for a Diary on ORT/CCD
- 12E Sample Problem Solutions

MATERIALS

Newsprint markers, Monitoring forms used in the country.

PROCEDURE

Trainer Note

This session should be done near the end of the training course, after Session 15 (Planning and Evaluating Health Projects).

Prior to the session ask one of the groups that planned a project together to prepare a role play on monitoring using the checklist in Trainer Attachment 12A (Examples of Items to Monitor) and Trainer Attachment 12B (Home Visits).

Obtain information and any forms on the national CDD surveillance system and prepare a handout on that system. You can link this information-gathering to the background work that you do for Session 10 (National Policies and Programs on Controlling Diarrheal Diseases), particularly with regard to the referral system. You may want to invite a guest from the CDD section of the Ministry of Health to attend this session as a resource person and to present a short talk on the National CDD surveillance system or any record keeping that is done for CDD.

"Monitoring Performance" WHO Supervisory Skills in CDD offers a good background for conducting this session.

Step 1 (15 min)

Discussing National CDD Surveillance and Monitoring System

Present a lecturette on the National CDD surveillance and Monitoring system, or on record keeping for CDD if there is no formal system. Include a definition of monitoring (See the Trainer Note below). Also include the monitoring tasks that are required in the national system. Distribute and explain the forms used in record keeping for CDD, how they are distributed, analyzed and used. Give a dehydration case example tracing one child's record from a local clinic to regional headquarters.

Ask the participants to distinguish between monitoring nod evaluation and to state why and when these two processes should be done ( see Trainer Note below,.

Facilitate a discussion of how the Volunteers and Counterparts can and should fit into this system'

- What are the main purposes of Monitoring in the system?
- At what level can you be most effective in this system?
- What information collected by the national system is useful to collect in your community work?

Trainer Note

The definition of monitoring should include the notion of routine checking of work or performance which occurs within the context of a program or project implementation and which has as its aim the provision of information on progress. Evaluation of an activity or performance implies comparing actual work or usage of service to what was expected to be achieved. Refer also to Session 15 (Designing and Evaluating a Health Education Project for CDD) for more discussion of evaluation. Be sure to relate this specifically to the Diarrheal disease control activities in which Volunteers and Counterparts are participating, particularly those related to ORT.

If you invite a guest from the Ministry, ask that person to give a very brief overview of the system. If some of the participants are already familiar with the CDD surveillance system, ask them to present the lecturette and share specific experience in working with that system.

The following points should be made during the discussion of why monitoring and evaluation are done:

- To determine why the use of a service, the quality of health personnel performance, or the health of a person, increases or decreases.

- To identify why targets/goals/objectives were or were not met.

- Do both monitoring and evaluation regularly.

Step 2 (15 min)

Determining What to Monitor

Tell the participants that for the rest of this session they will be examining the general tasks involved in monitoring. List the following on the board:

- Determining what to monitor,
- Determining how and when to monitor,
- Developing checklists for monitoring,
- Solving problems identified through monitoring, and
- Always providing feedback to mothers or health workers after monitoring.

Tell the participants that the first step in determining what to monitor consists of identifying the objectives for their project and planning the activities that they will do to achieve their objectives.

Write on newsprint examples of objectives and activities discussed in Session 15 (Planning and Evaluating a Health Education Project for CDD). Define the term "Indicator" and give an example based on the same objective (as shown in the Trainer Note below). Distribute Handout 12B, (Monitoring Worksheet). Ask each participant to fill in the chart using their own project objective and activities, adding indicators. Ask a few participants to share the indicators they listed. Critique the indicators and discuss how they decided what to monitor.

Trainer Note

Prior to this step you should write out four project objectives and list related activities for each one. Explain to the group that indicators are reference points that are observable, measurable behaviors or changes in health status or conditions that can be recorded and analyzed to assess progress towards accomplishing objectives .

You might find it useful to draw the following chart on newsprint and list a few examples of items to monitor for each project objective. This should assist the participants in their development of a list of indicators.

Step 3 (25 min)

Determining How and When to Monitor

Using the list of indicators developed in the previous step, ask participants to state different methods they could use to monitor their projects. They should also specify how often monitoring should be done.

