|Guidelines for Training Community Health Workers in Nutrition (WHO, 1986, 121 pages)|
The purpose of teaching is to facilitate learning. This is not an easy task. Teaching is commonly perceived as standing before a group of students and lecturing. Although this method of teaching is useful in certain situations, it is not always the best method of imparting information. Experience has shown that in the case of trainee community health workers lecturing alone is not enough to help them learn the necessary skills. This chapter considers the teaching and learning difficulties of trainers and trainee community health workers, respectively, and describes teaching methods suitable for training community health workers in nutrition.
Lectures alone are not enough to help trainees learn the necessary
Teaching difficulties of trainers
Trainers of community health workers in nutrition often have different educational backgrounds (medicine, nutritional science, nursing, midwifery, etc.). Although all trainers have the necessary knowledge about nutrition, they often do not have enough knowledge about teaching methods that can facilitate learning. This is so because they have not been trained to be teachers. Thus, a good doctor, a good nurse, or a good nutritionist is not necessarily a good trainer as well.
Trainers of community health workers often have no formal training
Therefore, it is recommended that, before starting to teach, all trainers should learn the basic principles of teaching, formulating a curriculum, and planning a lesson. They must also know the advantages and disadvantages of the commonly used teaching methods and aids.
Points to remember in planning a training course
Objectives of the course
The main aim of a nutrition training course for community health workers should be to train the students to carry out the tasks the, will be responsible for upon completion of their training. The trainer should obtain the job description of the community health workers he is expected to train to know what tasks should be included in the training course. It is most important to know exactly what tasks the trainees must learn. If the trainer is unsure about these tasks, it is very likely that the course will become excessively theoretical, dealing with the principles and science of nutrition rather than their application.
How much theory should be taught?
To be able to understand the reasons for carrying out particular tasks, the trainees must be taught some basic scientific facts about nutrition and human biology. The trainer must decide how much theoretical knowledge community health workers require in order to do the tasks well. In this regard the following points should be considered:
(a) Some trainers want to teach everything. This is not only impossible, but also not necessary.
(b) A good trainer should consider the subtasks associated with each task separately. He should then list these topics under two categories: "must learn" and "useful to learn". The first should include all the information all trainees must learn. After each lesson the trainer should ensure that the essential information has been learnt by each trainee. The second category should include information that may be useful to the trainees but is not essential for the performance of the tasks. The trainer should not spend much time on these topics. He should only guide the trainees as to where they can find that information. Often too much time is wasted on details that are of little importance to the objectives of the course. Sometimes the trainer may have difficulty in deciding what to teach and what to omit. In such situations the trainer should try to decide what the students would do poorly if this detail were left out. If the answer is "nothing", then that detail should be left out.
The trainer must specify and define the learning objectives
Helping students to learn
The role of the trainer is help the students to learn. The learning process can be made easier with the help of different teaching methods and aids. Lecturing is just one way of helping the trainees to learn; there are other, better methods. For example, the trainees can be given a hand-out and then asked to participate in a discussion on the subject of the hand-out. Another way is by assigning a task that requires the students to do something or to observe a real-life situation. The following Chinese proverb may be useful to remember in this context:
· Hear and you forgot
In the usual classroom teaching, most trainers prefer to lecture because it is the easiest thing to do. Moreover, in most training schools facilities are lacking for teaching by other methods. If lecturing is the only feasible method of teaching, some simple techniques can be used to improve its effectiveness.
Some simple ways of improving lectures
Planning topics in the lecture
First make a list of the topics to be covered in the lecture. This list should be in the order in which the topics must be learnt. Then decide what information and facts are essential for teaching each of the topics. Such planning facilitates the learning process.
Unplanned lectures confuse students.
Giving the lecture
There is no one ideal way of giving a lecture. The style of lecturing depends on the subject of the lecture and the type and level of the trainees. With experience most trainers develop an effective way of lecturing. The following are some useful suggestions:
(a) Find out how much the students already know. What the trainees already know determines what they can learn next. An example will illustrate this point. If the trainer is going to lecture on the nutritional care of young children, the trainees should have already learnt about the nutritional values of commonly available foods in the community. Similarly, the trainees must know about monitoring the nutritional status of young children with the help of a growth chart before they learn about the identification and management of protein-energy malnutrition. In training courses in which several trainers lecture one group of trainees, this practice is sometimes not followed. Often, lectures are fixed according to the convenience of the trainers.
Before giving a lecture find out what the trainees already know.
(b) Before starting the lecture summarize the main topics to be covered. It is a good practice to tell the trainees at the beginning of the lecture what topics are going to be covered and what is their importance with regard to the tasks the trainees will be expected to perform in the community. If the blackboard is normally used, write the headings of all the topics in the lecture before starting the lecture. This will help to create interest in the subject among the students.
