|Advising Mothers on Management of Diarrhoea in the Home - Instructions for Facilitators (WHO, 1993, 11 p.)|
1. Introduction (20 minutes)
Ask participants to read pages 1-5 to themselves. Then repeat the main points as follows:
Key points to stress. This guide is designed to help health workers better advise mothers on how to carry out Plan A at home. The content (what to advise) will be a review for the participants; the process (how to advise) will be new. In communication, the process is as important as the content. What makes this process different is the exchange of information between the health worker and the mother, and the practice of praising and encouraging the mother. Each of the steps will be practised during the training sessions. Although this guide is specific to CDD, many of the skills (using simple language, asking questions, praising and encouraging helpful behaviours, giving realistic advice, and using a pictorial aid) may also be useful in other situations.
2. Basic Skill: Remember the three rules (30 minutes)
Ask participants to read Basic skill: Remember the rules of case management in the home, and to write down the three rules of home case management. If it is available, an Information Summary Sheet may be inserted in this section with more specific, adapted information (this may have been completed by the national programme manager). Stress the following:
Key points: The three rules of home case management, plus advice about using antidiarrhoeal preparations and antibiotics for child diarrhoea, are standardized. However, health workers should be aware of variations in their areas, such as specific foods and drinks to recommend, local interpretations of certain symptoms, local terms, and behaviours which may be harmful.
Note: Special emphasis should be placed on continued feeding during diarrhoea, and increased feeding for two weeks after the episode.
3. Basic Skill: Use simple language (20-35 minutes)
Ask participants to read Basic skill: Use simple language, and the example preceding the short-answer exercise. They should then do the exercise, and compare their answers with those on page 10. Review by mentioning the key points below. If time allows, a group discussion may follow.
Key points: Health workers often use technical terms which mothers may not understand. Note that some problems of terminology may be important only in English: if a local language does not have comparable words, a simple description is often used. However, sometimes if a local term does not exist, the scientific word in English is simply used instead. This may be even more confusing to a mother. Health workers should try to find words or descriptions that mothers can easily understand.
4. Basic Skill: Ask questions (10 minutes)
Ask someone from the group to read aloud Basic skill: Ask Questions, from mid-page 10 to mid-page 11. Summarize the main points (below). Participants should then do the exercise, and compare their answers with those found on page 12.
Key points: Both types of question, open and closed, are useful. Closed questions give more limited information. In the sections that follow there will be the chance to practise using questions for getting information and for checking mothers understanding.
5. Step 1 (20 minutes)
Ask participants to read to themselves Step 1: Ask the questions (pages 12-13), and complete the exercise on page 14. Ask several participants to read their answers aloud and compare them with those on page 15. Stress the key points below.
Key points: The key questions on drinking, eating, and giving medications or other treatments form the basis for advising mothers. Health workers should memorize these key questions.
6. Step 2 (25 minutes)
Ask someone to read aloud Step 2: Praise and Encourage helpful behaviours (page 16). Discuss briefly with the group the importance of including praise and encouragement when advising a mother. Ask the participants to do the exercise. When they have all finished, discuss each of the situations and possible answers. (Suggested answers can be found at the end of this facilitators guide).
Key points: Giving praise and encouragement makes this system of advising mothers different and more effective than others. Sometimes it may be a challenge for the health worker to find something to praise, without appearing artificial or patronizing. However, even if a mother has done nothing right, her intentions are usually good, that is, she wants to do the best thing for her child. The health worker may praise her for bringing the child in for help.
7. Step 3 (50 minutes)
Ask participants to read Step 3: Advise the mother what else to do (page 18), and stress the key points below. For the exercise, divide the participants into pairs to work. Each pair should write answers for all four situations. Then ask each pair to present one situation to the group, and discuss their solutions. Some possible answers are suggested in this facilitators guide. If the participants have previous experience treating diarrhoea cases and advising mothers, they may wish to suggest specific examples of behaviours they need to praise, encourage, or advise against in their areas.
Key points: After praising the mother for what she has done right, it is important to discuss the remaining points in home case management. It is also important to correct anything the mother has done wrong, without sounding angry, disrespectful, or judgemental.
8. Advising about danger signs
Ask the participants to read the section, Advising about danger signs (page 21). Stress that different countries may have various ways of expressing these signs, in ways that mothers can easily identify and remember. In addition, there may be signs that are well-known and for which mothers commonly become concerned (for example, The child becomes weak). These adaptations and additional signs should be included in the list.
9. Step 4 (20 minutes)
Ask the participants to read Step 4: Check the mothers understanding (page 21), and to read the exercise. This exercise should be carried out in the form of a short drill: the facilitator reads the first checking question aloud, and then the Mothers response. One participant suggests a follow-on checking question; another participant suggests an additional follow-on checking question, and so forth. There should be at least two or three suggested follow-on questions after each Mothers response. After completing the drill, stress the following key points:
Key points: Checking understanding is another essential part of advising. Always check a mothers understanding using open questions. In addition to giving the health worker a clearer idea of what the mother has understood, it will also help the mother to think about what she has heard. Sometimes several questions may be needed to get enough information.