Facilitate a short discussion of the kinds of information each method can provide and the limitations of these methods. Also discuss how Jo decide when and how often to monitor. Then have them write how and when to monitor on the monitoring worksheet that they used in the previous step. Distribute Handout 12C (Ways to Do Monitoring as a reference.

Trainer Note

Encourage participants to discuss information gathering techniques they have used themselves, including those used during this training course.

There are several monitoring methods and techniques from which to choose. You should obtain information on what, if any, methods are used in the national CDD program Present these country/program specific methods during this step. Also, the monitoring methods described below should be mentioned if the participants do not include them in their list:

- Keep a diary of community activities and practices affecting diarrhea.
- Observe health workers and mothers mixing ORT and feeding children.
- Talk with health workers/mothers.
- Review health post records on diarrhea.
- Talk with mothers at time of treatment and/or health education session.
- Make home visits.

It is assumed that participants have had practice in the use of some of these information gathering methods. If not, provide opportunities for supervised practice and feedback during or after the training course. Note the example in the Optional Step at the end of this session (Home Visit Simulation).

In deciding when or how often to monitor, you should consider the following questions:

- How critical is it that work be done correctly?
- is this an item that is often done incorrectly?
- What monitoring method will be used?
- How many items will be monitored?
- What time constraints exist, if any?
- What is the likelihood that the item may change from satisfactory to unsatisfactory over a period of time?

Step 4 (20 min.)

Developing A Checklist for Monitoring

Introduce this step by telling the participants that one simple way to ensure that they are actually monitoring what they planned to monitor is by developing a checklist of what to look for when you monitor. A checklist helps them remember what to ask and what to observe in the community and how often to do so. Tell them that checklists should be:
- brief, that is, include only those items you consider it very important to monitor;
- easy to use, that is, designed so you can record your assessments of each item quickly and efficiently; and
- translated into simple local language so the person using it does not have to struggle with translation during the home visit.
- They should also include a section at the end where you can make written comments, particularly about any other problems identified and recommendations.

Tell the group that their next task is to develop a sample checklist of things to remember to ask, observe and record during a home visit following up on a health education session on ORT. Select one person's project objective and selected indicators as an example to use for the large group discussion. Discuss the items to include on the checklist and come to a consensus on the indicators to use. Review the criteria for a good checklist and ask the group if they want to make any changes.

Trainer Note

See Trainer Attachment 12A (Examples of items to Monitor). You may want to present this information if the participants appear to be having difficulty. Remind the participants to recall the discussions on what, how and when to monitor while developing their checklist.

Step 5 (30 min)

Monitoring Role Play

Ask the preassigned pair to conduct the monitoring role play. Ask the rest of the group to observe how the role players use the checklist during the home visit.

First debrief the role players:

Ask the Health Worker:

- What difficulties did you encounter in actually using your checklist as a guide to gathering information
- in what ways did it help?

Ask the Mother.

- How did you feel about the questions the health worker asked you?

Then ask the Observers 5

- How effective was the home visit in gathering monitoring data?
- Did the health worker provide additional health education and answers to questions?
- Why is this follow up on health education activities important?

What other information should be collected in follow up home visits?

- What other kinds of information gathering should be used to supplement home visits?

Trainer Note

Emphasize the importance of follow up and giving mothers and health workers feedback.

Home visits and other information gathering activities enable the health worker to assess the effectiveness of health education activities (such as teaching mothers to mix oral rehydration solutions), to see if additional health care or health education is needed, and to correct immediately any misunderstandings or mistakes resulting from the health education activity. It also provides more general information about people's beliefs, knowledge and practices, and helps assess the nutritional status of other children in the home.

Step 6 (15 min)

Introducing the Diarrhea Diary

Suggest that the checklists the participants Just developed can be combined with their observations on beliefs and practices recorded in Session 13 (The Impact of Culture on Diarrhea). The checklist provides a good start for a diarrhea diary which they can use as a simple, effective record-keeping tool for monitoring,

Facilitate a discussion of the kinds of information such a diary should contain, including qualitative and some quantitative information about conditions in the village affecting Diarrheal diseases, health education activities, follow-up and outcomes. Trainer Attachments 12C (Useful Tools: Diaries) and 12D (Suggestions for a Diary on ORT/CDD) offer some suggestions for applications of the diary.

Also discuss ways that keeping such a diary could help them in their work and help others working with them.

