Integrating Nutrition Into HIV/AIDS Care and Support Programs · 2019-12-17 · Integrating...

Integrating Nutrition Into HIV/AIDS Care and Support Programs

Training References for Trainers of Community Volunteers

Integrating Nutrition into Community HIV /AIDS Care and Support Programs

A Trainers Manual for Training Community Volunteers,

Integrating Nutrition into Community HIV /AIDS Care and Support Programs

A Trainers Manual for Training Community Volunteers,

Financial support for this training manual was provided by USAID, Cooperative Agreement number 617-A-00-08-00006-00. The views expressed in this document do not necessarily reflect those of USAID.

NuLife Project supports the Uganda Ministry of Health and partners to integrate Nutrition in HIV/AIDS Care and Treatment Programs.

NuLife is implemented by University Research Co., LLC, (URC) in collaboration with Save the Children U.S.A. and ACDI/VOCA.

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | i

Table of Contents

Acronyms ii

Topic Outline iv

How To Use This Manual vi

Start-Up Activities: xiii

Volunteering xvii

Effective Communication Skills xix

Theme 1. Basic Nutrition Care And Support For People Living With Hiv/Aids.

Topic 1: Basics Of Community Nutrition 1

Topic 2: The Relationship Between Nutrition And Hiv/Aids 20

Topic 3: Management Of Some Hiv-Related Symptoms And Illnesses 29

Topic 4: Important Behaviors To Improve And Maintain Good Nutrition 37

And Health For Plhiv

Theme 2. Role Of Community In The Care Of MalnuriShed Individuals.

Topic 5 : Dentifying Malnutrition In The Community 43

Topic 6: Treatment And Care For Malnourished Individuals 53

Topic 7: Other Roles Of Community Volunteers And Other Stakeholders 64

Appendix 93

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Acronyms

AFASS Acceptable, Feasible, Affordable, Sustainable and Safe

AIDS Acquired Immune Deficiency Syndrome

AL Adult Learning

ART Antiretroviral Therapy

ARV Antiretroviral

ANC Ante Natal Care

BCC Behavior Change Communication

CBO Community Based Organization

CC Counseling Card

CNP Critical Nutrition Practices

CRS Catholic Relief Services

CV Community Volunteer

ECS Effective Communication Skills (Topic)

EGPAF Elizabeth Glaser Pediatric Aids Foundation

EPI Expanded Program on Immunization

ETC Etcetera

FANTA Food and Nutrition Technical Assistance

FATVAH Frequency, Amount, Thickness, Variety, Active feeding, Hygiene

FBO Faith Based Organisation

F&N Food and Nutrition

FP Family Planning

GATHER Greet, Ask, Tell, Help, Explain, Reassure

GPM Growth Promotion and Monitoring

HCI/MOH-QoC Health Care Improvement / Ministry of Health-Quality of Care

HIV Human Immune Deficiency Virus

HW Health Worker

IMAM Integrated Management of Acute Malnutrition

IYCF Infant and Young Child Feeding

ITC In patient Therapeutic Care

LC1 Local Council 1

LAM Lactation Amenorrhea Method

LBW Low Birth Weight

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Acronyms

MAM Moderate Acute Malnutrition

MUAC Mid Upper Arm Circumference

MOH Ministry of Health

NGO Non-Governmental Organization

OTC Outpatient Therapeutic Care

OVC Orphans and other Vulnerable Children

PHA People living with HIV/AIDS

PLHIV People Living with HIV

PMTCT Prevention of Mother to Child transmission

RUTF Ready to Use Therapeutic Food

S1 Session 1

SAM Severe Acute Malnutrition

SFP Supplementary Feeding Program

SU Start-up Activities (topic)

T1 Topic 1

T13.S3.1 Topic 13, Session 3, Activity 1

TB Tuberculosis

TOT Training of Trainers

UNICEF United Nations Children’s Fund

URC University Research Co. LLC

USAID United States Agency for International Development

V Volunteering (topic)

VCT Voluntary Counseling and Testing

WHO World Health Organization

WFP World Food Program

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TOPICTIME ALLOCATED

(Minutes)

Start-up activitiesSession 1Session 2Session 3Session 4Session 5

155020 1030

Volunteering 30

Effective communication skillsSession 1Session 2Session 3Session 4

6040 4060

BASIC NUTRITION CARE AND SUPPORT PEOPLE LIVING WITH HIV/AIDS.

TOPIC 1: BASICS OF COMMUNITY NUTRITIONSession 1Session 2Session 3Session 4Session 5Session 6Session 7Session 8

15 1550 30 2550253080

TOPIC 2: THE RELATIONSHIP BETWEEN NUTRITION AND HIV/AIDSSession 1Session 2Session 3

25 40 40

TOPIC 3: MANAGEMENT OF SOME HIV RELATED SYMPTOMS AND ILLNESSESIntroductionSession 1Session 2

154040

Topic Outline

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TOPIC 4: IMPORTANT BEHAVIORS TO IMPROVE AND MAINTAIN GOOD NUTRITION AND HEALTH FOR PLHIVSession 1Session 2

5060

TOPIC 5 : IDENTIFYING MALNUTRITION IN THE COMMUNITYSession 1Session 2Session 3Session 4

1530 4060

TOPIC 6: TREATMENT AND CARE FOR MALNOURISHED INDIVIDUALS

Session 1Session 2Session 3Session 4

30401515

TOPIC 7: ROLES OF COMMUNITY VOLUNTEERS IN IMAM

IntroductionSession 1Session 2Session 3Session 4Session 5Session 6Session 7Session 8Session 9Session 10

1535 454530505510

1206015

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“Integrating nutrition into Community HIV/AIDS care and support: A trainer manual for community volunteers” is part of a training package to train community volunteers to help People Living with HIV/AIDS (PLHIV) and caregivers to improve nutrition practices. The manual contains 7 topics, divided in two main themes:

THEME 1: Basic nutrition care and support for PLHIV 6 topics

23 sessions

THEME 2: The role of community in the Care of Malnourished Individuals1 topics10 sessions

The training of community volunteers is four days however, the two themes can be conducted at one or two separate periods depending on programme planning and availability of resource. This modular approach allows for flexibility in scheduling training sessions, and also allows for practice between the teaching segments.

About the ManualThe training manual is accompanied by training references that guides the participants as also serves as a take home reference. The participants should also receive the relevant counselling materials and background information (see training preparation below).

It is important to plan the training ahead of time and prepare all the training materials needed in a training kit. The training kit should have the necessary training aids and demonstration materials organised by topic and session. These kits are available and can be borrowed from partners like NuLife.

Alternatively, the training aids can also be printed or photocopied (see annexes 3 and 5) .Community volunteers are also supposed to receive a bag containing the relevant counselling materials, all the MUAC tapes, and referral cards, a pen, a notebook etc.

Training methodologyThe competence-based participatory training approach used in this guide reflects key principles of behaviour change communication (BCC) with a focus on the promotion of small doable actions, a recognition of the widely accepted theory that adults learn best by reflecting on their own personal experiences.

The approach uses the experiential learning cycle method and prepares participants for hands-on performance of skills. The course employs a variety of low-tech training methods and aids, including the use of MUAC tapes, counselling materials, visual aids, demonstrations, practice, discussions, case studies, group discussion, recall situations, role plays, brainstorms etc. The use of flipchart paper is recommended but not in all sessions. e.g. Not all information brought up during brainstorming sessions should be written down, especially not in the low literate group of community volunteers. Participants act as resource persons for each other, and benefit from community practice.

How to use this Manual

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It is highly recommended that trainers use their creativity while using this manual, e.g. a) organise a visit to a health facility or nearby community to practice how to measure MUAC of clientsb) use two ripe bananas to demonstrate in class how to check for swelling of feet (oedema) etc.

Manual outlineEach theme has topics and each topic has sessions. Each topic has specific learning objectives, and contents showing the sessions and time allocated for each session.

The session objectivesThese should be introduced to the participants at the beginning of each session to stimulate their interest, raise curiosity. It will also enable them appreciate the relevance and importance of the session, link the session to the preceding ones and to the training context.

The session durationThe estimated timing is given for each session considering the participant’s experiences and their profile, very long sessions are avoided.

The training methodsFor each session, the interactive techniques to be used are mentioned.

The required materialsFor each session, the needed materials are mentioned. Examples are markers, flipchart (masking tape and flipchart stands are not mentioned but are indispensable), images, specific counselling materials etc.

The activitiesThese are step-by-step instructions to the trainer in order for him or her to carry out the session. The trainers are asked to use these instructions with creativity, taking into consideration the participants experience and their skills.

