|Training Manual in Combatting Childhood Communicable Diseases Part I (Peace Corps, 1985, 579 pages)|
|Module 3: Community analysis and involvement|
|Session 13: Survey and disease surveillance|
TOTAL TIME: 4 hours, 15 minutes
In Sessions 9-12, the participants learned about the need for and difficulty in obtaining and analyzing information about the community. The purpose of gathering this general information is to help the Volunteer have a better understanding concerning the way of life in the community and the problems people identify as being important to resolve. Later, as the participants begin their work in health programs, they may need specific health information concerning the knowledge, attitudes and practices of individuals in the community as well as information of disease trends in terms of person, place and time.
In this session participants are introduced to two methods of collecting disease specific information - survey and surveillance. They examine the functions of information collected through the use of each one.
· To define the terms survey and disease surveillance. (Steps 2, 5)
· To discuss the steps involved in conducting a survey. (Step 3)
· To discuss KAP Surveys. (Step 4)
· To explain the six major steps in disease surveillance (Step 6-9)
· To design graphic presentations of collected data. (Step 9)
- 13A Disease Surveillance Procedures
- 13B Charting Exercises
- 13A Defining Survey and Surveillance
- 13B Definition of Rates
- 13C Survey Methodology
- 13D Sample Out Patient Register
- 13E Examples of Surveillance Forms
- 13F Visualization of Numerical Data
- 33A Trainer's Glossary (from Session 33)
- 38B KAP Household Questionnaire on Malaria (from Session 38)
Pens, markers, newsprint, graph paper.
This session is extremely technical and requires a trainer with background and experience in surveys and surveillance. If your experience is limited, arrange for someone with more expertise to co-facilitate the session with you. Be sure to thoroughly study the session activities and attachments beforehand.
For the session, you will need to collect copies of the survey and disease surveillance forms used in the host country. If possible, collect any information regarding the incidence, prevalence or mortality rates for specific childhood diseases for the whole country and selected areas.
This session should be coordinated with the more technical
sessions in Module 6. The knowledge they gain about KAP surveys here will be put
to direct use in Session 42 (The Impact of Culture on Diarrhea) and to a lesser
extent during the sessions on malaria and nutrition. Please stress during this
session that Volunteers should not plan and conduct a survey or develop a
surveillance system on their own. The purpose of this session is to give them
basic information about these methodologies so if they are asked by MOH staff to
participate in a survey or review of a surveillance system, they will have a
basic understanding of the work.
Step 1 (15 min)
Health Knowledge Assessment
Ask participants to reflect on the information related to health they collected during their community investigation (Session 11). Tell them to answer the following questions about the host country as best they can and record their answers on newsprint.
- What are the major causes of death and illness in children under five?
- What do community members believe to be the major causes of specific childhood illnesses?
- Do these diseases occur more frequently in certain areas of the country than in others?
- Do some of these diseases occur more often at a particular time of the year or in certain cycles?
- What types of treatment do children receive in the home or at the clinic for any of the diseases?
- Do family members know how to correctly treat children with fevers or diarrhea?
- How do community members learn about health measures used for the prevention and or treatment of childhood diseases?
After participants have pooled what they know about health and illness in the host country, ask them to discuss:
- What they think of the reliability and validity of their information?
- What basic information they need to design a health education project?
- How they can collect this information?
Explain to the participants that reliability and validity are terms which have specific meanings. They are:
reliability - The degree to which the results obtained are repeatable using the same method
validity - The degree to which the information obtained actually reflects the truth one is trying to measure.
The following is an example you may choose to share: A method can
give reliable (consistent findings) results which may not be valid (true
measure). A single measure may be valid but may not be reliable if repeated
Step 2 (15 min)
Defining Survey and Surveillance
Building on the participants comments regarding how they can collect the information they need, introduce and define the terms survey and surveillance (see Trainer Attachment 13A). Explain that the first half of the session deals with survey, the second half with disease surveillance.
