(introduction...)

Now that you have practised the three basic skills, you can learn and practise the steps needed to advise mothers well. Some of the basic skills will be repeated in the various steps; some skills will be new.

Step 1: Ask the questions

The process for advising mothers is based on a series of simple key questions. These key questions, found in the following table, concern the main activities of home case management: increasing fluids, continued feeding, and appropriate use of medication. The things you praise and encourage, and the specific advice you give to each mother, will depend on the information you learn from her by asking these questions.

Home care activity	Key Questions
Increase fluids	Has the child been drinking? How much? or Why not?
Continue feeding/breastfeeding	Has the child been eating? What? or Why not?
Appropriate use of medication	Has the child taken other medication or treatments?

You will need to ask the mother both open and closed questions to get the required information. Sometimes it is useful to combine open and closed questions, that is, to ask for the information in two parts. The first part should be a closed question, to orient you to how the child has been treated at home. This can be followed by an open question to help you get more information. In the following exercise, you will find a series of questions that you can use. Each question is first presented as a closed question. It is followed by a "Yes" or "No" answer; there is then a space for a follow-on open question to help you to obtain more information. As an example, the first question has been filled out. Read it, then complete the other questions.

Exercise

Closed question	Mother's answer	Follow-on, open questions
Has your child been drinking?	Yes	What has he had to drink? More, less, or the same amount as usual?
Has your child been drinking?	No	What seems to be the problem?
Has your child been eating? or breastfeeding?	Yes
Has your child been eating? or breastfeeding?	No
Has your child taken any medication or other treatment for the diarrhoea?	Yes
Has your child taken any medication or other treatment for the diarrhoea?	No	(No follow-on questions needed)

Suggested answers to exercise

Closed question	Mother's answer	Follow-on, open questions
Has your child been drinking?	Yes	What has he had to drink? More, less, or the same amount as usual?
Has your child been drinking?	No	What seems to be the problem?
Has your child been eating? or breastfeeding?	Yes	What kinds of foods has he been eating? Does he eat (or breastfeed) more, or less than usual, or about the same?
Has your child been eating? or breastfeeding?	No	Why do you think not?
Has your child taken any medication or other treatments for the diarrhoea?	Yes	What kinds of medication or treatment has he taken? Who advised you to give these treatments?
Has your child taken any medication or other treatments for the diarrhoea?	No	(No follow-on questions needed)

Step 2: Praise and encourage helpful behaviours

People respond well to praise. Every mother that brings her child in for care has done something right, even if it is only to have brought the child to the health facility. Knowing that she is doing something right will motivate the mother to keep on doing it. The mother will also feel that you show respect for her, and she will be more likely to listen to your advice about things she could do better.

Sometimes only part of what the mother is doing is correct. In that case, you should try to praise that part. For example, perhaps the mother offers food to her child, but does not mash it first. You could say, "It is good that you try to get your child to eat while he is ill". Sometimes the mother has not done anything very helpful. In this case, you may just praise her for being concerned about her child.

Listen to the answers a mother gives to your questions, decide what she has done for her child that is helpful, then praise her for doing it, and encourage her to continue.

Exercise

In this exercise you will be given some of the common answers that mothers give when asked about the fluids, food, and medication that they have given to the child. For each case, first decide what the mother has done that is helpful and should be praised. Perhaps the mother has done nothing helpful, in which case you may need to praise some action that is simply not harmful. State the praise you would give, in simple language.

When you have finished, there will be a group discussion of the possible answers to each situation.

In each example the child is about 8 months old and has no signs of dehydration.

Example

The mother says, "My child vomits everything he tries to drink, so I have stopped giving him anything".

What has this mother done that is helpful? What could you say to praise and encourage her?

The mother has given her child liquids to drink. You could say, "It is good that you have been offering your child things to drink".

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?
2.	The mother says, "I offer my child food, 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?
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?
4.	The mother says, "My child hasn't taken any medication or other treatment."
	What has this mother done that is helpful? What could you say to praise and encourage her?