The ReferencesThroughout the training manual, codes (e.g. ECS.S1) will be encountered. The codes refer to references which can be found in the Community Volunteers’ Handbook.. They contain information like technical information, instruction sheets, definitions, images, figures, case studies etc.

The codes in the training manual are the same as the ones of the community volunteers’ handbook. They follow the numbering of the topics and the relevant session (and activity), and can be decoded as follows:AL: Adult LearningECS: Effective Communication SkillsSU: Start-up ActivitiesT1: Topic 1S1: Session 1T13.S3.1: Topic 13, Session 3, Activity 1

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The Notes to the Trainer.This is information for the trainer, to equip him or her with additional information in order to be able to answer questions. This information is not intended to be shared with the participants if no additional questions on the session arise.

Training LocationWherever training is planned, a community-based site should be readily available to support the practicum for measuring Mid Upper Arm Circumference (MUAC), for counselling and “reaching-an-agreement” skills with mothers/caregivers on small doable practices. Prepare the practicum site by coordinating with the community before arrival of participants and arranging for space to practice the skills.

The training preparation The training preparation starts as soon as one is selected for conducting the training. Each trainer should:

Refresh his or her knowledge of the training themes;•Review his or her sessions;•Get mentally ready;•Ensure perfection of his or her technical skills for conducting demonstrations;•Ascertain sufficiency of training aids such as flipcharts, masking tape, markers, manila •paper, scissors, images, etc. (see national counselling cards under “training methodology”)Besides the bag for community volunteers, observe a handbook for each participant and:•

Themes 1 & 2: the “Nutrition Care and Support” national counselling cards, sufficient •MUAC tapes and the community–level job aids.

Get some information on the participants. Among others, their experiences, particularly in •training; their profiles etc.Visit the training venue and make all logistical arrangements the day before.•

The co-trainingCo - training is an activity that involves several persons in conducting training. It allows co-trainers to complement each other and to provide required guidance to participants.Training is more interesting, less stressful and more effective when it is conducted by more than one trainer.

If the training is conducted by a team, the team members need to prepare and clarify the following:

Who is responsible for the overall training coordination?•Who is responsible for which theme? •Which of the co-trainers will be responsible for logistics issues that arise?•What does each trainer expect from the others?•

ParticipantsIt’s very important that the choice of participants is done according to the established criteria: community volunteers formerly trained in community mobilization, HIV infection and progress, HIV management with ARVs, support of PLHIV/OVCs and monitoring of activities.

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It is important for the trainers to create and maintain a good training ambiance and relationship with the participants. This includes:

Activities to create a good ambiance (e.g. start-up exercise);•Utilization of humour (e.g. jokes, funny stories, energizers, ice breakers);•Informal activities (e.g. chats with participants during breaks and meals);•Good verbal and non-verbal communication.•

The trainers should be interested in participants’ concerns and contribute to their problem solving.

The trainers’ meetingIn order to ensure the quality of the training and to build a strong and efficient training team, the trainers should support each other mutually, work together and have regular constructive feedbacks. At the end of each day, the trainers should have a meeting to review the daily evaluations and to discuss the course of the day. Participants’ views are taken into consideration and strategies for the coming day are defined.

Examples of Energizers The following are descriptions of several review energizers that trainers can select from at the end of each session to reinforce knowledge and skills acquired.

• Participants and trainers form a circle. One trainer has a ball which he or she throws to one participant. The trainer asks a question to the participant who catches the ball who responds. When the participant has answered correctly to the satisfaction of the group, that participant throws the ball to another participant. The participant who throws the ball asks a new question, the participant who catches the ball answers it.

• Form two rows facing each other, each row represents a team. A participant from one team/row asks a question to a participant opposite him in the facing team/row. That participant can seek the help of his or her team in responding to the question. When the question is answered correctly, the responding team earns a point and then asks a question of the other team. If the question is not answered correctly, the team that asked the question responds and earns the point. Questions and answers are proposed back and forth from team to team.

• Form two teams. Each person receives counselling cards and other images. These visual

aids are answers to questions that will be asked by a trainer. When a question is asked, the participant who believes s/he has the correct answer will show her counselling card or visual image. If correct, s/he scores a point for her/his team. The team with the most correct answers wins the game.

• From a basket, a participant selects a counselling card or visual image and is asked

to share the practices/messages which suit the image(s); feedback is given by other participants. The process is repeated for other participants.

• Divide the group into smaller subgroups of about 10 participants. Place a set of

Counselling Cards “face down” on a mat in the middle of the circle. A participant is asked to choose a counselling card and tell the other participants during whom opportunities a community volunteer can share the practices/messages the counselling card represents. Feedback is given by other participants. One trainer is present in each circle to assist in responding.

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Examples of How to Form Small GroupsDepending on the number of participants (for example 20), and the number of groups •to be formed (for example 5), ask participants to count off numbers from 1 to 5. Begin to count in a clockwise direction. On another occasion begin to count counter-clockwise.

Depending on the number of participants (for example 16), and the number of groups •to be formed (for example 4), collect 16 bottle caps (or colored cards) of 4 different colors: 4 of red, 4 of green, 4 of orange, and 4 of black. Ask participants to select a bottle cap. Once selected ask participants to form groups according to the colour selected.

• Sinking ship: ask participants to walk around as if they were on a ship. Announce that

the ship is sinking and life boats are being lowered. The life boats will hold a certain number of participants only. Call out the number of persons the life boats will hold and ask participants to group themselves in the number called-out. Repeat several times and finish with the number of participants you wish each group to contain (for example, 15 participants in groups of 3, the last “life boat” called will be the number 3).

Training assessment and EvaluationAssessment of participants’ knowledge

Participants’ knowledge evaluation is done at two different times:

1. In the beginning of the training, called the pre-assessment. This will give the trainers an idea of the participants’ needs.

2. At the end of the training, called a post-assessment. If individuals are scoring badly on many of the questions, the trainer should take time with those participants, find out what was not captured fully and go through the relevant information again.

3. As the learning objectives of the two first main themes, it is suggested to do a pre-and post-assessment before and after both themes.

4. To keep the evaluation informal and anonymous, a short exercise (20 mins) is proposed during which participants are seated or standing in a circle, facing outwards. Following are instructions to use for the assessment:• Askparticipantstoformacircleandsit/standsothattheirbacksarefacingthecentre.• Explainthatquestionswillbeaskedandaskparticipantstoraiseonehand(withopen

palm) if they think the answer is “True”, to raise one hand (with closed fist) if they think the answer is “False”, and to raise one hand (pointing 2 fingers) if they “Don’t know”.

• Askparticipantstoclosetheireyes.

5. One trainer reads the statement and other trainers record the answers on the pre-assessment guide and notes which topics (if any) present confusion, and in some cases who seemed to have difficulties.

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6. Blank assessment guides can be found in “The participants’ Handbook” and are supposed to be filled out in group after the post-assessment. Assessment guides with correct answers can be found in annex 2.

Daily EvaluationsThe following are descriptions of daily evaluations that trainers can select from at the end of each day (or topic) to assess the knowledge and skills that have been acquired and/or to obtain feedback from participants.

A. Form buzz groups of 3 and ask participants to answer one, two, or all of the following questions in a group*:

What did you learn today that will be useful in your work?•What was something that you liked?•Give a suggestion for improving today’s sessions.•

Ask a participant from each buzz group to respond to the whole group

B. “Happy faces” measuring participants’ moods. Images of the following faces (smiling, neutral, frowning; see Annex 1 for cut out) are placed on a bench or the floor cap on the “face” which best represents their level of satisfaction (satisfied, mildly satisfied and unsatisfied).

If there were many neutral and frowning faces, trainers should ask the group (the next day) what was less satisfying to them, and re-explain any sessions if necessary. If participants feel uncomfortable to be honest about certain issues, they can also write them on a piece of paper and put them in the parking lot.

Training EvaluationIt is useful for the trainers to have a feed-back on the training itself: the trainers’ skills, the methodologies used, the logistics etc. Following exercise can be used to evaluate the training:

1. Ask participants to form buzz groups of 3.2. Explain that their suggestions will be used to improve future trainings.3. Explain that questions will be asked and that each group should discuss among 4. Themselves what they think.5. Have one trainer read the questions below, one by one, allowing groups to share their

comments in the whole group in between. Another trainer records the answers:What did you like about the teaching methods?•What did you dislike about the teaching methods?•How will you use the information provided?•How will you use the MUAC tapes?•How will you use the Counselling Cards?•What did you learn in the practice in the community?•Do you feel ready to counsel PLHIV / caregivers?•What suggestions do you have to improve the training?•Do you have any other comments? Please share.•

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Learning objectivesBy the end of the topic, participants will be able to:

Name fellow participants and trainers•Discuss expectations•Understand the purpose of the training•Obey the ground rules of the training•

Content

Start-up activitiesSession 1Session 2Session 3Session 4Session 5

155020 1030

Duration: 2 hours, 15 mins

Session 1: Participants’ welcome and registration (15 mins)

Activity:GET • to the training venue 30 mins before participants’ arrival in order to receive themMAKE SURE• that everything is clean, and that chairs and tables are arranged in a U shapeWELCOME• participants, register and offer them seats as they come inMAKE SURE• that all the participants are seated comfortably.

