|Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 pages)|
|Module Four: Working with the health system|
|Session 12 - Monitoring and follow up for controlling diarrheal diseases|
3 hours, 30 minutes
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.
· To describe the National CDD Surveillance and Monitoring System.
· To describe the tasks involved in monitoring.
· To develop a checklist for monitoring an ORT project in the community.
(Steps 4, 5, 7)
· To resolve problem situations identified through Monitoring
- 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
- 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
Newsprint markers, Monitoring forms used in the country.
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?
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.
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.
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
Health Education Activities
Indicators (items to Monitor)
To prevent dehydration in all children with diarrhea within the
Train mothers to property mix and give sugar/salt solution when
children have diarrhea
· Signs of dehydration observed in children with
To identify all children in the community "at risk" for
Teach mothers to assess their childrens' health by filling in
a growth chart
· The child's growth curve
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.
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.
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?
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.
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?
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
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.
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.)
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.
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.
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.
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
How to Monitor
How Often to Monitor
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.
(Adapted from: WHO Monitoring Performance, pp. 5-6)
Given evidence that a performance problem exists:
1. Determine if the problem is important to
· 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
4. Identify reasonable solutions to the problem.
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.
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
· 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.
(Adapted from WHO "Monitoring Performance." p.3.)
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 community.
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. Getting 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).
- Referring the family to appropriate specialized services (for example, referring cases of dehydration to the health worker).
How to Make a Home Visit
The five essential steps of a home visit are:
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.
(Adapted from: Colgate et. al. The Community Health Nurse in Africa. pp. 51-56)
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:
· 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.
· Generally, requires writing skill (though participants may dictate entries to school-age children or use A cassette tape instead of a notebook).
· Generates a large amount of data, making compilation and analysis a challenge.
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.
(From: American Council of Voluntary Agencies for Foreign Service. Pp. 102-103)
What to include
This will depend very much on the work of the participants.
- 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.
- 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.
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
The cause of the problem is not an obstacle