Advising Mothers on Management of Diarrhoea in the Home - A Guide for Health Workers (WHO, 1993, 18 p.): Review of information using the Mother's Card

Advising Mothers on Management of Diarrhoea in the Home - A Guide for Health Workers (WHO, 1993, 18 p.)

		(introduction...)
		Introduction
		Basic skills
		Information summary sheet (blank)
		Practising the steps
		Review of information using the Mother's Card
		Review of the steps
		Summing-up exercise
		(Optional): Refer the mother to a small group session if necessary
		Leading a demonstration

(introduction...)

CDD/93.1
Original: English

Introduction

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 you as 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 you advise 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 you assess and treat a child with diarrhoea at a health facility, there is a systematic approach which allows you to follow the same process each time: "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 your part.

The purpose of this guide is to help you to improve this activity, by teaching a process which will allow you correctly and effectively to advise mothers on home case management. The process should also make it easier for mothers to remember the advice you give. The guide is to be used during a case management training course, or by health workers already trained in case management.

This guide includes two sample elements. The first is a suggested process to follow when advising mothers; the second is a visual aid (a pictorial Mother's Card) that you can use. These have both been adapted by your national CDD programme for use in your country.

Suggested process for advising mothers

This process will help you do several things. First, it will help you to limit what you tell the mother. In the short time you usually have with a mother, it may not be possible or realistic to give a great deal of information, nor can you expect her to reach a deep understanding. However, it should be possible in a limited time to convey the essential messages, and to make sure that the mother understands them and can carry them out.

Second, it will help you to structure the conversation. For each main point, the structure follows a series of steps:

Ask the question(s);
Praise and Encourage the mother's helpful practices;
Advise the mother what to do (and why);
Check her understanding.

There may also be cases where you will need to:

Refer her to a group session.

Third, the process will help you to focus on what the mother already does and knows. It gives you a way to praise and encourage what she does correctly, and to help correct what she does wrong.

An outline of the conversation between you and the mother would look something like this:

ASK - PRAISE - ADVISE - CHECK

(A P A C)

Ask about drinking
Praise and encourage the mother
Advise

Ask about eating
Praise and encourage the mother
Advise

Check the mother understands about eating and drinking

Ask about medication/treatments
Praise and encourage the mother
Advise

Advise the mother on signs to watch for

Check and review all advice using the Mother's Card

(Refer the mother to a small group session if necessary)

Review of the steps

Step 1: Ask the question(s).

Ask each question in two parts: the first part will orient you to how the child has been treated (e.g. "Has your child been drinking?"); the second part will help you get more information ("What has he been drinking? More, less, or the same amount as usual?" - or - "Why not?").

Step 2: Praise and Encourage the mother's helpful practices.

It is likely that the mother is doing some very good things for the child's diarrhoea (e.g., giving the child plenty of liquids to drink). If this is the case, praise the mother, and encourage her to keep doing these things.

Step 3: Advise the mother what else to do.

Even if the mother does some things correctly in treating her child's diarrhoea, she probably does not do everything right. She may also want (or need) to be told why some things are necessary. Use simple language and words that the mother will understand.

Step 4: Check her understanding.

This step will allow you to see exactly what the mother has understood from your advice, so you can complete the information or correct any misunderstandings. Use open questions, and let the mother explain in her own words; use the Mother's Card to review information.

(Optional): Refer her to a small group session in which she can learn how to prepare ORS, or arrange for her to have a review of the rules of case management in the home, if you feel this is necessary.

Skills you will need

In order to advise mothers well, you will need to be able to:

Remember the rules of case management in the home.
Use simple language.
Ask questions.
Find and encourage helpful behaviours (and advise against those that are harmful).
Give realistic advice.
Use the Mother's Card effectively.
Decide if the mother needs to be referred to a group session.

Depending on the organization of the facility where you work, and the time you have available, you may also need to be able to:

Conduct a small group session.

Important:
If the child needs treatment, make sure the treatment is given first,
then advise the mother.

It may be difficult to give careful and correct advice when there are many clients waiting, and when you feel as if you are simply saying the same thing to mothers over and over, every day. Remember, though, that the mother may never have heard this advice before. Even if she has, she has come to the health facility probably because she needs help in remembering the advice.

There are three points you must always observe:

Treat the mother(s) with respect.
Give advice that is realistic.
Be patient.

Basic skills

Several of the skills you will need are common to each of the steps; they may even be useful to you in your other work as well. They are:

Remember the rules of case management in the home.
Use simple language.
Ask questions.

Before learning the steps to good advising, you will first have the chance to learn and practise these skills.

Basic skill: Remember the rules of case management in the home

These case management rules are the basis for all information needed to advise mothers about caring for a child with diarrhoea. They are the basis of the rest of the exercises on communication.