Start-Up Activities

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Session 2: Opening remarks and participants’ introduction (50 mins)

Present an overview of objectives (listed below) and the time allocated for the topic.

Method: Speech, get to know the person next to you, on your right side.

Material: Flipchart, markers•A prepared flipchart saying: name, expectations, opportunities to talk to community •members about nutrition.

Activities

• GREET and welcome participants.• ASK an already notified person to give a welcome address and to officially open the

workshop. If this person is not available, refer to the handbook (SU.S1) to introduce the NuLife program.

• TAP every other person on his or her shoulder and ask him or her to turn to their right neighbour.

• Explain that each pair will get 5 mins to get to know each other; with a special interest in his or her name, expectations and personal opportunities to talk to community members. Hang the prepared flipchart as support.

• Start the exercise.• After 5 minutes• Ask each participant to present his or her partner in about a minute, focusing on the

discussion points on the flipchart.• WRITE the participants’ expectations on a flipchart when they are presented.• After all participants have been presented• Thank them

Note to the trainer:

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THEME 1 and 2

Training and learning objectives for community volunteers :By the end of this training, community volunteers should be able to:

Understand and appreciate the role of nutrition support in the care of people living with 1. and affected by HIV/AIDSDescribe their role in integrating nutrition support activities in their daily routines at 2. community levelTo implement nutrition support activities which include: 3.

health education •nutrition counselling •nutrition assessment •referral of clients to health facilities •follow-up and home visiting of clients in the community•supporting adherence to RUTF in the community•networking with other services providers, and reporting•


Session 3: Presentation of the training’s learning objectives, compare with expectations (20 minutes)

Method: Presentation on flipchart, comparison

Material: Marker, Prepared flipchart with learning objectives found in the note to the trainer.•A training agenda for each participant.•

Activity

• POST the learning objectives on the prepared flipchart and ASK a volunteer to read them• GIVE the participants time to ask questions of clarification and reply to questions asked• REVIEW the participants’ expectations, identify those which cannot be met during the

workshop and give the reasons why not (if they will be met later, explain when) • HANDOUT and PRESENT the workshop agenda.• ANSWERquestions.

Present the objectives which are relevant for the training you are carrying out: Themes 1 & 2

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Session 4: Discuss administration, logistics and ground rules (10 mins)

Method: Explanation, Brainstorm

Material: Marker, Prepared flipchart with learning objectives found in the note to the trainer.•A training agenda for each participant.•

Activity

EXPLAIN any administration and logistics arrangements.•GIVE the participants time to ask questions of clarification and reply to questions asked.•BRAINSTORM with participants on the ground rules of the training.•Add any missing rules.•ANSWER any questions. •


Ground rules of a training

Respect for each other1. No whispering2. Good listening3. Actively participate in all activities4. Talk one by one5. Come in time, do not run away during training6. Cell-phones on silent mode7. Minimize unnecessary movements8. No newspapers9.

Session 5: Pre- Assesment (30 mins) (See Introduction)

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Present an overview of objectives (listed below) and time allocated for the topic. At the end of each topic, refer back to these to make sure they are met.

Learning objectivesBy the end of the topic, participants will be able to:1. Realise that volunteering is part of life2. List the benefits and challenges of volunteering3. Think about the qualities of a good volunteer

Content:

Session 1: Volunteering (30 minutes)

Duration:

30 minutes

Session 1: Volunteering (30 minutes)

Method: Brainstorm

Material: Flipchart and markers.

Activity

BRAINSTORM• with participants about occasions or events in their community when people are involved in volunteering. CAPTURE• answers on a flipchart.ADD• missing examples; from the notes to the trainer.SUMMARISE• by saying ”Volunteerism is part of life and has always existed in communities. It is a normal and useful activity.”ASK• participants about the benefits of volunteering, one by one. Everybody should get a chance to mention a benefit. WRITE• new answers on a flipchart, complete the list using the notes to the trainer. If • challenges are mentioned, write them on a separate flipchart.ASK • participants (to add) challenges of volunteering. WRITE new answers on the flipchart. When the list is complete, ask the participants to mention some ways to overcome the challenges just mentioned, without writing these down. BRAINSTORM• with participants about what qualities a good volunteer needs. WRITE the answers on a flipchart.•ADD • missing examples; from the notes to the trainer.

Volunteering


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Some examples of volunteering in Africa are:“Bulungi bwansi” – Helping to improve the environment in the community•Weddings – volunteer to carry out a task•Rotational digging•Burial groups (twezikye, muno mukabbi) digging graves, cooking at burials•Looking after orphans – concept – children belong to the community•Immunization exercises•Volunteering at church•

Some benefits of volunteering are:Gives people a chance to gain work experience or learn new skills•Makes the community a better place to live•Often includes training, which will be useful both to the project later in life•Volunteering is a fun and fulfilling experience. It helps people to access opportunities not •usually available to themGives a chance to meet and interact with people from all walks of life – people one might •not normally come acrossMakes use of one’s talents and abilities•Improves communication skills•Develops greater knowledge and understanding for people in one’s own community•Learn how to appreciate the blessings in life•Feel great about helping those in need•People become more confident in their abilities•Gives one the opportunity to make a difference in people’s lives. By using their skills and •experiences to help and enrich their communities.

Some challenges of volunteering:Not receiving a payment•Community members thinking that the volunteering is receiving payment•Community members receiving contradicting advice by other people•Community members not trusting the volunteer•Community members not following the advise of the volunteer•Covering a large community•Not having a bicycle, or having a bicycle which brakes down all the time•Not having enough time to do all the work•Not receiving support supervision•Receiving support supervision of poor quality•Not receiving additional training•

Some qualities needed by a volunteer:Willingness to volunteer•Loving his or her community•Understanding and executing his or her duties•Well trained to be able to perform his or her duties•Team approach•Good monitoring and reporting•Exchanges information and influences decision making•Commitment and hard work•Able to build trust and rapport with community members•

Note to the trainer (VSI):

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Present an overview of learning objectives (listed below) and time allocated for the topic. Inform participants that this is not a training on counselling, but a session to equip participants with simple skills, knowledge and attitudes to enable them integrate nutrition into their activities. At the end of this topic, refer back to the objectives and ensure that they have been met.

Purpose: Participants will learn the basic communication skills which will enable them to effectively negotiate with PLHIV and their home-based caregivers to undertake do-able actions to improve their nutrition and eating practices.

Participants will also improve their skills in planning, conducting and evaluating a health education session.

Learning objectives:By the end of this session, participants should be able to:

Define Communication•Understand the importance of the basic communication skills•Appreciate the importance of counselling to community volunteers•Identify 6 important steps of counselling (GATHER method)•Practice using GATHER•Identify basic communication skills (listening and learning skills)•Plan, conduct and evaluate a health education session•

Contents:

Effective communication skills

Session 1: Basic communication skills

Session 2: The importance of counselling for community volunteers?

Activity 1: Why community volunteers should learn basic counselling skills

Activity 2: 6 important steps in counselling (GATHER method )

Session 3 Reaching an agreement

Session 4 Planning and conducting a health education session)

Activity 1: What is health education?

Activity 2: What to do before, during and after a health education session?

Activity 3: Simulating a health education session

Minutes

60

40

20

20

40

60

15

25

20

Effective Communication Skills


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Duration: 3 hours, 20 minutes.

Session 1: Basic communication skills (60 mins)

Session objective: By the end of this session participants should be able to:define Communication •differentiate between verbal and non-verbal communication skills•

Methodology: Brainstorm, demonstration

Materials needed:Prepared flipchart with the “Meaning of communication” (see notes to the trainer)1. Prepared flipchart with the definitions of “Verbal and Non-veral communication” (see 2. notes to the trainer) Flipcharts, markers3.

Activity

EXPLAIN• to the participants that communication and helping skills are important in order to pass on information to individuals, families and communities. Therefore community volunteers need to be equipped with basic communication skillsASK• participants what they think communication meansWRITE • their responses on a flipchartSHOW • participants the previously prepared flipchart with the “Meaning of communication” and MAKE sure they understand what communication isASK • them to identify key comunication skills.EXPLAIN• to them that there are two types of communication: verbal communication and non-verbal communicationASK• them what they understand by the terms: “verbal communication and non-verbal communication”, without writing responses down.SHOW• them a flipchart with the explanation of these terms.EXPLAIN• to participants that they are now going to look at some effective and non-effective communication skillsDEMONSTRATE• with a co-trainer each one of the skits with the examples of non-verbal communication very briefly (see below,each skit should not take more than 5-10 minutes, make sure the one with the open and closed question follow each other immediately)

Meaning of communication:

The process of sharing ideas and experences with other people using verbal and non-verbal language.

