(introduction...)

CDD/93.2
Original: English

Introduction

Why was Advising Mothers produced? Every child that is seen at a health facility with mild diarrhoea, and every dehydrated child that has been successfully treated at the facility, will be sent home to follow Plan A of the WHO/CDD Diarrhoea Management Chart, Case Management in the Home (give increased fluids, continue feeding, and seek medical care when needed). Unlike many other treatments, which are provided by the health worker, case management in the home is entirely the responsibility of the mother or other child caretaker. If correctly carried out, it can have a significant impact on the health of the child. How well the mother carries it out depends partly on how well the health worker advises her.

Advising a mother on home case management is often the last activity carried out during a consultation, and often the least well done. The advice and the manner in which it is given are often not sufficient to enable the mother to understand and have confidence in her ability to care for her child’s diarrhoea. There are many reasons for this: the health facility may be crowded, a health worker may have little time, and it is not always clear just how to advise the mother. When assessing and treating a child with diarrhoea at a health facility, the health worker should follow the same, systematic approach with every child: “Look, Ask, Feel, Decide, Treat.” Advising a mother on how to care for the child at home may seem like a less structured activity; it is definitely one which calls for good judgement and understanding on the part of the health worker.

It was for these reasons that the CDD Programme produced Advising Mothers. This guide teaches a process and skills which will help the health worker to advise mothers on home case management correctly and effectively. The process will help the health worker to communicate all the essential information to the mother in a structured manner, and in a reasonable amount of time. It will also help the health worker to limit the amount of information to give, and it should make it easier for mothers to remember the advice.

How should Advising Mothers be used?

Advising Mothers is a training tool, to be used either during a case management training course, or as a brief course for health workers who are already trained in case management.

If used alone, the course from Advising Mothers will last about one and one-half days. A sample agenda can be found following this section.

It is preferable to integrate Advising Mothers directly into clinical management training. On the following pages is a suggested agenda for incorporating Advising Mothers into the Clinical Training Course for Health Centres and Small Hospitals (the “short course”). Some of the activities may be carried out during periods in the course that would in any case be set aside for individual work, others can be practised during the sessions on practical work in a health facility.

Sample agendas

Sample agenda for diarrhoea management training course
(with activities from Advising Mothers)

Day 1
8.30 - 9.00		Registration
9.00 - 9.30		Welcome: Objectives, planned activities, introduction of participants, administrative announcements.
9.30 - 9.45		Break
9.45 - 10.45		Presentation on Principles of Clinical Management modified to include Advising Mothers (A/M)
10.45 - 12.00		Individual work on “Management of the Patient with Diarrhoea” module (Introduction by facilitator, A/M Information summary sheet, Short-answer exercise p 29 of management module).
12.00 - 13.00		Lunch
13.00 - 16.30		Individual work (continued): A/M Basic Skills; Steps 1-4 (including review/use of Mother’s Card, role-play if time allows)
16.30 - 17.00		Presentation on Management of Acute Diarrhoea
Day 2
8.30 - 9.30		Instructor demonstrates proper case management techniques
9.30 - 12.00		Practical work (with break between 10.00 and 10.30); Practice using Mother’s Card
12.00 - 13.00		Lunch
13.00 - 15.00		Individual work on module (pages 33-49; Plans B, C, other problems)
15.00 - 15.15		Break
15.15 - 17.00		Continue individual work on module
Note:	The presentation on Epidemiology and Etiology of Diarrhoea, originally scheduled for the end of Day 2, should be carried out as an optional evening session on the same day. If this is not convenient, an alternative method may be that participants learn the information by reading.
Day 3
8.30 - 9.00		Presentation on Prevention of Diarrhoea
9.00 - 12.00		Practical work (break between 10.00 and 10.30); include drills on ORS preparation, and other case management drills as needed.
12.00 - 13.00		Lunch
13.00 - 14.00		Practice ORS demonstration
14.00 - 15.00		Exercise F, management module (Role-play on dehydrated child)
15.00 - 15.15		Break
15.15 - 17.00		Course Progress Check, with A/M Summing-up exercise
Day 4
8.30 - 9.00		Discussion of results of Course Progress Check
9.00 - 12.00		Practical work (break between 10.00 and 10.30) with practice conducting ORS demonstration
12.00 - 13.00		Lunch
13.00 - 15.00		Individual and group work on improving case management
15.00 - 15.15		Break
15.15 - 16.00		Improving case management (continued)
16.00 - 17.00		Course evaluation