Trainer Note

See Trainer Attachment 12D (Suggestions for a Diary on ORT/CDD). Such a diary provides a valuable record of a project's progress that can be used by others continuing that project or developing other similar projects. The diary provides a simple but systematic way to organize Monitoring and evaluation information This organization makes it easier to locate information needed to plan and make decisions. In countries where there are regional or national diarrheal disease control programs, such descriptive community level data is extremely valuable for program planning.

Step 7 (30 min)

Problem Situation Assignment

introduce this step by telling the participants that a normal outcome of monitoring is the identification of problems which need attention. Part of the monitoring process includes stating the problem and identifying and implementing a reasonable solution. The purpose of this step is to provide them with a technique for doing this.

Distribute Handout 12C (Steps in Problem-Solving) to the group. Briefly review the steps.

Divide into small groups. Distribute Handout 12D (Problem Situations) and assign one problem to each group. Give the groups 15 minutes to work out some possible actions to take in these situations, following the problem solving steps in Handout 12C (Steps in Problem Solving).

Step 8 (30 min)

Sharing Solutions to Monitoring Problems

When the groups report have them read each problem, write it at the top of a page of newsprint, and list the suggested solutions. Discuss how realistic the solutions are.

Step 9 (10 min.)

Summary Discussion

Conclude this session by asking a few of the participants to describe;

- How they can use Monitoring in their CDD work in the community.
- How they plan to carry out this monitoring along with their other tasks.
- How they will use the information they collected to improve their CDD/ORT activities in the community and contribute to national or regional programs.

Trainer Note

The participants should understand by the end of this session that information obtained from monitoring has several uses:

- to assist decision making, especially in the short-term, for increased project effectiveness.
- to provide objective means of gathering information that can be used to inform a health worker or others involved in the program of work that is being done well and should continue, as well as ways to improve their work. In other words, it is a means for providing useful "feedback".

Optional Step (30 min.)

Home Visit Simulations

Participants plan and practice a home visit in groups of 4. Two people play the roles of mother and health worker for the home visit and the other two observe and give feedback after the "home visit".

After the first role players finish, the people who were observers play the roles of the mother and health worker and receive feedback from the other group members. Trainer Note

Observe each group during this activity and contribute to the feedback portion. If participants already have some experience in conducting home visits, you may want to arrange opportunities to do home visits in the community, working with the local health worker, extension officer or school teacher, depending on interests and ongoing projects.

Handout 12B: Monitoring worksheet


Worksheet

Handout 12C: Ways to do monitoring

How you monitor an item to determine if it is being done correctly will depend on the availability of time, records, and your role in a CDD project or program. There are several monitoring methods to choose from. Some of these methods are described below.

1. Talk. with Mothers at Time of Treatment. Talking with mothers at the time of treatment (or listening to health workers as they talk with mothers) will help you determine if mothers understand the instructions given to them. For example, to determine if mothers uncle stand the information about feeding, you can ask a few of them how they will feed their children during and after diarrhea.

2. Make Home Visits. Visiting the homes of patients who have received services to observe them and to talk with their mothers will help you determine if the patients were treated correctly, whether instructions given at the time of treatment are being followed, and what the mother plans to do the next time her child suffers from the disease. You can also observe conditions of the children and the surroundings of the home.

3. Observe Mothers and Health Workers. An effective monitoring method is to observe mothers and health workers as they actually DO their task in the setting in which the task is done. For example, you can observe a health worker treating a child who has diarrhea to see if the child is being treated properly. You can observe another mixing ORS to see if he or she mixes it properly. It is important the people know you are not observing them to criticize their skill but to help them improve it.

4. Talk with Mothers and Health Workers. Talking with mothers and health workers will help you identify what they know and what they think about preventing and treating diarrhea. If you have identified problems' talk to them to find out causes of these problems and to get ideas on how to solve them. Talking with health workers will also allow you to compliment them on tasks being done especially well.

5. Review Records. This monitoring method is often used because the records kept by community health workers and health facilities are usually available it generally does not take a lot of time to review records. To obtain the necessary information from records, however, the records must be properly designed and completed. Some types of information that can be obtained from record review are whether patients are befog sent to the appropriate referral facility or whether the medicines being administered to patients are appropriate for their conditions. Some types of information that cannot be obtained from record review are how well certain treatment procedures are befog done, or what mothers are being told.