The exchange of information from one person to another with appropriate feedback from both ends

Note to the trainer Definitions of communication (ECS.S1):

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Types of communication:Verbal communication: Face to face with short words to encourage the client to talk. (Where speech is involved.)

Non- verbal communication: Usually uses body language (like facial expressions, using hands, sitting or standing postures, movement of the eyes) and signs.

Important Communication Skills a Community Volunteer must

have:This also implies qualities of a good counselor and they could include:

Active Listening

Is the art of engaging meaningfully with someone who is trying to communicate with you. It includes conveying open and welcoming body language, asking follow up questions, re-phrasing key points to ensure that you are understanding, and providing feeddback.

Body Language

This is a set of expressions that we make using our bodies. The expressions include eye contact, smiling, nodding and other gestures and signals. They communicate how we are feeling and what we are thinking. For example, if one crosses h/her arms in front of h/her body, it usually means that person is reserved about something and need to warm up to the issues at hand.

Asking Questions

A useful technique for asking questions is using ope-ended questions . These are questions that cannot be answered with a “yes” or “no”. They usually start with “how” or “why”, like “ Why do PLHIV need to eat well?”. Open – ended questions are more usefull than closed questions because they require reflection. They are a great way to start a discussion, increase participation, and get more information from community members/ target audience.

Empathetic understanding

This is the ability for the community volunteer in course of communicating, tries to put h/herself in the situation of the client, and help them cope and be able to stand up on their own feet as soon as possible.

Genuine/ Sincerity

Ability and willingness to be open, real and consistent in the relationship with the client. To be prepared to give time and attention, to be a “real” person not just some one in a proffefesional role.

Unconditional Positive Regard

The ability to communicate with the client without blame or negative feelings, expelling all fear from the client and making h/her feel h/she is accepted the way h/she is and wanted despite the weeknesses one may have.

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WarmthThe Counselor cares and respects the clients:

This conveys love and care•Breaks down resistance from the clients•Brings about healing.•

Demonstration 1: Examples of non-verbal communication

With each demonstration say exactly the same few words, and try to say them in the same way, for example: “Good morning, Kato. How are you feeling today?”

A: Taking time:

Helps: make him feel that you have time. Sit down and greet him without hurrying; then just stay quietly smiling at him, waiting for him to answer

Hinders: be in a hurry. Greet him quickly, show signs of impatience, and look at your watch

B. Posture:

Hinders: stand with your head higher than the other person’sHelps: sit so that your head is level with him

C. Eye Contact:

Helps: look at her and pay attention as he speaksHinders: look away at something else, or down at your notes

D. Barriers:

Hinders: sit behind a table, or write notes while you talkHelps: remove the table or the notes

Demonstration 2: Closed questions that can only be answered “Yes” or “No” and also give specific short answers .

CHW: Good morning, (name). I am (name), the community health worker. Are you well?

Client: Yes, thank you.CHW: Are you eating?Client: Yes.CHW: Are you having any difficulties?Client: No.CHW: Are you taking your medicines?Client: Yes.

Note to the trainer: Skits for Demonstration (ECS.S1):

xxii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Demonstration 3: Open questions

CHW: Good morning, (name). I am (name), the community health worker. How are youfeeling today?Client: I’m well, but I don’t have much appetite.CHW: Tell me, what have you been eating?Client: I’ve had some porridge this morning. I’m not sure what I will have later on.CHW: What foods do you have at home?Client: Let me see … I know there is some rice and beans.

Demonstration 4: Reflecting back and showing interest

CHW: Good morning (name). How are you feeling today?Client: All right, but I’ve noticed some sores in my mouth, and I don’t feel like eating.CHW: Oh dear, are the sores in your mouth keeping you from eating?Client: Yes. The sores just started this week.CHW: Aah, you’ve noticed these sores for about a week?Client: Yes, and my sister is telling me that there’s some food I shouldn’t eat.CHW: Mmm, your sister says that you should avoid some food?Client: Yes. Which foods should I avoid?

Demonstration 5: Not using judging words

CHW: Good morning, may I see your chart?Client: Here you are.CHW: You are losing weight. Why, are you not eating?”Client: I don’t know … I hope so, but may be not ... (looks worried) I’m trying.

Demonstration 6: Empathy

CHW: Good morning, how have you been feeling lately?Client: I have been having nausea and am not eating much and also losing weight.CHW: I understand. Nausea can make you really feel like not eating. Is there anything you have been able to eat or drink?Client: Yes, some cups of juice.CHW: That’s good. I can help you manage the nausea so you can eat a little more and gain weight

Refer participants to the notes in their handbooks on Basic Counselling Skills.

Note to the trainer :

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxiii

Session 2: The importance of counselling for community volunteers? (40 mins)

Session objective: By the end of this session participants should be able to:

understand what counseling is•

explain the basic communication skills•

understand why community volunteers should learn basic counselling skills•

identify 6 important steps in counselling (GATHER method)•

Methodology: Brainstorm

Materials needed: Flipcharts , markers

Activities:Activity 1: Why community volunteers should learn basic counselling skills (20 minutes)

ASK• participants to tell you what they understand by ‘counselling’.

WRITE• the responses down on the flipchart

CORRECT or GIVE• additional information

EXPLAIN• that counselling is not the same as teaching or giving advice/ guidance, it is much broader.

ASK• participants the Basic Communication skills used in counselling

ASK them• ‘why is it important for community volunteers to learn counselling skills?’

DISCUSS and SHOW• participants the previously prepared flipchart on why community volunteers should learn counselling skills

MAKE• any corrections or changes and SUMMARISE the session

xxiv |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer (ECS.S2.1):

Definition of counselling:

The act of providing a safe and secure environment for a client to talk over h/her •problem(s) so as to figure the way out or accept the problem and learn to live with it and be able to cope with appropriate interventions.

Specifically:

COUNSELLING is a relationship in which a client is helped to make decisions and plan appropriate actions.

Basic Communication Skills in Counselling

Active Listening, Asking questions, Answering questions and Checking understanding •and offering support where necessary

Why community volunteers should learn counselling skills:

In order to effectively communicate the behaviours to improve nutrition•In order to help clients try the small do-able actions•In order to help clients look at the different options•To be able to determine when it might be necessary to refer clients to a more •experienced counsellor and/or other support services

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Activity 2: The 6 important steps of counselling (GATHER method) (15 minutes)

Objective: By the end of this activity participants will be able to:

know the six important steps in counselling using the GATHER approach.•

Materials: Instructions for group work, flipcharts, markers

ActivityINTRODUCE this activity telling participants that there are some important steps •to consider when counselling clients. (Some of them might have heard of different methods). This activity will focus on 6 simple steps which community volunteers should recall and •use when they counsel clients in the communityHANG the flipchart with the letters G, A, T, H, E, and R on a wall or stand•ASK participants to think about each letter and mention what they think each letter •meansWRITE their responses down on a flipchart and mark with the corresponding letter•SHOW participants an already prepared flipchart showing GATHER and the explanation •for each letter

G =Greet the client (create rapport,)

A = Ask ( ask how they are feeling, how you can help, etc.)

T = Tell (tell client about alternative choices to address problems, use counselling cards if available, get client to think what is done differently in their community)

H=Help (help the client to make informed choices, develop small do-able actions)

E =Explain (explain the choice the client has made fully, discuss any barriers)

R= Reassure/ Remind participant about next appointment/

Note to the trainer (ECS.S2.2):

xxvi |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Energizer: Bad/ Good listening skills in pairs INFORM participants that they are going to demonstrate bad and good listening skills•DIVIDE participants into pairs. In each pair, ask one person to play the speaker and the •other the listenerEXPLAIN that the speaker is going to talk for 3 to 4 minutes (on any topic) and that the •listener is to demonstrate ‘bad’ listening techniques-the opposite of the points made in the presentationWhen this is done, DEBRIEF by ASKING the speaker what it felt like to be with a ‘bad’ listener. •ASK the speakers what the ‘bad’ listeners were doing or not doing.Go back into the pairs and swap roles. This time INSTRUCT the listener to practice ‘good’ •listening skills. When the speaker has finished, DEBRIEF by ASKING the speaker what it felt like to have a ‘good’ listener. ASK the speakers what the ‘good’ listeners were doing or not doing•DRAW out the key points about active listening and SUMMARISE •

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Session 3: Demonstration of “reaching-an-agreement” to encourage a PLHIV to try increasing energy intake though small frequent meals: initial visit to the client (40 mins)

Session objective: By the end of this session, participants will be able to:

define the steps used for “reaching-an-agreement” with clients, using the 6 important •steps in counselling

Methodology: Demonstration, discussion

Materials needed: Nutrition care and support national counselling cards, flipchart with GATHER in full, role plays

Activity USING the 6 important steps in counselling (GATHER), the trainers (not the participants) should:

• DEMONSTRATE a counselling session including the initial “reaching-an-agreement” visit of a community volunteer to Jane, the mother of a 12 year old HIV-positive boy, John

Jane tells the community volunteer that she gives John 2 meals a day because he does •not have appetite and feels weak. Community volunteer praises Jane for looking after John.•Community volunteer uses the Card 4 in the national counselling cards, explaining •that eating extra food (small frequent meals) gives more energy and “reaches-an-agreement” with Jane.