List here the three rules of case management in the home. (State them as your national programme states them. This information should come from your national CDD programme policy):

1.
2.
3.

The correct advice about using antidiarrhoeal preparations and antibiotics for child diarrhoea is:

If there is any part of the above information about which you are unsure or unclear, please review Case Management in the Home before continuing.

The following page suggests a way in which adapted information may be summarized and presented. The information to fill in the boxes may come from national CDD programme policy, from research done in all or in parts of your country, or from your knowledge of the area in which you live and work. Your national programme may already have completed such a summary sheet with the information available.

Information summary sheet (blank)

Drinks to recommend in your area

Foods to recommend in your area

Names for diarrhoea	How each is treated now ( for harmful treatments)**	What to suggest in place of harmful treatments


Other related illnesses	How each is treated now ( for harmful treatments)**	What to suggest in place of harmful treatments

Other harmful practices to advise against:

How to advise against; what to suggest in its place:

Basic skill: Use simple language

One very important skill which will help you when you are advising mothers is to use clear and simple language.

Health workers learn about diseases and treatments using very technical or scientific terms. When these terms become familiar, it is easy to forget that people who are not health workers may not understand them. It is also easy to forget that there may be other, simpler ways of saying things. For these reasons, health workers often use technical terms which mothers do not understand, or they give instructions that mothers cannot follow. For example, a health worker may advise the mother to prepare rice water using 50 grams of rice. If the mother does not know what "grams" are, or if she does not have a way of measuring the rice, she may not know what to do. It would be clearer to tell her to use "one open handful" of rice.

Short-answer exercise

In this exercise you will practise changing several difficult sentences into simple, everyday language. You will need to decide which of the terms used in the sentence may be difficult for a mother to understand, and then replace them with a more common expression. Some suggested answers can be found on the page following the exercise.

Example:	"Diarrhoea can lead to dehydration, so you must give your child greater quantities of fluids than usual."

Simplification:	"Diarrhoea can make your child lose a lot of water from his body, and he may become dry and weak, so you should give him more to drink than usual."

Explanation:	The words "dehydration", "greater quantities", and "fluids" may not be familiar to the mother. It is simpler to say "lose water" (or "become dry"), and "more to drink".

For each of the following sentences, write the same thing in a simpler way.

1.	"Mix the contents of this ORS packet with 1 000 ml of water and give your child 200 ml each time she has loose motions."

	Simplification:

2.	"After the diarrhoea episode, your child needs increased nutrition."

	Simplification:

3.	"Antidiarrhoeal preparations seem to stop the symptoms of diarrhoea but do not prevent dehydration, so they should never be used for children."

	Simplification:

4.	"Bring your child to the health centre if he is in danger of becoming dehydrated."

	Simplification:

(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.

Review of information using the Mother's Card

The CDD programme has developed a two-sided visual aid (a pictorial Mother's Card) to help health workers to teach home case management to mothers, and for mothers to take home when they leave the health facility. This card can be useful in several ways:

It reminds you of the main points to cover when advising a mother how to care for her child with diarrhoea at home.
It helps the mother understand these points, so she will remember what to do for her child when she gets home.
It helps her remember what to do the next time her child has diarrhoea.
The mother may show the card to other family members, or to neighbours, so more people will learn the messages it contains.

The Mother's Card should be used at the end of a session with a mother, to help review what she should do at home. Here are a few techniques that will help you to use the material effectively:

1.	Hold the card so that the mother can easily see the pictures, or allow the mother to hold it herself.

2.	Explain each picture to the mother. This will allow her to look at the pictures while listening to the message.

3.	Point to the picture (not to the text) as you talk. This will help the mother to remember what the pictures represent.

4.	Observe the mother to see if she looks puzzled or worried. If she does, encourage her to ask questions.

5.	Ask the mother to tell you in her own words what she should do at home, using the card to help her remember.

6.	Give the card to the mother to take home with her. Suggest that she also show it to others in her family or her community.

Exercise

With a partner from your group, practise using the Mother's Card included with this guide, or the Mother's Card developed by your national CDD programme. Sit next to your partner or facing her, as you would a mother in your health facility. Use all the techniques described above.

Review of the steps

Step 1: Ask the question(s).

The first part of each key questions is:

Has the child been drinking?
Has the child been eating?
Has the child taken any medication or other treatments?

Step 2: Praise and Encourage the mother's helpful practices.

Step 3: Advise the mother what else to do.

Even if the mother does some things correctly in treating her child's diarrhoea, she probably does not do everything right. She may also want (or need) to be told why some things are necessary. Or, she may be doing harmful things. Advise against the behaviour, and suggest something else in its place. Use simple language and words that the mother will understand.