Sample agenda for Advising Mothers as an independent course

Day 1
8.30 - 9.00	Opening
9.00 - 9.15	Introduction
9.15 - 10.30	Basic Skills:	Rules of home case management
		Simple language
		Ask questions
10.30 - 11.00	Break
11.00 - 12.30	Step 1: Ask
	Step 2: Praise and encourage
	Step 3: Advise
12.30 - 13.30	Lunch
13.30 - 14.30	Step 4: Check
	Review and Summing-up exercise
14.30 - 15.30	Role-play “APAC”
15.30 - 16.00	Break
16.00 - 17.00	Use of Mother’s Card
Day 2
8.30 - 11.00	Practice in a real situation
	Lead a demonstration (done concurrently with practice)
11.00 - 11.30	Feedback on practice
11.30 - 12.00	Closure

Supervise and monitor activities from Advising Mothers

The skills learned in Advising Mothers may be new to many health workers, and they will need support and encouragement to apply these skills in their daily work. They will also need sufficient stocks of the Mother’s Card. A distribution system will need to be set up so that the cards can be distributed with ORS packets or other regular supplies.

The following is a suggested checklist to help you monitor the activities dealt with in Advising Mothers. You or the appropriate supervisor can use it when you observe a health worker advising a mother during your regular supervisory visit to a health facility.

Checklist

Process: Did the health worker
		Ask questions?
		Praise and encourage the mother?
		Advise the mother what else to do?
		Check the mother’s understanding?
		Explain the Mother’s Card?
		Give the Mother’s Card to the mother?
		Refer the mother to a group session (if appropriate)?
Content: Did the health worker
		Advise the mother to increase fluids?
		Specify which fluids?
		Advise the mother to feed/breastfeed the child?
		Specify what kinds of foods?
		Suggest small, frequent feedings?
		Advise the mother not to use medicines?
		Advise the mother on signs for referral?
			Cannot eat or drink;
			Very thirsty;
			Passes many watery stools;
			Repeated vomiting;
			Fever;
			Blood in the stool;
			Child not getting better.
Skills: Did the health worker
		Treat the mother with respect?
		Use simple language?
		Give realistic advice?
		Use the Mother’s Card effectively?
Mother’s Cards
		Is there a sufficient stock of the Mother’s Cards at the health facility? (If not, how many are needed?)

Suggested methodology

1. Introduction (20 minutes)

Ask participants to read pages 1-5 to themselves. Then repeat the main points as follows:

Key points to stress. This guide is designed to help health workers better advise mothers on how to carry out Plan A at home. The content (what to advise) will be a review for the participants; the process (how to advise) will be new. In communication, the process is as important as the content. What makes this process different is the exchange of information between the health worker and the mother, and the practice of praising and encouraging the mother. Each of the steps will be practised during the training sessions. Although this “guide” is specific to CDD, many of the skills (using simple language, asking questions, praising and encouraging helpful behaviours, giving realistic advice, and using a pictorial aid) may also be useful in other situations.

2. Basic Skill: Remember the three rules (30 minutes)

Ask participants to read “Basic skill: Remember the rules of case management in the home”, and to write down the three rules of home case management. If it is available, an Information Summary Sheet may be inserted in this section with more specific, adapted information (this may have been completed by the national programme manager). Stress the following:

Key points: The three rules of home case management, plus advice about using antidiarrhoeal preparations and antibiotics for child diarrhoea, are standardized. However, health workers should be aware of variations in their areas, such as specific foods and drinks to recommend, local interpretations of certain symptoms, local terms, and behaviours which may be harmful.