DISCUSS• what happened in the demonstration visit.REPEAT• the whole counselling session including “reaching-an-agreement” step with Jane, stopping after each step, and discussing the step with participants. The questions are questions to be asked to the mother being counselled – GATHER:

Greet• – Greet JaneAsk• – Ask questions to find out what is happening, how she and the John are doing etc.Tell• : Tell the options. Now is the time to use the cards from the nutrition care and support national counselling cards and to ask: What is happening in Card 4? • What do people in your community do? What do you agree or disagree with? Why? •Help• – Help to find a do-able action by asking: Would people in your community be willing to try this same behaviour? Would you be willing to try this practice?

Explain: “This is what is meant with “reaching an agreement” with the person you are counselling. This is to have her or him try a new or “improved” behaviour), which you will evaluate during your follow-up visit. Whatever you ask the person to try, make sure it is a small doable action. You can always ask for further changes during a next visit.”

Remind • / Reassure/Refer – Remind about a follow-up visit

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Note to the trainer: The GATHER approach in counselling

Greet the client and introduce yourselves. Discuss status and well-being at the time of / since the last visit.

Ask how the client feels today and how you can help them about his/her nutritional status and food intake.

Ask about any symptoms, nutritional problems and concerns.•With the client, identify any nutritional needs. For example, not increasing weight •adequately, not adhering to medicine, needing to use dietary approaches to manage symptoms.Find out what the client has done in the past to address these problems. What was his/•her success?

Tell and discuss with the client alternative choices to address his/her nutritional problem(s).Use the counselling cards, choosing the appropriate set of cards that relate to the problem identified above.

Help the client make informed choices. With the client (and family members/caregivers), develop approaches/actions to attain the nutrition goal the client has set. As much as possible, let the client come up with choices that are practical and relevant to his/her context.

Explain fully the choice(s) the client has made

Discuss any barriers the client may have in implementing the choices he/she has •made.Ensure the client can explain the actions he/she will take. Do demonstrations if •necessary.Summarize what has been agreed and how it will be done (the client can do this).•

Reassure and give a return date for the next visit.

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Session 4: Planning and facilitating health education sessions (50 mins)

Session objective: By the end of this session, participants should be able to:

plan, conduct and evaluate a health education session•

define health education•

Materials: Flipcharts, markers, Brainstorm instructions; reference; flipcharts; markers, a flipchart on how to plan and conduct a health education

Methodology:Brainstorming and demonstration

ActivitiesActivity 1: What is health education? (15 minutes)

Activity 2: How to plan, conduct and evaluate a health education session? (25 minutes)

Activity 3: Simulating a health education session (20 minutes)

Activity 1: What is health education (15 minutes)

ASK • participants:‘what does health education mean to you?’ COLLECT • all the answers on a flipchart and offer to summarize the ideas at the end of this first brainstorm;MAKE SURE• at the end that everyone understands that when referring to health education on : A get together, organized in an interactive manner by a health worker or a communityvolunteer to talk with a group of individuals in a community on a topic relevant to the health issues of that communityASK• participants, “Why is it important to conduct health education sessions in the community?”COLLECT• all the answers on a flipchart and summarize using section 2 of reference ECS.S4.1.

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Refer to the reference on “norms and procedures for planning and facilitating a health education” (Reference ECS.S4.1).

Activity 2: What to do before, during and after a health education session (25 minutes)

Activity

INFORM• the participants that it is time to look in details into to how such health education sessions should be organized and facilitated and that this task is going to be done in three groupsREAD• the brainstorm instructions out loud for everyone and answer questions of clarification. (See below for breainstorm instructions)BRAINSTORM• on the three phases of carrying out a health talkSUMMARIZE • the discussion using reference ECS.S4.2.REPLY• to any questions, and announce the coming session.

Brainstorm instructions

The LC1 of your village has learned that you have recently attended training on nutrition and HIV. He has invited you to a village meeting where you will give a health talk on the benefits of nutrition for people living with HIV/AIDS.

How are you going to go about it in order to properly conduct the meeting? In order to facilitate thinking, consider that every meeting has 3 important phases :

phase 1: Before the meeting •phase 2: During the meeting •phase 3: After the meeting •

How are you going to proceed with these phases? Be as specific as possible. There are perhaps people in this group who have never been in such a situation, and they will benefit from a detailed description of what you will need to do or prepare.

Activity 3: Simulating a health education session (20 mins)

Activity

INVITE • one participant to simulate or demonstrate the actual session to the rest of the groupINSTRUCT• the remaining participants to observe the health education sessionGIVE• time for feedback, SUMMARISE

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxxi

BASIC NUTRITION CARE AND SUPPORT FOR PEOPLE LIVING WITH HIV/AIDS

Theme 1

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 1

BASICS OF NUTRITION

TOPIC

1

Purpose: Participants will learn the basics of nutrition needed in the care of PLHIV (infants, children, adolescents, pregnant and lactating women and adults). This will also make it easier to understand the relationship between nutrition and HIV.

Learning objectives: By the end of this session participants will be able to:

Define nutrition and some key words: e.g. ‘good nutrition’, ‘eating well’•Describe the importance of food groups •Identify local foods that belong to each food group•Explain the other important factors required for eating well: frequency (F), amount (A), •thickness / consistency (T) Variety of different nutrient-dense food groups (V), active feeding (A) and hygiene (H).

Understand the role of breastfeeding in the protection against illnesses of babies in •their communities


Present an overview of learning objectives (listed below) and time allocated for the topic. .

At the end of this topic, refer to the objectives and ensure that they have been met.

For session 2 on the food groups, you will need to ask community volunteers to bring some local food items available in their communities in order to have a food demonstration.

2 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Reflect on how breastfeeding can prevent these common illnesses •Understand the risks related to the infant feeding options•Practice choosing foods to make ‘eat well’ meals using seasonally, locally available •foods

Outline

minutes Session 1: Basics of nutrition

Session 2: The food groups and their importance

Session 3: How to improve ways of eating

Session 4: What Breast milk contains

Session 5: What is malnutrition?

Session 6: Causes of malnutrition and how they can be prevented

Session7: The role of breastfeeding in the protection against malnutrition and

illnesses of babies in their communities

Session 8: Breastfeeding practices in the community and recommended practices

Activity1: Discuss infant and young child feeding practices in their communities.

Activity2: Discuss problems related to the different infant feeding practices

Activity3: Learn the recommended feeding practices in Uganda

155030255025

30

80

30

3020

Duration: 5 hours, 5 minutes


Basics of Nutrition (15 mins)

Session objective: By the end of this session participants should be able to define some basic nutrition terms.

Methodology: Discussion

Materials needed: markers, flipcharts, prepared reference T1.S1

Activity:

REFER participants to reference T1.S1 in their handbooks and ASK them to read the text in •the handbookDISCUSS the meaning of nutrition and the other key words in the reference and ENSURE •that all the participants are able to define these key wordsASK participants to go to reference T1.S1 and REQUEST a volunteer to read the reference. •MAKE SURE that all the participants understand this information.

•••

Refer to reference T1.S1 for this session.


Session 1


The food groups available in the community and their importance (50 mins)

Session objectives: By the end of this session participants should be able to:

identify different foods that belong to the food groups of the • Grow, Glow, Go. use local foods to make meals •

Methodology: Food demonstration and discussion

MaterialsA variety of foods available in that particular community and some dry food rations•

The laminated cards showing 1) a jogging man 2) a little girl growing into a tall woman 3) •a glowing man

Card 3 in the national counselling cards (different food groups)•

References T1:S2 (the list of available foods in food groups & the seaonally available foods •table)

ActivityAs participants to form small groups according to their community•

Distribute laminated cards of the different foods to the groups•

ASK each group to divide the foods into foods available during given seasons (months)•

Ask each group to divide the foods into food group (Grow Grow and Glow). Go round and •correct where necessary. Let the group mention other foods available. Write on a VIP card and let them place in the good group they belong.