Write the topics of the lecture on the blackboard before starting
(c) Make the lecture interesting. Standing before a group of trainees and talking in a dull and monotonous voice is the surest way of making the lecture ineffective. Some ways of making lectures more interesting are: asking questions, telling some real-life experiences related to the topic, and posing problems and asking trainees to suggest ways of solving them.
(d) Speak loudly enough. Speak loudly so that those sitting at the back of the class can hear clearly. Experience has shown that trainee community health workers are likely to remain quiet and not ask the trainer to speak louder even if they cannot hear clearly.
(e) Face the trainees and speak clearly. It is most important to face the students while giving a lecture. Many trainers spend a lot of time looking at their notes or facing the blackboard while lecturing. This is a bad practice. It results in students losing interest in the lecture. Lecturing to a class of students should be regarded as similar to talking to a small group of people. Look at each of your trainees from time to time while giving the lecture. This is called "making eye contact".
(f) Use simple language. Speak in as simple language as possible so that all the trainees understand everything you say. Often, persons training to become community health workers have a poor educational background and therefore may have difficulty in understanding difficult words. Moreover, they may be from different regions of the country and may speak different dialects or even different languages.
Three simple rules for making a lecture effective:
· Speak loudly and clearly
(g) Use visual aids whenever possible. During a lecture it is good to use visual aids, such as a blackboard, charts, slides, or photographs to explain certain ideas. When properly used, visual aids can create interest in the subject among the trainees and can break the monotony of the lecture. Many trainers use visual aids, but not always in the best way. Here are some simple rules:
· Write clearly. Trainers should remember that students have
a tendency to copy everything that is written on the blackboard. Quite often
trainers write only a few words or incomplete sentences on the blackboard and
speak the rest of the sentence. This may result in the trainees writing down a
jumble of words which they will not be able to understand later. Therefore, all
writing on the blackboard should be clear and legible. The trainer should also
make sure that trainees in all parts of the classroom can clearly see the
· Draw simple diagrams. If a diagram or a rough illustration is necessary to explain something, make sure that the drawing is as simple as possible. It should be noted that while the trainer may find a diagram simple it may still be confusing to the trainees. Avoid using graphs, bar diagrams and similar illustrations because these may be difficult for the trainees to understand.
(h) To conclude the lecture summarize the main points again. Some time should be kept at the end of the lecture for summarizing the main points which the trainer wants the trainees to remember. This will also provide an opportunity for the trainer to find out how much the trainees have learnt.
Teaching of skills
Community health workers have to acquire certain skills to perform the tasks required to provide health care to the community. In nutritional care, for example, community health workers have to perform tasks such as weighing children to monitor their growth, identifying children who are at risk of becoming malnourished, and advising mothers on how to feed young children. To do any one task well, the community health worker must first understand why that is necessary; for this she will need to have knowledge. Then, she must learn the skills needed to carry out that task.
Community health workers need to learn three types of skill to do their job well. First, they must have reasonable manual dexterity. For example, they would need to use their hands skillfully in weighing children and recording the weights on growth charts. Such skills are called manual skills. Second, they would need thinking skills, for such tasks as identifying children at risk of becoming malnourished, for example. Finally, they would need the ability to convince mothers and other people to change some of their habits and practices. For this they would need communication skills. (For example, community health workers would have to convince parents to get their children immunized.)
Skills cannot be learned through lectures and demonstrations alone. They have to be practiced. Community health workers will need a lot of practice in doing tasks before they develop the necessary confidence to do those tasks independently.
Teaching of skills is best done in three steps. First, describe the task and the skills required to do it. Then demonstrate the skills. Finally, allow the trainees to practice the skills. The first two steps should be done at the same time so that the trainees understand the link between them. Once the trainees have understood why a task is necessary and how to do it, they should start practicing it quickly, while it is still fresh in their minds.
Three steps in teaching particular skills:
· Describe the task and skills required to do it
Description of skills
First, the trainer should describe the task and the skills required to do it. He should also explain why the task is necessary, under what circumstances it is required, and what might go wrong if the skills are not learned properly.
For example, to do the task of monitoring growth by using a growth chart, a community health worker will need to learn various skills, including:
· Convincing mothers to bring their babies for
· Checking the accuracy of weighing-scales
· Weighing babies correctly
· Recording their weights on growth charts
· Interpreting growth curves
· Giving appropriate advice to mothers.
In a lecture, the trainer should first describe the above task and skills using visual aids (such as pictures of a weighing-scale and a growth chart). While describing each of the above skills the trainer should point out what might go wrong and what would be the result of a mistake; for example, that if the weighing scale is not checked properly before use all results would be wrong.