Note: Special emphasis should be placed on continued feeding during diarrhoea, and increased feeding for two weeks after the episode.

3. Basic Skill: Use simple language (20-35 minutes)

Ask participants to read “Basic skill: Use simple language”, and the example preceding the short-answer exercise. They should then do the exercise, and compare their answers with those on page 10. Review by mentioning the key points below. If time allows, a group discussion may follow.

Key points: Health workers often use technical terms which mothers may not understand. Note that some problems of terminology may be important only in English: if a local language does not have comparable words, a simple description is often used. However, sometimes if a local term does not exist, the scientific word in English is simply used instead. This may be even more confusing to a mother. Health workers should try to find words or descriptions that mothers can easily understand.

4. Basic Skill: Ask questions (10 minutes)

Ask someone from the group to read aloud “Basic skill: Ask Questions”, from mid-page 10 to mid-page 11. Summarize the main points (below). Participants should then do the exercise, and compare their answers with those found on page 12.

Key points: Both types of question, open and closed, are useful. Closed questions give more limited information. In the sections that follow there will be the chance to practise using questions for getting information and for checking mothers’ understanding.

5. Step 1 (20 minutes)

Ask participants to read to themselves “Step 1: Ask the questions” (pages 12-13), and complete the exercise on page 14. Ask several participants to read their answers aloud and compare them with those on page 15. Stress the key points below.

Key points: The key questions on drinking, eating, and giving medications or other treatments form the basis for advising mothers. Health workers should memorize these key questions.

6. Step 2 (25 minutes)

Ask someone to read aloud “Step 2: Praise and Encourage helpful behaviours” (page 16). Discuss briefly with the group the importance of including praise and encouragement when advising a mother. Ask the participants to do the exercise. When they have all finished, discuss each of the situations and possible answers. (Suggested answers can be found at the end of this facilitator’s guide).

Key points: Giving praise and encouragement makes this system of advising mothers different and more effective than others. Sometimes it may be a challenge for the health worker to find something to praise, without appearing artificial or patronizing. However, even if a mother has done nothing “right”, her intentions are usually good, that is, she wants to do the best thing for her child. The health worker may praise her for bringing the child in for help.

7. Step 3 (50 minutes)

Ask participants to read “Step 3: Advise the mother what else to do” (page 18), and stress the key points below. For the exercise, divide the participants into pairs to work. Each pair should write answers for all four situations. Then ask each pair to present one situation to the group, and discuss their solutions. Some possible answers are suggested in this facilitator’s guide. If the participants have previous experience treating diarrhoea cases and advising mothers, they may wish to suggest specific examples of behaviours they need to praise, encourage, or advise against in their areas.

Key points: After praising the mother for what she has done right, it is important to discuss the remaining points in home case management. It is also important to correct anything the mother has done wrong, without sounding angry, disrespectful, or judgemental.

8. Advising about danger signs

Ask the participants to read the section, “Advising about danger signs” (page 21). Stress that different countries may have various ways of expressing these signs, in ways that mothers can easily identify and remember. In addition, there may be signs that are well-known and for which mothers commonly become concerned (for example, “The child becomes weak”). These adaptations and additional signs should be included in the list.

9. Step 4 (20 minutes)

Ask the participants to read “Step 4: Check the mother’s understanding” (page 21), and to read the exercise. This exercise should be carried out in the form of a short drill: the facilitator reads the first checking question aloud, and then the “Mother’s response”. One participant suggests a follow-on checking question; another participant suggests an additional follow-on checking question, and so forth. There should be at least two or three suggested follow-on questions after each “Mother’s response”. After completing the drill, stress the following key points:

Key points: Checking understanding is another essential part of advising. Always check a mother’s understanding using open questions. In addition to giving the health worker a clearer idea of what the mother has understood, it will also help the mother to think about what she has heard. Sometimes several questions may be needed to get enough information.