ASK participants to form a circle, bringing their national counselling cards and the food •they brought.

PUT the laminated card with the jogging man in the middle of the circle and ASK them •to discribe what they see

PUT the laminated card with the grown woman in the middle of the circle and ASK •them to discribe what they see

PUT the laminated card with the glowing man in the middle of the circle and ASK them •to discribe what they see

ASK participant to put the food which they have brought next to the card they think it •belons. (Some participants may not have foods, so you can GIVE them the dried foods from the training kit).

Session 2

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 5

ASK participants to take Card 3 of the national counselling cards and study it.•ASK participants to correct the foods on the ground, following the GO, GLOW and •GROW grouping

Once this activity is completed, ASK participants if there are any foods which have •been left out, or are out of season and in which food group would they put them.

ASK participants to practise making balanced meals using the foods in the middle of •the circle. MAKE SURE that each meal has foods from all the food groups. EMPHASISE to participants that they can make healthy, balanced and affordable meals using locally available foods in all seasons.

To wrap this session up, refer participants to the references T1:S2: the list of available •foods in food groups & the seaonally available foods table. ASK participants to read the first reference at home, and to fill the table out as their own reference as homework.

6 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

The food groups are important for ‘eating well’;

The foods are grouped according to the major food values they provide•Almost all foods contain more than one nutrient but they differ in the amount and •qualityEach food value has a role in the body•Different amounts are needed for different groups of people and individuals•

The food groups

GO FOODS: Energy giving foods: staple foods:

Cereals, roots and tubers: mainly providing carbohydrates and fibre. Examples include rice, millet, wheat, sorghum, matooke and maize. Also included are cooked foods prepared from these cereals like posho, bread and porridge. Other foods in this group are yams, cassava, sweet potatoes and Irish potatoes.

GROW FOODS: Body building foods

1) Animal sources: mainly providing proteins, minerals and vitamins. Examples are rd meat, chicken, fish, mukene, enkejje, eggs, milk, grasshoppers, and white ants (enswa).

2) Plant sources (legumes): mainly providing proteins, minerals and vitamins. Examples are different kinds of beans, peas and nuts.

GLOW FOODS: Protective foods

1) Vegetables: mainly providing minerals, some vitamins and fibre. Examples are dark leafy, green and orange coloured vegetables, such as carrot, pumpkin, sweet potato leaves, spinach, nakkati, buga, pumpkin leaves (ssunsa), amaranthus (dodo), okra, pumpkin, eggplant, tomato, onion, green pepper and other local vegetables.

2) Fruits: mainly providing minerals, some vitamins and fibre. Examples are oranges, guava, mangoes, pawpaw, pineapple, jackfruit, passion fruit, water melon, sweet bananas, avocados etc. Fresh fruit juices belong in this group, as well as in the water group.

OTHERS:

Extra energy: Fats, oils and sugars: mainly providing energy and taste. Examples are animal fats e.g. ghee and butter; vegetable fats and oils e.g. margarine, sunflower and palm oil; sugar e.g. cane sugar, honey

Water: Water is important for life and is necessary every day.

Water helps in digestion, absorption and transportation of food•Water regulates body temperature. It is recommended that a person drinks at least 8 •glasses (1.5 litres or 1.5 full NICE cups) of water a day. When it is hot, while doing heavy physical work, sweating or suffering from diarrhoea, vomiting or fever one needs to drink more water per day.One can also get water by drinking soups or fruit juices•Water for drinking, taking medicines or making juices should always be boiled or treated •to make it safe.

Rest group: Not providing anything else than energy. It is recommended to consume items from this group in moderation as they interfere with the consumption of healthy foods and drinks. Examples are artificial juices, sodas, alcoholic drinks, sweets, biscuits etc.



Other ways of increasing the required food values (30 mins)

Session objective: By the end of this session, participants should be able to describe other ways of increasing the food values.

Methodology: Question, discussion

Materials needed: Flipcharts, markers

ActivityASK• participants: “How how many times families in their community eat every dayWRITE• the responses on the flipchart and PROBE: When, Why, How about children/adults/pregnant women.ASK• participants: “How food should be handled and why? PROBE: during preparation, cooking, serving, eating, storage and eating of left over foods.TELL• the participants that there are 6 importants ways of increasing food values (Frequency, Amount, Thickness, Variety, (Actively feed and support), Hygiene (FATVAH)DISCUSS• each way and ask participants why that particular way is important. GUIDE the discussion as follows (T1.S3):

Frequency of meals (Number of times meals are eaten per day)

This refers to the number of meals eaten in a day. In order to meet our body’s needs, we must have frequent meals: 3 main meals and 2 small meals (snacks) each day. The frequency should increase for those who are sick or recoverying from illness.

Amount of foods

This refers to how much food is eaten at each meal. It is important to eat foods in the appropriate amounts, again to ensure thatt we are not getting too little or too much food. For example an adult needs 1 full NICE cup of food at each meal and children would need less.

Thickness of foods

Not too watery as the food values will not be enough and not too thick as the child may have difficulty in swallowing or chewing). The thickness of foods is an important factor to eating well, because if food is too thick, it might make it difficult to chew and swallow. However, if food is too watery, the energy value of the food is reduced.

Session 3


Variety

of different foods from each food group. In session 2 we learned about the food groups and their importance. We now know that each food serves the body differently (GO. GLOW, GROW), therefore it is important to have a variety of foods from each food group in order to eat well.

Actively feed and support:

Active feeding and support is important, particularly for PLHIV.This is more than just feeding PLHIV (both adults and children), but involves a number of actions to support PLHIV to have access to food, grow foods, and prepare these foods.

Hygiene

(washing hands before eating and handling foods, clean utensils, clean water). This is a very important factor needed for eating well. Good hygiene reduces the risk of diseases such as diarrhoea, which in turn can lead to malnutrition. It is important to maintain good hygiene especially for PLHIV.

GO BACK to the flipchart with the factors which participants mentioned and SEE if these •factors have been covered and discussed under the 6 factors above.INTRODUCE the next session by telling participants that in addition to other factors, •some times people may not be ‘eating well’, which could lead to malnutrition.


Breast milk and what it contains (25 mins)

Session objective: By the end of this session, participants should be able to: appreciate the food value of breast milk


Materials needed: images and comparison of breast milk with other animal milks

ActivityAsk • participants: “What breast milk containsPut • an image of the difference in amount of the food values (Grow, Glow and grow) in the different milks drawn in chart and posted on the wall.Probe• until all images are displayed.Put• the cow’s milk next to the breast milk and let them identify the difference.Put• the goat’s milk next to the cow’s milk and let them comment on the differences they seeLastly put the porridge next to the milks and let them appreciate the difference•Let them• discuss which type of milk/feed they would give their babiesSummarise• by saying: “Breast milk contains all the food values (Grow, Glow and Grow) in the right amount for the babies need for the first 6 months of life which are not found in all the other milks or porridge

Session 4


What is malnutrition? (50 mins)


define malnutrition and describe the different types of malnutrition•

Methodology: Brainstorm and interactive lecture

Materials needed: Illustrations of malnourished adults and children, flipcharts, markers, flipchart with flow- diagram on types of malnutrition

ActivityDIVIDE • participants into 3 working groupsGIVE• each group illustrations as described below. ASK • groups to respond to the following questions written on a flipchart:

Group 1: What are the differences in the 3 illustrations? (well nourished child, •oedematoes and non-oedematous child)Group 2: What has caused these differences? (well nourished and undernourished •adult)Group 3: What would the “ill looking” man need to reverse his condition? (well •nourished and undernourished adult)

•After 10 minutes,

ASK• groups to present their group work in plenary, other groups can make additional comments.MAKE• sure that all the participants see the key roles of ‘food intake and illness’ as factors affecting nutrition status.MAKE SURE• they can see and understand the difference between malnutrition with and without swelling of the feet.

Session 5


Definition of malnutrition: ‘Mal’ means poor or bad, malnutrition therefore refers to poor nutrition.Some people will get malnourished because they are ill. But other people will also get malnourished because the food they eat does not provide foods from all the food groups, even though they get enough to eat.In the context of HIV/AIDS, malnutrition refers to the result of a combination of inadequate dietary intake and infection.You can be moderately malnourished (bad) and severely malnourished (very bad), the last one requiring immediate care.