10. Review of information using the Mothers Card (30-60 minutes)
Ask the participants to read the top half of page 24. Then ask one participant to read aloud the techniques of using the Mothers Card, while you demonstrate the techniques one by one. Distribute a Mothers Card to each participant, and review the contents of the card/pamphlet if necessary. Divide the group into pairs to work together. Each pair should sit together, as a health worker and a mother might sit at a health facility. One member of the pair uses the Mothers Card to explain and review home case management to the other; when one participant has finished, partners should switch roles and practise again. Circulate among them as they practise, and observe participants to make sure that they are able to use the techniques described earlier.
When the participants have completed the exercise, stress the key points below:
Key points: There are three principal reasons why a Mothers Card is useful: it reminds the health worker what to say, it helps the mother to understand the advice, and it helps her to remember what to do next time her child has diarrhoea. Health workers must become familiar with the pictorial aid used in their national programme.
Remember - A pictorial aid is only useful if it is used well.
The six recommended techniques for using the Mothers Card may seem too simple. However, they have been selected based on the mistakes that health workers make most often, i.e., holding the card so that the health worker can see it but the mother cannot; talking without pointing to the pictures; and not asking the mother to explain what she will do at home.
11. Review of the steps (5 minutes)
Ask the participants to read to themselves Review of the steps (page 29) and to complete the outline. Check the participants answers individually.
12. Summing-up exercise (20 minutes)
Ask the participants to read the sample conversation (page 31) to themselves, and to answer the questions at the end. Discuss the answers to each question with the group. (There are suggested answers at the end of this guide).
13. APAC role-play (60 minutes)
If the participants are sufficiently at ease in the group, you can ask one pair of participants to perform the APAC role-play in front of the group. Limit each role-play to 10 minutes, with an additional 10 minutes of discussion. (If the members of the group are shy, the role-play should be performed with the participants in pairs, as they were when using the Mothers Card). Point out that this is not a complete consultation, but rather the treatment part of plan A. The health worker has already assessed the child, and must now advise the mother. After conducting the role-play, participants should evaluate themselves, noting whether they were able to follow the APAC procedure, what went well, what was difficult, and what improvements they feel they could make in their method of advising mothers.
Hint: If you ask the participants to perform the role-play in front of the group, it may be useful if you provide each pair with a written situation. In this case, you need to prepare these situations in advance. Some sample situations are included at the end of these guidelines.
Key points: Learning the steps and the skills is a necessary base, but they must be practised in order to be well applied. Participants may wish to discuss the various opportunities they have to use this system, for instance while taking the medical history of the child, or while the mother is giving the child ORS in an ORT corner.
14. Practice in a real situation
Note: If these exercises are carried out as part of clinical management training, practice in a real situation should take place during regular clinical practice sessions.
If the exercises are carried out separately, at least one-half day will be needed for practice. Arrange for the participants to spend several hours at a nearby health facility, where they can advise mothers with sick children. It can be either an outpatient or inpatient facility, provided that there are children with diarrhoea whose mothers can be advised. It is best to have cases without dehydration. After the practice session, hold a discussion with participants to allow them to evaluate themselves as they did after the role-play.
15. Optional section: Refer the mother to a small group session (can be carried out concurrently with the practice (above), if there are too few patients for all participants to be practising at once, and if there is a room near where the practice will be carried out).
Ask the participants to read to themselves Refer the mother to a small group session if necessary (pages 36-37). Discuss how to decide which mothers to refer to small group sessions, and how these sessions are (or could be in the future) organized in local health facilities.
Key points: Small group sessions should be used to teach or review specific subjects that mothers with sick children need to learn, but that cannot be covered during the individual consultation. Because they permit the mothers to participate, the sessions differ from the large group lectures often held during pre-clinic waiting time, or during community meetings.
Each small group session should cover only one subject, for instance ORS preparation, or home fluid preparation; questions and discussion should be encouraged. The following section gives an idea of how to conduct a session on ORS preparation.
16. Leading a demonstration. (This can also be done concurrently with the practice. Allow 20 minutes per demonstration - 10 minutes for demonstration and 10 minutes for discussion.)
This session requires some preparation. Before you begin, have on hand everything you will need for an ORS demonstration: ORS packets (at least one per participant); local containers for measuring water; large bowl and spoon for mixing; small cups and spoons for tasting and/or for giving ORS to children; scissors for opening ORS packets; soap, towel, and basin for washing hands; clean water. Seat the participants in a semicircle.
Ask participants to read Leading a demonstration. Read aloud the listed qualities of a good demonstration. Ask the participants if there are other qualities that they think should be added to the list.
Conduct a demonstration of ORS preparation as though you were the health worker, and the participants mothers in an ORT corner. Ask the participants to evaluate your demonstration, in accordance with the listed qualities of a good demonstration. As many participants as possible in the time available should then practise conducting a demonstration.