Figure

Handout 12D: Steps in problem solving

Given evidence that a performance problem exists:

1. Determine if the problem is important to solve.

· How urgent is it?
· How serious is it?
· Is the problem getting better or worse?
· Are several problems related to each others

2. Describe the problem.

· Where does the problem occur?
· With whom does the problem occur?
· Whom does the problem affect?
· When and how often does the problem occur?
· When did the problem start occurring?

3. Identify possible causes of the problem.

· Lack of skill or knowledge
· Lack of motivation
· Obstacles

4. Identify reasonable solutions to the problem.

Handout 12E: Problem situations

Adapt the following situations to the local setting, Add other problems common in the host country.

1. You have found through monitoring health post attendance that mothers are not using services because there are only male health workers, and in their culture there are taboos about seeking treatment for themselves and their children.

2. As you have become acquainted with your community you have learned that the only health facility with ORS packets cannot be reached easily by public transport.

3. You have learned from your home visits that the health workers assigned to teach ORT are not giving mothers an opportunity to practice mixing, and many mothers can't mix the solution correctly.

4. From talking with mothers and health workers, you are learning that health workers have been diagnosing cases of mild and severe dehydration incorrectly and are not doing village follow-up. The result has been unnecessary use of intravenous solution and two deaths from unnoticed severe dehydration.

5. Your observations of sanitation around the community suggest that the health committees clean-up campaign did little to change poor sanitation practices despite great enthusiasm expressed by community members.

6. From talking with mothers in the community you find they are reluctant to use ORT because they find mixing the solution very difficult using the equipment available in their homes. They fear they will mix it incorrectly and kill their children.

Trainer Attachment 12A: Examples of items to monitor

Mothers Understanding of Diarrhea

· Understanding of causes and risks of dehydration
· Understanding of signs and symptoms of dehydration
· Understanding of prevention of dehydration at home
· Understanding of how to prepare and give ORS
· Understanding of feeding during and after diarrhea

Outcomes

· Recovery, referral for further treatment, or death
· Feeding practices of mothers during and after diarrhea
· Practice of measures for prevention of diarrhea
· Mothers satisfaction with service

Activities of Health Workers

· Assessment of dehydration
· Preparation of ORS
· Provision of treatment
· Instructions to mothers on what to do at home
· Recording of treatment on patient records

Note that the list includes examples of items to monitor for diarrhea treatment. You may wish to modify this list for your own use depending on how much time you will be able to devote to monitoring and your role in the diarrheal diseases control program. Remember that you will not always have to look at all the items on your lists every time you monitor.

Trainer Attachment 12B: Home visits

By making home visits, the health worker can better understand -the behaviour of the family, living conditions and factors affecting its health. The visit is an opportunity to collect the necessary information to plan future health education, for the finally and the communitty.

During the home visits, the health worker should be aware of the relationships between environmental influences end family health. He or she should constantly work toward greeter understanding of the causes of family health problems. Gettng to know the family better will make it possible, in the long run, to bring about changes in harmful health practices and encourage helpful ones.

Objectives of Home Visiting

Home visits differ from ordinary social calls in that they pursue specific objectives. Home visits in community health are usually conducted with view to:

- Discovering the conditions in which the family lives and identifying how these conditions effect their health, particularly of diarrhea.

- Promoting family health by providing family members with health education adapted to their needs and appropriate to their levels of growth and development:

- Monitoring the use of skills learned in health education, for example, observing mothers mix and give ORS to children with diarrhea.

- Showing the mother or other relative how to administer health care needed by another family member (for instance mixing ORT solution).

- Reffering the family to appropriate specialized services (for example, reffering cases of dehydration to the health worker).

How to Make a Home Visit

The five essential steps of a home visit are:

1. Preparation

2. Introduction

3. Working

4. Closing

5. Evaluation and Planning

Step 1: Preparation

When there is limited time for home visiting, he or she should give priority to the (a) pregnant women and new mothers, and (b) infants and preschool-aged children. These are high risk groups for illness and death.

First determine objectives for the visit. Is the only goal of a particular visit to see if a mother learned to mix and give ORT properly during a recent health education session, or is there some other purpose! To help clarify the objective of a planned visit, ask : What do I hope to achieve? How will I accomplish my objectives? How will I approach the problems about which I will be visiting the family?