10. Review of information using the Mother’s Card (30-60 minutes)

Ask the participants to read the top half of page 24. Then ask one participant to read aloud the techniques of using the Mother’s Card, while you demonstrate the techniques one by one. Distribute a Mother’s Card to each participant, and review the contents of the card/pamphlet if necessary. Divide the group into pairs to work together. Each pair should sit together, as a health worker and a mother might sit at a health facility. One member of the pair uses the Mother’s Card to explain and review home case management to the other; when one participant has finished, partners should switch roles and practise again. Circulate among them as they practise, and observe participants to make sure that they are able to use the techniques described earlier.

When the participants have completed the exercise, stress the key points below:

Key points: There are three principal reasons why a Mother’s Card is useful: it reminds the health worker what to say, it helps the mother to understand the advice, and it helps her to remember what to do next time her child has diarrhoea. Health workers must become familiar with the pictorial aid used in their national programme.

Remember - A pictorial aid is only useful if it is used well.

The six recommended techniques for using the Mother’s Card may seem too simple. However, they have been selected based on the mistakes that health workers make most often, i.e., holding the card so that the health worker can see it but the mother cannot; talking without pointing to the pictures; and not asking the mother to explain what she will do at home.

11. Review of the steps (5 minutes)

Ask the participants to read to themselves “Review of the steps” (page 29) and to complete the outline. Check the participants’ answers individually.

12. Summing-up exercise (20 minutes)

Ask the participants to read the sample conversation (page 31) to themselves, and to answer the questions at the end. Discuss the answers to each question with the group. (There are suggested answers at the end of this guide).

13. “APAC” role-play (60 minutes)

If the participants are sufficiently at ease in the group, you can ask one pair of participants to perform the “APAC” role-play in front of the group. Limit each role-play to 10 minutes, with an additional 10 minutes of discussion. (If the members of the group are shy, the role-play should be performed with the participants in pairs, as they were when using the Mother’s Card). Point out that this is not a complete consultation, but rather the “treatment” part of plan A. The health worker has already assessed the child, and must now advise the mother. After conducting the role-play, participants should evaluate themselves, noting whether they were able to follow the “APAC” procedure, what went well, what was difficult, and what improvements they feel they could make in their method of advising mothers.

Hint: If you ask the participants to perform the role-play in front of the group, it may be useful if you provide each pair with a written situation. In this case, you need to prepare these situations in advance. Some sample situations are included at the end of these guidelines.

Key points: Learning the steps and the skills is a necessary base, but they must be practised in order to be well applied. Participants may wish to discuss the various opportunities they have to use this system, for instance while taking the medical history of the child, or while the mother is giving the child ORS in an ORT corner.

14. Practice in a real situation

Note: If these exercises are carried out as part of clinical management training, practice in a real situation should take place during regular clinical practice sessions.

If the exercises are carried out separately, at least one-half day will be needed for practice. Arrange for the participants to spend several hours at a nearby health facility, where they can advise mothers with sick children. It can be either an outpatient or inpatient facility, provided that there are children with diarrhoea whose mothers can be advised. It is best to have cases without dehydration. After the practice session, hold a discussion with participants to allow them to evaluate themselves as they did after the role-play.

15. Optional section: Refer the mother to a small group session (can be carried out concurrently with the practice (above), if there are too few patients for all participants to be practising at once, and if there is a room near where the practice will be carried out).

Ask the participants to read to themselves “Refer the mother to a small group session if necessary” (pages 36-37). Discuss how to decide which mothers to refer to small group sessions, and how these sessions are (or could be in the future) organized in local health facilities.

Key points: Small group sessions should be used to teach or review specific subjects that mothers with sick children need to learn, but that cannot be covered during the individual consultation. Because they permit the mothers to participate, the sessions differ from the large group lectures often held during pre-clinic waiting time, or during community meetings.