Have the definitions of survey and surveillance written on
Step 3 (30 min)
Planning and Designing a Survey
Tell the participants that aside from conducting a general community survey, there are other types of surveys they may became involved in during their two years as Volunteers. These may include:
- Vaccination Coverage Surveys
- Program Review Surveys
- Prevalence Surveys
- Knowledge, Attitudes and Practice Surveys
Based on their work in Sessions 9-12, ask them to state four basic steps they think should be followed when designing and conducting any type of survey. List these steps on newsprint and discuss any steps that differ considerably from those listed in the Trainer Note below.
Tell participants that in their technical programs, they will most often be involved in conducting Knowledge, Attitudes and Practice (KAP) surveys which, as the name implies gathers information on the knowledge, attitudes, and practices of community members.
Distribute copies of the RAP Survey from Session 38 (Trainer Attachment 38B). Ask the participants to look at the questions and identify which questions will give them information concerning the community member's:
- Knowledge about the causes, signs and ways to treat malaria
- Attitudes about the importance of treating or preventing malaria
- Practices concerning how they treat the disease.
Have the group briefly discuss and give examples of how the information they gather from the KAP survey, will help them design effective health education projects on malaria.
The following are the four basic steps to follow when designing and conducting a survey:
- Determining the kind of information you need, how it will be used and the resources from which it will come.
At this time you might choose to explain the information found in
Trainer Attachment 13C (Survey Methodology).
Step 4 (25 min)
Assessing Survey Techniques
To help the participants understand the difficulty in obtaining valid information when conducting a survey, do the following brief activity: Describe three or four interview scenarios using the example in the Trainer Note below. For each scenario ask a participant to be the interviewee and respond to your survey question. Ask the group what it is about the questions and circumstances of the different scenarios that affect their responses, and, in turn, how their response affects the validity and reliability of the information obtained.
Close the discussion by asking participants to identify the main points to consider when developing and conducting a KAP survey.
Prior to this step develop, or select, from Trainer Attachment 38B, three or four questions that pertain to gathering information on the health related knowledge, attitudes and practices of the participants. Develop a scenario for each question which pointedly shows how the interviewee's answer is affected by:
- how the question was asked (e.g., leading question, threatening manner)
Following the interview scenarios, be sure the group discusses these important considerations for adapting and using KAP Surveys:
- Sequencing of Questions
- Nature of the information asked (e.g., questions that ask about
practices considered taboo or against the tenents of one's faith, questions
relating to moral issues.)
10 Minute Break
Step 5 (20 min)
Introduce this step by telling participants that the KAP survey they have just studied may be used as one method of surveillance. The baseline information collected in an initial KAP survey can be compared to a later KAP survey to assess the status of the project's interventions.
Tell them that another surveillance method is routine disease surveillance which yields information on cases of disease, deaths and their characteristics.
Distribute Handout 13A (Disease Surveillance Procedures). To help participants understand how routine surveillance works, use the disease specific information and rates you collected from the MOH and/or local health center to explain the following:
- what data is collected (e.g., disease specific cases in terms of person, place and time)
- how data is collected (e.g., routine reporting, active surveillance, special studies, surveys)
- how it is analyzed (i.e., in terms of person, place and time)
- hew rates are determined (see Trainer Attachments 13B and 33A)
Explain to the group that a good way to understand the process of disease surveillance is to work through the steps using health center records. Tell them this is what they will be doing for the rest of this session.
As the participants work through the surveillance procedures,
identify which step in the procedure they are doing and have them review the
information an the handout that pertains to that step.
Step 6 (15 min)
Distribute a sample record of an outpatient register form that you obtained from the MOH or use the one found in Trainer Attachment 13D. Using the register, have the participants discuss the purposes for collecting the information asked for on this form.
The information on this sheet can be used to:
- identify approximate time of illness (date of clinic visit)
Explain that to find out about outbreaks of communicable diseases
in remote areas, those who visit the health center can be asked about
communicable diseases in their villages. However, tell the participants that
these reports should not be counted as cases, because they have not been seen
and diagnosed by health workers. These reports should be used to provide health
workers with information about hard to reach areas so that they can better serve
the people living there.