Review information related to the objectives of the visit. For example before visiting a woman with a child with diarrhea, review you notes based on previous visits. Be prepared to give advice and correctly answer any questions that may be raised. For example, why it is important to give liquids and food during diarrhea.

It is also a good idea to pick out and get together ahead of time any educational materials, such as pictures, brochures or charts to use during the visit.

Arrange the date of the visit with the family ahead of time.

Step 2: Introduction

Exchange the customary greetings and make initial observations. This is the best time to explain the purpose of the visit to the family.

Step 3: Working

Gradually request information answer questions and discuss the problem with the family. Teach the family whatever they need to know about the subject.

Gather new observations during each visit to the family. Watch how they behave when they are sick and when they are well. Observe and record the steps they take to stay healthy and to avoid illness. Try to detect problems before it is too late, such as lags in the children's growth and development. Observation will indicate what the family does or does not do to keep its house and compound clean.

Notice and respond to the nonverbal messages from members of the family such as smiles, nods, gestures of either interest or indifference, bored or angry looks, nervous tics, etc. Listen while people present their problems and respond with empathy or sympathy. Respect their periods of silence. Discuss things at their speed without rushing them or being brusque.

Step 4: Closing

At the close of the visit, summarize what has been discussed in order to point out the progress that has been made. After the summary, draw up a plan of action to be undertaken with the family. For the example cited above, help the mother decide which days are most appropriate for her to attend the clinic, making sure that she knows the clinic schedule and the services which are available. Make sure that all the family's questions have been answered. If returning for a second visit, arrange the next visit before leaving the family. Always record your observations immediately after a home visit, to avoid forgetting important points.

Step 5: Evaluation and Planning

During the home visit, the healthworker collects information, hold discussions with members of the family on their health problems and does health teaching. Has the visit successful?

To answer this questions, evaluate both the content of the visit and the approach used. Ask some of the following questions:

- Have I attained the objective for which I visited the family?

- What happened during my discussion with the family which distracted us from the purpose of the visit?

- Did I pay enough attention to the priority needs of the family?

- Did I adapt my teaching to the family's level of understanding?

- Did my attitude encourage a friendly exchange of ideas with the family?

- Did I impose my views on the family members instead of moving at their speed to encourage them to change their beliefs and taboos?

- Did my approach create an atmosphere of trust within which the family could express its feelings and health problems without hesitation or fears

This information gained in the home visit provides the basis for planning future health education activities to help the family members improve their health. Analyze the information and try to discover the cause-effect relationships between the family's surroundings and practices and their health status. Use all tints information to develop objectives for future visits and health education activities in the community.

Trainer Attachment 12C: Useful tool: diary

Definition:

Diaries are records of events that occur over time. They record how the events happened, the problems that occurred, and peoples' feelings and thoughts about what transpired. Diaries can be kept by individuals, groups, or communities; they can focus on a narrow topic, such as rice planting and harvesting, or on wider aspects of community life, such as community development efforts.

Diaries are a unique source of data in that they record activities as well as personal reflections on those activities.

Now It's Used:

Diaries need to be introduced early in the life of a project, and participants may require some training to use them effectively. It may be useful to review samples of other diaries. Participants may also want to meet after they've made a few entries to discuss what makes a valued entry and problems they may have encountered. Diaries can be kept in blank notebooks, or packets of forms, or even on cassette tapes for participants with minimal literacy skills. Guidelines should be set to determine what is to be included in the diaries and how often entries are to be made.

The data from diaries can be compiled in one of two ways. First, an outside evaluator c an collect the diaries at specific times and review them. Second, participants themselves can meet to share their entries and discuss their themes and perceptions. The questions of who will have access to the diaries and how the information will be used should be determined from the outset. Some participants may be unwilling to present parts of their diaries to an outsider or even to another community member.

Diaries have been used creatively in some development programs. For instance, in Bolivia, farmers kept "technical agricultural diaries' to record how they carried out crop and livestock tasks (see Hatch. 1981) The information in these diaries wag considered so valuable by agriculturalists that it is being compiled into a ' people's text book."

Thus, the diary material is useful for a number of purposes: tracking the life of project activities; identifying major turning points or problem areas; noting changes and accomplishments; getting a picture of individual satisfactions and dissatisfactions - even promoting learning among community members or between communities.