Each small group session should cover only one subject, for instance ORS preparation, or home fluid preparation; questions and discussion should be encouraged. The following section gives an idea of how to conduct a session on ORS preparation.

16. Leading a demonstration. (This can also be done concurrently with the practice. Allow 20 minutes per demonstration - 10 minutes for demonstration and 10 minutes for discussion.)

This session requires some preparation. Before you begin, have on hand everything you will need for an ORS demonstration: ORS packets (at least one per participant); local containers for measuring water; large bowl and spoon for mixing; small cups and spoons for tasting and/or for giving ORS to children; scissors for opening ORS packets; soap, towel, and basin for washing hands; clean water. Seat the participants in a semicircle.

Ask participants to read “Leading a demonstration”. Read aloud the listed qualities of a good demonstration. Ask the participants if there are other qualities that they think should be added to the list.

Conduct a demonstration of ORS preparation as though you were the health worker, and the participants mothers in an ORT corner. Ask the participants to evaluate your demonstration, in accordance with the listed qualities of a good demonstration. As many participants as possible in the time available should then practise conducting a demonstration.

Suggested answers to exercises

Exercise: Praise and encourage helpful behaviours
1.	The mother says, “Yes, my child is drinking. I give him two spoonfuls of ORS, three times each day.”
	What has this mother done that is helpful? What could you say to praise and encourage her?
	The mother has used ORS. You could say, “It is good that you have tried using ORS, and you should keep doing this.”
2.	The mother says, “I offer food to my child, but she doesn’t want anything but breastmilk.”
	What has this mother done that is helpful? What could you say to praise and encourage her?
	The mother has been breastfeeding her child, and has tried to get her child to eat. You could say, “Good. Keep breastfeeding; that will help your child. I know it may be difficult to get her to eat, but as you know, food is important, so keep offering her little bits of food at a time.”
3.	The mother says, “I have given my child two of the pills that the pharmacist sold to me.”
	What has this mother done that is helpful? What could you say to praise and encourage her?
	In this situation, the mother has not done anything that is helpful. However, she has shown concern for her child, and she has come to you for help. You could say, “I am glad you have come to me for help. It is good that you are concerned and want to do something to help your child get well.”
4.	The mother says, “My child hasn’t taken any medications or other treatments.”
	What has this mother done that is helpful? What could you say to praise and encourage her?
The mother has given no inappropriate medications, nor any treatments which may be harmful to her child. You could say, “You have done well by bringing your child to me before giving any medicines or treatments.”
Exercise: Advise the mother what else to do
1.	The mother says, “Yes, my child is drinking. I give him two spoonfuls of ORS, three times each day.”
	(a)	Has the mother done anything that is harmful, or not helpful? What?
		Yes. She has given her child too little ORS to be effective.
	(b)	How would you advise this mother on what she is doing?
		You could say, “It is good that you have used ORS to treat you child. But the amount of ORS you have given to your child is not enough. In order for the ORS to help your child, you need to give him as much as he can drink. Try to give him about half a cupful each time he has diarrhoea.”
	(c)	What else do you need to advise her about giving fluids?
		You should tell her that she can also give her child other things to drink, such as fruit juice or water (or other fluids available in her area).
2.	The mother says, “I offer my child food, but she doesn’t want anything but breastmilk.”
	(a)	Has the mother done anything that is harmful, or not helpful? What?
		She seems to have accepted her child’s lack of appetite, and has not encouraged him to eat.
	(b)	How would you advise this mother on what she is doing?
		You could say, “It is very good that you are breastfeeding, and that you offer food to your child. He needs to eat to stay strong during the diarrhoea. If he at first refuses food, don’t force him, but don’t give up. Try to encourage him to eat little bits at a time.”
	(c)	What else do you need to advise her about giving her child food?
		You could tell her that it is very important for the child to eat, and that foods that are soft and mashed may be easier for the child to eat. She should offer him small amounts of food several times a day.
3.	The mother says, “I have given my child two of the pills that the pharmacist sold to me.”
	(a)	Has the mother done anything that is harmful, or not helpful? What?
		Yes, she has given her child medicine that is probably not needed. Also, she has given it without consulting a health worker first.
	(b)	How would you advise this mother on what she is doing?
		You could tell her, “It is good that you brought your child in for treatment. You see, for most diarrhoea, medicine like the one you bought is not needed and will not be helpful. It should be used only for diarrhoea with blood in it. If this ever happens, come to see me or someone else here at the clinic and we can discuss what is the best medication.”
	(c)	What other advice do you need to give her on using medications?
		In most cases of diarrhoea, medications are not needed. The best thing the mother can do is to keep encouraging the child to eat and to drink.
4.	The mother says, “My child hasn’t taken any medications or other treatments.”
	(a)	Has the mother done anything that is harmful, or not helpful? What?
		In this case, the mother has not done anything harmful.
	(b) and (c) are not necessary in this case.