Step 4: Check her understanding.

(Optional): Refer her to a small group session in which she can learn how to prepare ORS, or arrange for her to have a review of the rules of case management in the home, if you feel this is necessary.

Now that you have learned and reviewed all the steps, try to complete the following outline:

A ____ P ____ A ____ C

Ask about __________
__________ and encourage the mother
Advise

Ask about __________
Praise and __________ the mother
__________
__________ _____ __________ __________ eating and drinking

Ask about __________ __________
__________ _____ __________ the mother
Advise

Advise the mother on __________ ___ __________ __________

__________ and review all advice using __________ ______

(__________ the mother to a _____ _____ if necessary)

Summing-up exercise

Sample conversation

Let us look at an example of a conversation that may happen between a health worker and a mother. In this example, the health worker has already examined the child, named Sami, and has found that he has mild diarrhoea and is not dehydrated. Sami is 9 months old, and is still breastfeeding.

Please read the conversation and answer the questions at the end.

Health worker	Has Sami been drinking anything?

Mother	Yes.

Health worker	What has he had to drink?

Mother	Some water, rice water, and a little guava-leaf tea.

Health worker	In general, has he been drinking more than usual, less than usual, or about the same amount?

Mother	About the same amount.

Health worker	It is very good that you give him water and rice water. With the diarrhoea, what do you notice about Sami's stools? They are very watery, no? This means he is losing water, and drinking will help replace this so he will not dry up and get weak. You should continue to encourage him to drink, maybe even a bit more than usual.

	Now, has he been eating, or breastfeeding?

Mother	He hasn't eaten anything, only breastmilk.

Health worker	What seems to be the problem?

Mother	He isn't hungry.

Health worker	Yes, this often seems so. It is good that you are still breastfeeding him, and you should keep on doing that. But it is important that Sami eats, to stay strong. What could you give him, in addition to the breast?

Mother	Rice.

Health worker	Rice is very good. Maybe you could try mixing the rice with some mashed vegetable, and a little oil. If you make the food very soft, it will be easier for Sami to take. Try to get him to eat a little bit at a time, several times a day. Be patient in encouraging him to eat; he will need the food to stay strong.

	Has he taken any medicine, or other treatments?

Mother	No.

Health worker	That is fine. Sami will be well in a few days if you give him plenty to drink, and help him to eat to stay strong.

	Here is how you will know if he needs medical care:

	If he cannot eat or drink, or
	If he is very thirsty;
	If he has many watery stools, or
	If he is vomiting a lot, or
	If he has a fever, or
	If there is blood in his stools

	If you notice any of these things, continue to give Sami food and drink if you can, and bring him back to see me.

	Let me give you this card to help you remember what to do:

(Health worker reviews the rules for home care by going over the pictures on the Mother's Card).

Health worker	Now, can you please tell me what to do for Sami at home?

Mother	I will help him to eat and drink.

Health worker	Anything else?

Mother	And breastfeed.

Health worker	How much should he drink?

Mother	He should drink more than usual.

Health worker	Right. How can you encourage him to eat?

Mother	I will make soft, mashed food, and try giving him little bits at a time.

Health worker	Good. And what would tell you if you needed to come back here?

Mother	I will watch to see if he has a fever or if there is blood in his stools.

Health worker	Good, but also watch to see if he is very thirsty, if he can't eat or drink, if he vomits frequently, or if he has a lot of watery diarrhoea.

	Since you live quite far from here, I'll give you two packets of this medicine to take home and give to Sami. It must be mixed carefully with 1 litre of water. Please stay for a few minutes to attend the group talk in the next room so you can remember exactly how to mix and give it.

Now answer these questions about the example above:

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

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

Give an example of an open question he asked to check the mother's understanding.
Why did he refer the mother to a group session?

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

Exercise: Role-play

In a pair with another participant, you will now have the opportunity to practise all the skills you have learned about Advising Mothers. One participant will play the role of a health worker, while the other plays the role of a mother. Use the example you have just read as a model to follow. Remember to follow the process: "Ask-Praise-Advise-Check". Use the pictorial Mother's Card.

Note about the role-play:

This is not a complete consultation. In this situation you, the health worker, have already greeted the mother, and you have examined and treated the child. The child is 7 months old and has no signs of dehydration. You must now advise the mother.

When the role-play is finished, switch roles with your partner and repeat the exercise.

When each person has had the chance to play both roles, answer the following questions in a discussion with your group:

What went well in your situation?
What was difficult to do?
What improvements could you make in your method of advising mothers?

Practice in a real situation

Now you will have the chance to try this in a real situation. The director of the training course has arranged for you to practise advising mothers, either at a nearby health facility, or with mothers who will come to the training site. After you practise, you will meet again in your group and discuss the questions listed above.