Pros, Cons, Other Issues:

PROS:

· Combined focus both on project contents (what happens) and process (how it happens)
· Creative - reinforces writing and analysis skills.
· Enables participants to be the first users of the evaluation data.

CONS:

· Generally, requires writing skill (though participants may dictate entries to schoolage children or use A cassette tape instead of a notebook).

· Generates a large amount of data, making compilation and analysis a challenge.

Participatory Applications:

Diaries are useful evaluation tools because participants control the data that is gathered. recorded and shared. Therefore, the approach described for using diaries is highly participatory. If trust is promoted among community members or between community members sod an outsider, the data from their diaries will often be more comprehensive than if it had been gathered through interviews or questionnaires.

Groups and communities can also keep diaries collectively. Individuals can male entries in turn. or groups can discuss together what to include. Such collective diaries, in addition to presenting a composite view of project activities. become a means of self-reflection for groups and contribute to building solidarity.

Trainer Attachment 12D: Suggestions for a diary on ORT/CDD

What to include

This will depend very much on the work of the participants.

Descriptive Section

- Description of local beliefs, practices and knowledge about diarrhea causes and treatment.

- See Handout 13A (A Sample Diarrhea Questionnaire) for a list of questions. This section can be done as a running dally, weekly, diary written in narrative. It can also be organized by specific topics to cover in each entry, based on the checklist.

Record Section

- Checklists and notes made during home visits in the community

- Any Ministry of Health forms related to Diarrheal disease control that the participant uses in his or her regular work.

How to Make Entries

- The Volunteer and Counterpart may want to share the same diary for their project.
- Set a schedule for making entries ( dally, after activities, weekly).
- Record the information in a standard way.

How to Use the Diary

The information in the diary can be used to:

- Monitor the progress of the project over time.
- Check on skill in mixing ORT, assessing dehydration using growth charts etc.
- Provide background for future volunteers and counterparts working on the project or similar projects.

Trainer Attachment 12E: Sample problem solution

Problem:

When monitoring the community health loader, the health worker in Bornu Health Area found that the community health worker had been referring children with some dehydration to a clinic, without giving the child's other complete follow-up instruction on what to do at home.

1. Importance of Solving the Problem

To help determine the importance of solving the problem, the health worker asked the questions in Section 1 of the Problem-Solving Checklist. Conclusions are summarized below.

· The problem is a serious one which should be resolved soon. If mothers are not given complete instructions on what to do at home, their children may become dehydrated again Also, the next time their children get diarrhea, mothers may not be able to prevent them, from becoming dehydrated by providing early treatment at home.

· If mothers are not shown how to use the ORS packets the community health leader gives them, they may not use them at all or may use them improperly. As a result, their children will not get the best care. Mothers may soon distrust the health leader or her treatment methods and may decide not to seek health care from her at all.

2. Describe the Problem

To help him describe the problem, the health worker asked the questions in Section 2 of the Problem-Solving Checklist. The conclusions were the following:

· The problem is occurring with this community health leader only.

· The problem affects children, mothers, and health leader.

· The problem occurs every time the community health leader treats children with moderate or no dehydration (Treatment Plans A and B).

· The community health leader volunteered and was trained two months earlier. The health worker was not sure, but believes the problems have been occurring since that time.

3. Identify Possible Causes and Reasonable Solutions to the Problem The health worker investigate to determine possible causes. For each cause he found, he identified a solution.

· Lack of Skill and Knowledge

The community health leader may not know all the follow-up instructions to give to mothers. The emphasis in her training was on Preparing and giving ORT.

The health worker should praise the health leader for correctly assessing the dehydration status of patients, and for correctly preparing and giving treatment with ORS solution. He could also explain to the health leader that it is necessary to teach these things to mothers.

The health worker could provide training on the Job. He or she could demonstrate for the community health leader how to explain to mothers the importance of increased fluids and continued feeding during and after diarrhea, ho. to explain to mothers other ways to prevent diarrhea, how to teach others to prepare ORS solution at hone, and hoe to show mothers the amount of ORS solution to give after each stool.

After observing the health worker the health leader could practice giving these instructions herself, the supervisor could encourage and praise the instructions the health leader gives well and help her improve any that she lives incorrectly.

· Lack of motivation

The cause of the problem is not a lack of motivation

· Obstacles

The cause of the problem is not an obstacle

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