Exercise: Checking questions

First checking question	Mother’s response	Follow-on checking question
What will you do for the child’s diarrhoea when you get home?	I will give him something to drink.	What will you give him to drink? How much will you give him? How often will you give it to him?
What will you give your child to eat?	Soft, mashed foods.	Which foods will you give him? How can you encourage him to eat? How often will you give him food?
How will you make the ORS solution at home?	I will mix the packet with water.	How much of the packet will you use? How much water will you use? How will you measure the water?
How much ORS or other drinks will you give to your child?	One small cup.	How often will you give him one small cup? What will you do if he wants more?
How will you know if your child needs to come back to the health centre?	If he’s not getting better.	How will you know he’s not getting better? What other signs can you look for?

Exercise: Sample conversation

Did the health worker follow the process: “Ask-Praise-Advise-Check”?

Yes, he followed the process. Even though he did not “Check eating and drinking” before moving on to questions about other medications and treatments, he asked all the necessary questions, praised, encouraged, and checked the mother’s understanding.

Give an example of how he praised and encouraged the mother to continue to do something that she had been doing.

After the mother answered the questions about the child’s drinking, the health worker said, “It is very good that you give him water and rice water.”

Give an example of an open question that he asked to check the mother’s understanding.

He asked the mother, “How much should he drink?”

Why did he refer the mother to a group session?

Because she needed to learn and practice how to mix ORS solution. (Note: he should have verified whether she already knew how to mix ORS before he referred her to a group session).

In general, did the health worker advise the mother correctly? Why or why not?

Yes, this health worker did a very good job in advising the mother.

Sample situations for APAC role-play

Mother 1:	Your little girl is nine months old and has had diarrhoea for two days. You have tried to feed her some rice but she doesn’t want anything but breastmilk. Your mother-in-law says your breastmilk must be spoiled, and she thinks you should stop breastfeeding for a few days. You have not used ORS or any recommended home fluid.
Health worker 1:	This girl is nine months old. She has had simple diarrhoea for two days and shows no signs of dehydration.
Mother 2:	Your boy is seven months old. He has had diarrhoea for three days. You went to the drug seller and bought some pills that she told you would stop the diarrhoea, but even though you have given him two of them the diarrhoea has not stopped. The child drinks well (he likes rice water) but he is eating very little, although you have been trying. You live a long way from the health centre.
Health worker 2:	This boy is seven months old. He has had diarrhoea for three days but he is not dehydrated. The mother lives a long way from the health centre.
Mother 3:	Your child is one year old. Because you are pregnant, you have stopped breastfeeding, and because the girl has had diarrhoea for three days you decided yesterday to stop giving her food, to let her stomach rest. But the diarrhoea has not stopped. You have heard of ORS, but you are not sure how to use it or what it is for.
Health worker 3:	This child is one year old and has had diarrhoea for three days. She shows no signs of dehydration. The mother is pregnant.