(introductory text...)

TOTAL TIME: 4 hours, 15 minutes

OVERVIEW

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.

OBJECTIVES

· 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)

RESOURCES

Handout:

- 13A Disease Surveillance Procedures
- 13B Charting Exercises

Trainer Attachments:

- 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)

MATERIALS

Pens, markers, newsprint, graph paper.

PROCEDURE

Trainer Note 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?

Trainer Note 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 measures vary.

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.

Trainer Note Have the definitions of survey and surveillance written on newsprint.

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.

Trainer Note 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. - Select a technique or approach for collecting the information (i.e., formal questionnaire, observation, review of clinic records). - Collect the information (i.e., select a representative sample, identify cases). - Report on and use the information collected. 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.

Trainer Note 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) - who asked the question (e.g., close friend, stranger, authority figure) - where the question was asked (e.g., in private, amongst a group of friends or family members). Following the interview scenarios, be sure the group discusses these important considerations for adapting and using KAP Surveys: - Sequencing of Questions - Types of questions used (simple, culturally sensitive) - Relationship between the interviewer and interviewee (e.g., are they from different tribes/countries; personal friends; relatives) - Manner in which the question is asked (threatening, authoritative, friendly) - Environment (private setting, crowded household) - 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)
Disease Surveillance

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.

Trainer Note 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)
Identifying Cases

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.

Trainer Note The information on this sheet can be used to: - identify approximate time of illness (date of clinic visit) - identify outbreaks in one or several families (name of patient) - identify the location of illness that can be used to assess clustering of disease (address) - assess the impact of disease on a certain target population (age, sex) - identify the disease and/or describe major symptoms (symptom/diagnosis) - evaluate CDD and Malaria programs (treatment) - identify success of preventive health programs or problems related to methods of treatment techniques (comments) 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.

Trainer Note Generally, the disease forms should be: - Self-Explanatory - Contain only essential information needed for identifying cases and disease trends - Easy to fill out - Standardized

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.

Trainer Note 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) - How many cases there are - When the cases are occurring (month, year) - Who the cases are - age and sex groups - Whether or not the pattern of cases is expected based on previous years · Explain that, after reading the graphs and charts, but before taking the action which seems to be indicated, several points must still be considered, for example: - Completeness of reports. Have the registers been completely reviewed to identify all cases diagnosed? Have all cases seen in outreach clinics been included? Have there been errors in recording data? - For vaccine preventable diseases, the vaccination status of the children - For diarrhea and malnutrition cases, the treatments given - Whether or not the program has proven its effectiveness in reducing disease. · When discussing the needs to promptly report data, point out the following: - Delayed reports are of limited value in assessing the action that needs to be taken to prevent or control the spread of a disease. - No clear picture of disease activity can be obtained if reports are delayed or not sent at all. If no cases are seen, a report to that effect must be made, otherwise, those responsible for collecting and analyzing surveillance information at the next level may believe that the report has simply been delayed.

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.

Trainer Note 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 - how they can find it and - how they can use it to analyze and monitor their activities and the impact they are having on major diseases in the community.