Step 7 (20 min)
Counting Reported Cases
Distribute the weekly or monthly surveillance forms used in the host country or the forms found in Trainer Attachment 13E. Ask the participants to review these forms and to assess them in terms of the following questions:
- Is there information requested which cannot be accurately supplied? tare there obvious discrepancies in the form design such as overlapping brackets)
- Is there a greater level of detail requested than is likely to be used? (Can you identify items which are unlikely to be used in a subsequent analysis)
- Is there information that is needed but not requested on the form? (cases and deaths of certain diseases not mentioned, vaccination status, age?)
- Are there symbols used which are unnecessarily complicated or ambiguous?
- Are there standardized case definitions? (e.g., are acute and chronic diarrhea defined)
Based on the answers to these questions ask the participants what guidelines should be used in designing forms which will facilitate a health worker's job of recording and counting cases of disease.
Generally, the disease forms should be:
Step 8 (30 min)
Analyzing Data, Taking Action, and Reporting Promptly
Post the graphs and charts that you have adapted from Trainer Attachment 13F. Explain the function of each chart, graph or map and then have the group interpret the graphs and discuss how they are used in identifying disease trends.
Explain that disease trends are analyzed in terms of:
- person (for example trends related to age, sex, treatment given)
- place (e.g., urban and rural differences and geographical clustering)
- time (as in, annual and seasonal trends, e.g., measles, polio, whooping cough, diarrhea and malaria, are often more prevalent during same months or years than others).
Tell the participants that after analyzing their data, if they discover that an outbreak of a disease is occurring in a certain target group or geographic area, they must immediately investigate the problem to determine what is causing it (e.g., breakdown in cold chain, incorrect techniques for immunizing children, etc.), and take action to correct the situation.
The next step they must do is to promptly send their surveillance reports to the next higher level of the health system, using the standardized reporting forms.
Examples of visual aids and questions that you may adapt for this step are found in Trainer Attachment 13F. Ideally, you should obtain this material from the Health Ministry or at least base your examples an data that have been supplied to you by them. Use these examples to do the following:
· First, have the group look at what each of the graphs and charts are saying (i.e., the information they provide). For example:- Reasons for the geographic clustering of diseases (for example, transmissible diseases like measles can be localized in certain villages; a contaminated water source would also result in clustering of diseases)
10 Minute Break
Step 9 (50 min)
Monitoring Monthly and Yearly Totals
Recall for the participants that the sixth step in surveillance is that of monitoring monthly and yearly totals. One way of doing this is to prepare graphs and charts.
Distribute Handout 13B (Charting Exercises). Ask the participants to form three groups and develop a visual way of presenting the data described in their handout. Tell them to summarize the data in such a way that health center staff will be able to look at the information and use it to monitor disease patterns and determine how effective their activities have been in improving the health status of the targeted population.
After 30 minutes reconvene the large group and have each small group present their graphs, charts and maps. After the groups have made their presentations lead a discussion based on the following questions:
- How difficult was it to prepare the material?
- Can the visuals stand alone? (i.e., is information concerning titles, disease, location and dates recorded? Are the axes labeled?)
- How useful these techniques of displaying data are in terms of providing feedback to health personnel as to the effectiveness of their health program and identifying where there are problems.
Step 10 (15 min)
Summarizing the Session
Conclude the session by asking the group to briefly restate the 4 steps for conducting a survey, and the 6 steps in surveillance.
Have participants also discuss possible ways that they may be able to incorporate this information in their work.
Depending on when this session is acne, participants may or may not be able to discuss hew the information presented in this session can be useful in their work as health educators. Therefore, you may need to tell them that over the course of 2 years they may be asked by health officials to participate in various types of surveys to determine the impact of CCCD projects, and to determine the knowledge, attitudes and practices of the local community before developing a health education project plan and related activities. Also, knowing the 6 steps in disease surveillance may help them to determine:
- what information they need for developing appropriate health education activities