Several skills may be needed to do one task.
Demonstration of skills
After describing and explaining the task and associated skills, the trainer should demonstrate each skill separately. Sometimes, persons other than the trainer may do the demonstration. For example, doctors in a clinic or health centre may be asked to demonstrate how to identify nutritional deficiencies in a child.
Most of the skills can be demonstrated anywhere (classroom, health centre, etc.). Two simple rules should be followed during the demonstration:
(a) The demonstration should be clearly visible to all the trainees. When there is a large group of trainees, it is common to see a crowd around the demonstration, with quite a few trainees unable to see what is happening.
(b) Each step in the demonstration should be explained clearly. Also, the trainer should draw attention of the trainees to the common mistakes and omissions in each step. For example, if the trainer is demonstrating how to weigh a child, he should point out that it is easy to forget to make the zero adjustment before each weighing session. At the same time, the trainer should remind the trainees about the need for checking the scale with known weights from time to time. Both these points are important for accurate weighing.
Practising of skills
This is the most important part of the learning process. It is only by practicing the tasks on their own that the trainees will develop the confidence necessary to do the tasks independently in the community. Unfortunately, enough attention is not always paid to this aspect of training because practice sessions are difficult to arrange and are time consuming. What usually happens is that one or two visits are arranged to a health centre or community for the trainees to see how trained community health workers do the same tasks.
There are a number of different ways of helping trainees to practice skills, depending on the type of skill involved. One way is to assign projects to small groups of trainees. For example, two or three trainees may be asked to go to a community and identify children with malnutrition. Another way of practicing the same task of identifying malnourished children is to let trainees examine malnourished children in a health centre. Role-playing, when properly organized, can also be a very effective method of practicing communication skills (e.g., nutrition education).
The best method of helping trainees to practice skills is, however, to let them work for a short period under the supervision of a trained community health worker. This will give the trainees an opportunity to practice skills in a real-life situation.
In any training course for community health workers, a major portion of the training time should be spent on the teaching of skills. One or two visits to a clinic or community are not sufficient for trainees to practice skills.
Assessing how much the students have learnt
It is important for all trainers to know how much the students have learnt. This is the only way to know if the students will be able to do their job well after completion of the training. The process of knowing what the students have learnt is known as assessment. Most commonly assessment is done by means of an examination, in which there are usually three components-theoretical, practical, and oral. Assessment also enables the trainers to know how they themselves have performed as teachers. From the results of the assessment, trainers can find out which part of the training programme is strong or weak or how the training should be modified to get better results.
Final versus continuous assessment
In most training courses, the students are assessed at the end of the course on the basis of a final examination. However, students can also be assessed periodically during the entire course. Generally, this form of continuous assessment has many advantages over final assessment. Some of the advantages are:
· Continuous assessment is a more reliable indicator of what the students have learnt during the course
· The tension and worries of a final examination are avoided and the students are motivated to work hard throughout the course, instead of leaving everything to the end before the final examination
· Continuous assessment enables the trainers to keep a continuous check on their own performance and on the usefulness of the course, and, if necessary, the trainers can modify the course.
Methods of assessment
There are many methods of assessment, but none of them is perfect. Each has some advantages and some drawbacks. The trainer must choose one or a combination of methods to assess the trainees. The choice of the method (or methods) will depend on what exactly the trainer wants to assess. The trainer will also have to fix a minimum acceptable level of performance for the trainees. A brief description of methods of assessment is given below.
(a) Informal testing can be done inside the class or outside.
In class, you may put questions to the class as a whole. You can assess the difficulties of the class, or of individuals, with the subject matter. Outside the class, the questions will usually be put to individual trainees or small groups of them. Some points to bear in mind are:
· The questions should be related to the objectives.
· The questions should be clear and precise.
· The questions should require fairly short answers.
· Give everyone an equal chance to answer questions.
· Encourage the students and do not ask any question in a way that might embarrass a student.
After class, the trainer should check his/her own performance:
· Were the learning objectives clearly specified and defined?
· Did all the trainees know what the objectives were and understand them?
· Were the content of the lesson and the teaching methods and aids right for the learning objectives?
· Were the teaching aids properly prepared for the lesson?
· Was there a proper check of how the trainees were progressing?
· Did the introduction to the lesson link it clearly with the previous lesson?
· Were the right examples used to clarify important points?
· Was there enough time for questions?
· Was the material presented clearly and could the trainer always be heard?
· Was there a good summary at the conclusion of the lesson?