Step 3: Advise the mother what else to do

In Step 2, you learned how to find out what the mother was doing that was correct, and to praise and encourage her for it. But it is unlikely that the mother has done everything exactly as she should have done, and she will need to be advised about what else she should do. For example, to the mother who gives her child food, but who does not mash it you may say, "He will probably find it easier to eat if you try giving him soft, mashed foods. He may also be more willing to eat small amounts at a time, but several times a day".

The mother may even be doing some things that are harmful. In this case, you must carefully advise against this behaviour, and suggest something else in its place. For example, a mother may be giving the child some antibiotics she bought in the market-place. You could tell her, "Your child does not need these medicines right now, and they will not help him. The kind of diarrhoea he has will stop in just a few days. The most important thing is to keep helping him to eat and drink so he will stay strong."

It is important that this step be carried out carefully, that is, in a way that shows respect for the mother rather than making her feel that she has done something very wrong.

In the previous exercise you were asked to find out what a mother did correctly in each of four common situations. In the following exercise, look at the same situations, and:

Listen to the mother's answer.

Decide if she has done something harmful (or not helpful);

Say how you would carefully advise her against that;

Say what else you need to advise her. (Limit your answer to drinking, eating, or medication, according to each situation).

Remember to use simple language.

Exercise

For this exercise, work in a pair with another person in your group. Discuss and write answers to the questions for all four of the situations. When everyone has completed the exercise, each pair of volunteers will present to the group their suggestion of how these situations may be carried out. Each pair should demonstrate one situation.

As in the previous exercise, each child is about 8 months old and has no signs of dehydration.

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?
(b) How would you advise this mother on what she is doing?
(c) What else do you need to advise her about giving fluids?

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?
(b) How would you advise this mother on what she is doing?
(c) What else do you need to advise her about giving her child food?

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?
(b) How would you advise this mother on what she has done?
(c) What else do you need to advise her about using medication?

4. The mother says, "My child hasn't taken any medication or other treatment."

(a) Has the mother done anything that is harmful, or not helpful? What?
(b) How would you advise this mother on what she has done?
(c) What else do you need to advise her about using medication?

Advising about danger signs

Mothers need to know what signs to watch for in their children, to decide whether the child needs medical care. Since understanding and recognizing dehydration may be difficult, the CDD programme suggests a few simple signs that most mothers can recognize easily. These are:

If the child cannot eat or drink;
If the child is very thirsty;
If the child passes many watery stools;
If the child is vomiting;
If the child has a fever;
If there is blood in the child's stools;
If the child is not getting better.

It will be very important to make sure that the mother understands these signs and can remember them. The Mother's Card that you will learn to use later in this session will help both you and the mother to remember the essential signs.

Step 4: Check the mother's understanding

You have now learned how to:

Ask questions to find out what a mother has done for her child,

Praise and encourage her current correct practices, and

Advise her what else she needs to do (includes: correct harmful practices).

But how can you be certain that the mother has understood and can remember your advice?

Many health workers try to do this by asking the mother, "Do you understand?" Most mothers probably answer this question with "Yes," thinking they have in fact understood what was said. Unfortunately, you cannot judge from this answer exactly what the mother has understood.

The way to help you do this is to ask checking questions. Think about the exercise earlier in this session, where you changed closed (Yes/No) questions into open ones. A good checking question is an open question, phrased so that the mother must answer more than just "Yes" or "No". For instance, if you have just explained how to prepare ORS solution, you might ask the mother, "How will you prepare the ORS solution at home?"

However, sometimes you may get an incomplete answer to a checking question, even if the question is open. Then you will need to ask a follow-on checking question to see if the mother has really understood what has been taught. For example, if the mother answers, "I will mix the packet in water", you could ask, "How much water will you use? How will you measure it?"

Exercise

This exercise is to be done in the form of a drill.

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 your child to eat?	Soft, mashed foods.
How will you make the ORS solution at home?	I will mix the contents of the packet with water.
How much ORS or other drinks will you give to your child?	One small cup.
How will you know if your child needs to come back to the health centre?	If he's not getting better.