(Optional): Refer the mother to a small group session if necessary

The four steps for advising a mother, Ask-Praise-Advise-Check, cover all the essential information that most mothers will need to learn. However, there will be other important things that you may not have time to teach during an individual consultation. It is likely, for example, that some mothers will need to learn how to prepare ORS, and that others will need an additional review of the rules of case management in the home. It would probably be most useful to you, and to the mothers, to teach and discuss these subjects in a small group session.

For this you will need to be able to do three things: decide which mothers need to be referred, organize small group sessions at your facility, and carry out the sessions. It is important to note here that advice on preventing diarrhoea is also best presented in group sessions, although a mother whose child is ill is likely to be more interested in learning how to care for that child than how to prevent the diarrhoea from happening again. Sessions on prevention should be organized as regular events at your health facility or in the community.

Deciding which mothers to refer

Mentioned above are several topics which could be taught in group sessions on diarrhoea. To decide if a mother should attend a group session, think about:

1. What she needs to do for her child at home, in addition to what you have already discussed with her.
2. What she needs to learn or review in order to be able to do this, and
3. How much time you have for the individual consultation.

If you find the mother needs additional information, review, or practice, you should refer her to a group session.

Organizing small group sessions in your facility

To organize small group sessions in your facility, you will need to decide:

At what days and times should the sessions be scheduled? (Every day, or on certain days only? Should the sessions be held during or after clinic hours? Is it more realistic to ask mothers to wait at the health centre until all consultations are finished, or to come back on another day?)

What kind of space is available in your health facility where group sessions can take place? ORT corners are usually the best place for small group sessions.
What topics should be covered? Some suggestions are: ORS preparation, home fluid preparation, feeding, and a review of the three rules of home care of diarrhoea.
Who in your facility can conduct the group sessions?

Hints for conducting a group session

Much of what you have already learned about advising mothers individually also applies to group counselling. In addition to these skills, you should:

Choose an appropriate time to present an idea. For example, talk about ORS preparation or about the rules of home care when mothers whose children have diarrhoea are present. You can talk about prevention at another time.
Limit the session to one main idea or message.
Seat people comfortably, and try to sit among them.
Ask questions to get the group involved in a discussion based on their own experiences.
Present an idea through a real situation, such as a demonstration, whenever possible.

Leading a demonstration

Demonstrations are an effective way of helping someone to learn a skill and to remember the message.

Demonstrations are based on the principle:

What I hear, I forget;
What I see, I remember;
What I do, I know.

Demonstrations should be simple and include only the necessary details. They must be given with the participation of the audience and with local, familiar utensils.

Here are some important qualities of a good demonstration:

1. The technical content is correct.
2. The actions are clear, visible, and coordinated with the words.
3. The tasks are easy to understand.
4. The language and words are simple.
5. The actions follow in a logical order.
6. Group discussion and questions are encouraged.
7. Checking questions are asked during the demonstration and at the end.
8. At least one group member repeats the demonstration (if time permits).
9. The main points are summarized at the end.

Exercise

In this exercise you will watch a model demonstration of ORS preparation. After the demonstration, there will be a group discussion on how the demonstration was conducted. Discuss whether each of the nine qualities (listed above) was included. Then, as many of the participants as possible should practise conducting a demonstration.

ASK - PRAISE - ADVISE - CHECK
(A P A C)

Ask about drinking
Praise and encourage the mother
Advise

Ask about eating
Praise and encourage the mother
Advise

Check that the mother understands eating and drinking

Ask about medication/treatments
Praise and encourage the mother
Advise

Advise the mother on signs to watch for

Check and review all advice using the Mother's Card

(Refer the mother to a small group session if necessary)

Closed:	"Do you have a 1-litre container at home to measure water for mixing ORS?"

Open:	"What containers do you have at home to measure water for mixing ORS?"

1.	Closed:	"Will you feed your child when you get home?"

	Open:

2.	Closed:	"Do you know when to bring your child back?"

	Open:

3.	Closed:	"Do you understand what you should do at home now?"

	Open:

1.	"What kinds of foods will you feed your child when you get home?" or,
	"How will you encourage your child to eat when you get home?"

2.	"When will you bring your child back?"

3.	"What will you do for your child at home now?"

1.	"Mix the contents of this ORS packet with three soft-drink bottles of water and give your child a small cupful every time she has diarrhoea."

2.	"After the diarrhoea is over, your child needs to eat more than usual."

3.	"Some medicines will make it look like the diarrhoea has stopped, but they do not make the baby well. They should not be used for children."

4.	"Bring your child to the health centre if he has difficulty eating or drinking, if he has many watery stools, if he is vomiting, has a fever, or has blood in his stools."