Forms of malnutritionSevere malnutrition is classified into two categories: with and without swelling. A severely malnourished individual may also present with a combination of the two.1. Without swelling

Outlines of ribs and shoulder blades seen•Muscle wasting leading to looseness of skin of the upper arm •Muscle wasting leading to presence of skin folds ‘baggy pants’•

2. With swellingPresence of swelling of both feet •The swelling can spread to the whole body including the face•Skin and hair changes •Lack of emotion/interest or easility irritated/moody•

Reference T1.S4: Picture: Clinical signs of severe malnutrition

Note to the trainer (T1.S4):

Malnutrition without swellingMalnutrition with swelling


Causes of malnutrition (25 minutes)


identify the factors which lead to malnutrition•

Methodology: Brainstorm and discussion

Materials needed: Card 5 in national counselling cards (constraints to eating well), flipcharts, markers

ActivityBRAINSTORM• with participants: ‘why do PLHIV become malnourished?‘ (Look for responses such as: little food available, low food intake, poor digestion and absorption, etc.)WRITE• the responses down on the flipchartASK• participants to look at card 5 in the the national counselling cards ASK• participants to describe what they see in the cards. DISCUSS each constraint and MAKE SURE participants understand how these constraints can lead to malnutrition in PLHIV

The possible constraints to getting enough foodPoverty and socio-economic conditions (not enough money)

Reduced food production (due to reduced labour because of disease

or other reasons, weather)

Poor storage practices, leading to spoiled food

Lack of enough cooking fuel / firewood

Stigma or other social factors

The possible constraints to “eating well”Illness and related symptoms

Unavailability of someone to help prepare meals

Lack of support / encouragement during meals

Stigma, depression

Lack of information

Food taboos or other causes of food avoidance

Poor hygiene practices

Lack of access to a variety foods available

Session 6

Note to the trainer (T1.S5):


The role of breastfeeding in the protection against Malnutrition and illnesses of babies in their communities (30 mins)


See the link between breastfeeding and its protection against common illnesses in their •community.Discuss on Common illnesses of babies in the community and reflect on the relationship •between breastfeeding and common illnesses of babies (10 minutes)

Methodology: Brainstorm common illnesses of infants and young children

Materials needed:Images of common illnesses in the community: diarrhoea, cough/pneumonia (difficulty •breathing), malnutrition (2), vomiting, fever, convulsionsImages of breastfeeding mother and baby, and healthy mother and baby•

ActivityASK participants: “What are the common illnesses of infants and young children in your •community?PUT an image of each of the illnesses mentioned on the floor or wall so that all can see.•PROBE until all images are displayed.•PUT the ‘breastfeeding mother and baby’ in the centre of the other images.•ASK participants: what is the relationship between “these illnesses” and breastfeeding •(especially respiratory and diarrhoeal infections)?PUT the ‘healthy mother and baby’ in the centre as a result of breastfeeding.•DISCUSS and SUMMARISE by saying: “Breast milk contains a lot of agents that can protect •babies and young children against a lot of diseases.”EXPLAIN to them that breastfeeding has other benefits for mother and baby than •protecting against illnesses. These will be discussed later in the training.

Session7


Infant and young child feeding practices in the community and recommended practices (80 mins)


Discuss infant and young child feeding practices in their communities.•Discuss problems related to the different infant feeding practices•Learn about the recommended feeding practices in Uganda•

Activity:1Discuss infant and young child feeding practices in their communities.(30 minutes)

Methodology: Brainstorm, small group work, observation of Counselling Cards #2 and 4, naming the key and supporting message(s) demonstrated in the Counselling Cards, Role-play

Materials neededCounselling Cards #2 and 4 on optimal breastfeeding practices/messages •

Activity

Brainstorm

on the following (do not write down answers), “In your community, …”

• When do mothers in the community initiate breastfeeding? • For how long do mothers exclusively breastfeed (only breastfeeding with no water, liquids or solids)? • How often do mothers breastfeed over a 24 hour period? • For how long do mothers breastfeed their babies (how many months/years)?

Divide • participants into small groups, asking participants in each group to use their Counselling Cards for the following exercise.

Have each group study Counselling Card 2 and name the breastfeeding practice/s and key •message/s the cards represent.

Session 8


After 5 minutes,

ASK one small group to share with the whole group and other small groups add additional points.

PROBE • until the key and supporting messages are mentioned.

Stress that exclusive breastfeeding is the best infant feeding option until around the day the baby turns 6 months. This is the case for HIV negative women but also for HIV positive women as will be discussed later in this training.

HAVE• the small groups repeat the process with Counselling Cards 4 IYCF.

ASK• them to form a circle.

THROW• the ball to one participant and ask her/him to name an optimal breastfeeding practice or message.

When s/he has named an optimal breastfeeding practice or message, s/he in turn throws the ball to another participant and asks that participant to repeat a different practice or message.

CONTINUE• until all optimal breastfeeding practices and messages have been repeated.

Activity: 2

Discuss problems related to the different infant feeding practices (30 min)

Methodology: Reading from a flipchart, individual study of a Counselling Card, discussion

Materials needed:Counselling Card #15: Infant Feeding Mode and Risk of HIV Transmission.•Prepared flipchart 1 saying the following (reference T12.S1:1):•

Major problems related to Infant Formula•It has to be prepared correctly in order to prevent diarrhoea and malnutrition•It has to be fed with a clean open cup in order to prevent diarrhoea•It is very expensive•It does not contain the protective agents against diseases•

Prepared flipchart 2 saying the following:•Major problems related to Fresh Animal Milk•Nothing should be added to the milk before it arrives in the baby’s home•It has to be prepared correctly in order to prevent diarrhoea and malnutrition•The milk and water have to be boiled very frequently•A mineral/vitamin mix needs to be added •It does not contain the protective agents against diseases •It is expensive•


ActivityExplain• the following to participants: “Even though passing HIV from mother to baby can be reduced by exclusive breastfeeding and ARVs, there remains a chance of passing the virus. That is why in some rare cases other infant feeding options than breastfeeding might be preferable. Only trained health workers can evaluate which infant feeding option is most appropriate for an individual mother. The health worker will determine so on a case by case evaluation with strict guidelines.”

When a child is tested HIV-positive (this can be tested a 6 weeks), exclusive breastfeeding •is always the best infant feeding option.

The other two infant feeding options are:•

Infant formula•Fresh but modified animal milk•

SAY• : “The infant formula option is the option which comes the closest to breastfeeding, without the risk of passing HIV to the baby.”

HANG• prepared flipchart 1 and have a participant read the major problems related to infant formula feeding including cost.

MAKE SURE• that everybody understands that Animal milk does not contain all food values a baby needs and is too strong for a younger baby. Hang prepared flipchart 2 and have a participant read the major problems related to feeding fresh animal milk.

MAKE SURE• that everybody understands.

BRAINSTORM• on the meaning of mixed feeding and write the answers on a flipchart.

SUMMARISE• with the help of the reference. Ensure that everybody understands.

ASK• participants to take Counselling Card #15.

EXPLAIN• that this card shows results of research throughout Africa.

ASK • them to study Counselling Card #15 during 5 minutes.

After the 5 minutes,

ASK• a participant to explain what he or she understands.

ASK• other participants to add on until the Counselling Card is fully understood.

DISCUSS and SUMMARISE• with the help of the key and supporting messages.


What do the terms “acceptable, feasible, affordable, sustainable and safe” (AFASS) mean in relationship to infant feeding in the context of HIV?

Counselors will use the AFASS criteria to determine which infant feeding option is the best for a given mother. These criteria are best counseled on with the help of the related Counseling Card. The AFASS criteria are explained below:

Acceptable: The mother perceives no barrier to choosing the infant feeding option for cultural or social reasons, or for fear of stigma or discrimination.

Feasible: The mother and family have adequate time, knowledge, skills, and other resources needed to prepare and serve replacement feeds. They also need support to cope with family, community, and social pressures.

Affordable: The mother and family, with available community or health system support, can afford the costs of preparing and using replacement feeding including all ingredients, cooking fuel, clean water, etc without compromising the health and nutrition of the family.

Sustainable: The mother and family have access to a continuous and uninterrupted supply, through a dependable system of distribution, of all ingredients and commodities needed to safely feed the baby using the chosen method, for as long as the infant needs it.

Safe: Replacement milk can be correctly prepared and done so in nutritionally adequate quantities, and it can be hygienically stored and fed to the baby using clean utensils.

Note to the trainer (T12.S1:2):

Note to the trainer (T12.S1:3):

Mixed Feeding means feeding the baby BOTH breast milk and other foods or liquids, such as water, glucose water, tea, infant formula, animal milk or other breast milk substitutes, porridge or rice. Mixed feeding is harmful when a mother has HIV because the virus can pass easily through the immature intestines. It is therefore NEVER recommended for an infant before 6 months. An HIV positive mother should choose exclusive breastfeeding or exclusive replacement feeding.