(b) Formal testing or examination may be done in various ways
Practical tests. The trainee demonstrates her ability to perform certain practical tasks. These must be relevant to the learning objectives. There should be enough time to complete the test. The trainees should have been shown how to do the task and should have practiced it before being tested. As an example of a practical test, trainees may be asked to demonstrate how to weigh a child accurately and how to record the result on a growth chart.
Oral tests. The trainee's knowledge of a subject is probed deeply by verbal questions and answers. The ability of the trainee to give satisfactory answers may be affected by her communication skills, her self-confidence, and the encouragement given by the trainer or the person conducting the testing. If a grade is given, it may be affected by the personal feelings of the tester.
Written tests. The trainee's knowledge is tested by writing answers to questions. When writing test questions, always think how relevant they are to the learning objectives and to the trainees. There are two types of written tests:
(i) Written tests with long answers or essays. These are often used in academic situations and may not be advisable for community health workers. They are useful for judging the depth of knowledge of trainees and how they express themselves. It is often difficult to grade the results with fairness.
(ii) Written tests with short answers. These may require one-word answers, completing a sentence, stating whether a given answer is true or false, or choosing the correct answers among several that are given. For each question, there is a precise answer. It takes time to prepare the questions, but the correction and marking of the tests is very easy and quick.
Useful hints about teaching aids
Selecting teaching aids
The proper use of teaching aids requires much careful thought. This is particularly true if they have to be prepared from scratch. The trainer should always make quite sure that the subject matter, the training methods and the visual aids are all suited to each other. The trainer should also have adequate rehearsal in their use, especially if they are being used for the first time, to ensure that she is quite familiar with them. Some factors to consider in choosing the aids are:
· Situation. To whom will the presentation be made-one trainee or a group of trainees? Where will the presentation take place-clinic, classroom or field? This will affect the size of the aid. How often will the aids be used? If they are to be used once only, it may not be worth while to prepare expensive and elaborate aids. Will the use of the aids depend on such things as electricity, transport or other equipment like projectors; if so, are these available?
· Subject matter and desired effect. What emotion is the trainer trying to arouse-fear, surprise, shock? A much stronger impact can be made when teaching the symptoms and effects of kwashior-kor or marasmus by showing real severe cases or coloured pictures than by using sketches. Does the information require gradual building-up and linking with other information?
· Cost. Teaching aids cost money, and some are very expensive. Film and slide projectors and overhead projectors are the most expensive, followed by the magnetic board and the flannel-board. Blackboards are cheap and are practical in many situations.
A number of common teaching aids, their advantages and disadvantages and some useful tips on their preparation and use are listed in Table 1.
Designing visual aids
Visual aids are intended to improve the transfer of knowledge and skills by showing what has to be learnt or done. They must be very carefully chosen to suit the subject. If new ones have to be designed, the following points should be borne in mind:
· Use pictures whenever possible.
· When words and numerals must also be used, use as few as possible.
· Use graphs to present statistics and numerical information such as the results of weight surveys.
· Use colours as often as possible. The use of colours can increase the effectiveness of a picture and emphasize key points. They can be used for coding, contrast, and improving visibility. Colour combinations or contrasts are important. The colours that attract attention best are red and blue.
· Make the visual display simple and easy to understand. Use only key words and phrases, simple shapes and lines, and a few well-chosen colours. Do not crowd the display.
· For lettering, use special pens of the desired size, colour and boldness. You may use commercial pre-cut letters, lettering guides (stencils) and stick-on letters, or you may write free-hand. Be sure the letters are large enough and not overcrowded so that those at the back can read them.
· If a complex figure is necessary, the different elements should be introduced one by one. If you build up the picture step by step it will be more easily understood and accepted. Flannel-boards and overhead projectors are very good for this purpose; for instance, a flannel-board can be used to teach the use of a growth chart.
There are many methods of teaching. Five of them are summarized in
Table 2. Each one has to be studied to determine its suitability for certain
The main factors to be considered in choosing teaching methods are:
· The trainer's knowledge and experience in teaching, familiarity with the methods, and ability to communicate.
· The trainees' intellectual level, educational background, age and practical experience, and social and cultural environment.
· The objectives of the training. The changes to be brought about through training are defined in terms of knowledge, attitudes, and skills. Depending on the objectives, one method or a combination of methods may be used. For instance, if trainees are to acquire skills in identifying problems and in decision-making, it is better to give a brief talk, and have them work on a case-study or to practice role playing than to give them lectures. Role playing is also useful to improve communication skills and behaviour.
· The subject matter. Different subjects lend themselves to different teaching methods.
The self-confidence that trainees need in order to teach mothers can be built up by role-playing. Comparing the cost of breast feeding and bottle-feeding can best be done in an actual exercise.
· Time and other resources. The costs involved, the amount of time available, the time of the day when training is given, and the availability of facilities and equipment are important.