This is for your own information. The community volunteers only need to know that health workers will do a case by case evaluation to determine what feeding option would be most appropriate.


Activity 3: Learn the recommended feeding practices in Uganda

Study the leaflets (20 minutes)

Session objective: By the end of this session, participants should be familiar with the two leaflets on infant feeding options (other than exclusive breastfeeding).

Methodology: Working groups

Materials neededLeaflet “How to Feed Your Baby Infant Formula”•Leaflet “How to Feed Your Baby Fresh Animal Milk”•

Activity• EXPLAIN the following to participants: “Community volunteers might encounter the

following leaflets in their communities: “How to Feed Your Baby Infant Formula” and “How to Feed Your Baby Fresh Animal Milk”. Trained counsellors will give these leaflets only to caretakers who have been counselled on infant feeding options and who have opted for infant formula or fresh animal milk. In that case, the role of a community volunteer is to support these caretakers in their choice. That is the reason why we will go through the leaflets together, so that you can train them to support and help the caretaker in case of any problem.”

• Explain the following: “We have already seen that infant formula is very expensive, that is why this option might not be feasible for many Ugandans. But some caretakers will opt for feeding their baby with infant formula. In that case they will always be counselled on the fresh animal milk option too. When caretakers run out of infant formula, they can rely on the somewhat cheaper animal milk while raising money to buy more infant formula.”

• SEPARATE the participants in two groups, each group having one trainer to lead it.

• GO THROUGH the “How to Feed Your Baby Infant Formula” leaflet by reading the titles of each panel. After reading a title, ask participants which messages they think are below the title.

• After the first leaflet, ask participants of the two groups to switch places with the • other group. After this, everyone except for the trainers will have changed chairs.• The same process is repeated for the “How to Feed Your Baby Fresh Animal Milk” • leaflet.• Ask everyone to go back to their places.• Discuss and summarise with the help of the flipcharts on the wall.



THE RELATIONSHIP BETWEEN NUTRITION AND HIV/AIDS

TOPIC

2

Purpose: Participants will learn the relationship between nutrition and HIV/AIDS and the importance of good nutrition for PLHIV

Learning objectives: By the end of the topic, participants should be able to:

Be familiar with the “Nutrition Care and Support” national counselling cards and the job •aidsExplain the relationship between nutrition and HIV•Explain the importance of good nutrition for PLHIV•Discuss and understand why PLHIV become malnourished•


Present an overview of learning objectives (listed below) and time allocated for the topic. At the end of this topic, refer back to the objectives and ensure that they have been met.


Contents

Session 1: Present and review the “Nutrition Care and Support” National

Counselling Cards and the Community-level Job Aids

Session 2: Relationship between nutrition and HIV (how HIV/AIDS affects

nutrition and how nutrition affects HIV/AIDS)

Session 3: How should PLHIV eat? (40 minutes)

Minutes

25

40

40

Duration: 1 hour, 45 minutes


Present and review the “Nutrition Care and Support” National Counselling Cards and the Community-level Job Aids (25 mins)


Have an idea of what cards can be found in the “Nutrition Care and Support” national •counselling cards.

Methodology: Buzz groups of 3 participants

Materials neededOne copy of the national counselling cards for each participant •

ActivityDISTRIBUTE• the national counselling cards to each participant and then asks the participants to form buzz groups of 3. EXPLAIN that the national counselling cards is to be their tools to keep and that they are going to take a few minutes to examine the content of the cards.EXPLAIN• that each group is to find the card that shows:An arm being measure it (job aids CCs #1, 2, 4, 5; NCC• 1 CC#15)ASK• a group to report which card(s) show the item.ASK• the other groups if they agree disagree or wish to add another card.REPEAT• the process with the remaining items/characteristics:a woman looking in the mirror while wiping her tongue (NCC CC #10)•

a man and a woman fetching water (NCC CCs #14)•Groundnuts (NCC CCs #3, 4) •a woman walking to a health centre with a baby on her back (NCC CC #16) •a woman standing on a scale (NCC CC #15) •Someone eating (NCC CCs #1, 2, 6, 15; job aids CCs 1, 9, 10) •a child being breastfed (job aids CC #9) •Someone with stomach-ache (CC #11)•different positions of breastfeeding the baby( NCC #17)•a woman holding a cup giving to a feeding mother (NCC # 18)•Feeding a sick infant/young child (NCC #19 and 20)•Hygiene practices (NCC #21)•

1 National Counselling Cards

Session 1


The relationship between nutrition and HIV/AIDS (40 mins)

Session objective: By the end of this session, participants will be able to”

describe how nutrition affects HIV/AIDS and how HIV/AIDS affects nutritional status•

Methodology: Brainstorm, work in pairs and plenary

Materials needed: Cards 1 and 2 in the national counselling cards showing the relationship between Nutrition and HIV /AIDS

ActivityBRAINSTORM • with participants on what HIV and AIDS mean. Do not write during the brainstorm but share the definition in note to the trainer after the discussion.PAIR • the participants with their neighbours and ASK each pair to study and discuss:1) the illustration of the relationship between good nutrition and HIV and 2) the illustration of the relationship between poor nutrition and HIV/AIDSASK • one pair to present their understanding of the first cardINVITE• the rest of the group to give additional informationASK • another pair to present their understanding of the second cardSUMMARISE • using the key points in the notes to the trainer (Interaction between nutrition and HIV/AIDS)

Session 2



HIV stands for Human immunodeficiency Virus- the organism or virus which weakens a person’s immune system and causes AIDS. People referred to as having HIV are mostly not showing any symptoms of the disease yet.

AIDS: Acquired Immuno Deficiency Syndrome is a combination of signs, symptoms, infections, and cancers which attack an HIV infected person’s body as result of the weakened immune system. A person with AIDS is showing the symptoms of the disease.

Nutritional status: The state of a person’s health resulting from intake and use of nutrients.

The relationship between nutrition and HIV/AIDS:• HIVaffectsnutritionbydecreasingfoodconsumption,absorptionandcausingchangesin

metabolism and HIV associated wasting.

• NutritionalstatusaffectsHIVdiseaseprogressionanddeath

• Improving and maintaining good nutrition may prolong health and delay HIV diseaseprogression. This needs to start early in the course of the HIV infection, before other symptoms are observed

• Interventionstopreventandtreatmalnutritioncanhavegreatimpactifstartedearlyinthe course of the disease.


Illustration: The Relationship between nutrition and HIV/AIDS

Decreased Risk for Disease

Eating Well

Maintaining Healthy

Weight

“Eating Well” Delays HIV Developing to AIDS

Ability to Fight Diseases

Card 2

Reduced Ability to Fight Diseases

Increased Risk for Disease

Not Eating Well

The relationship between nutrition and HIV/AIDS

Loosing Weight

Not “Eating Well” Quickens HIV Progressing to AIDS

Card 1


How should PLHIV eat? (40 mins)


mention at least 3 ways in which PLHIV can eat to meet their requirements•


Materials needed:flipcharts, markers, card 4 in national counselling cards

ActivityTELL• participants that PLHIV stands for people living with HIV/AIDS, that is, they are infected with the HIV virus. REMIND• participants about the importance of good nutrition status in relation to HIV/AIDS and ASK them to recall the benefits of good nutrtion for PLHIVWrite• the letters F, A, T, V, A, H (back of Card 1) one under the other on a flipchart. REMIND• participants about these 6 important factors for eating well.BRAINSTORM• with participants how PLHIV should eat to ensure that all their nutrient and energy needs are met, write answers next to the relevant letter.ADD• any missing information guided by the information in the notes to the trainer.ASK• participants to form buzz groups of 3 and DISCUSS Card 4. After 5 minutes,ASK• a few groups to share their thoughts.SUMMARISE• for the group, stressing the importance of frequent and varied meals and snacks.BRAINSTORM• on the meaning of a snack, SUMMARISE• using the notes to the trainer.

Refer participants to reference T2.S3: The benefits of adequate nutrition for PLHIV.


Session 3


Benefits of adequate /good nutrition for PLHIV:

Good nutrition can maintain and promote health weight, normal growth and •developmentPLHIV with good nutrition have a stronger body for fighting other illnesses and are able •to recover quickly from infectionsAdequate nutrition reduces the effects of HIV symptoms such as diarrhoea and vomiting•PLHIV with adequate nutrition have increased strength and are able to carry on working•Good nutrition helps medicines like ARV to work properly•

How should PLHIV eat to ensure that all nutrient and energy requirements are met?

Eat at least 3 main meals and at least 2 snacks each day•Increase the variety and amount of food eaten at meals and snacks•Increase consumption of foods from all food groups•Add a little oil or sugar to food or drinks (but use foods with refined sugar very •moderately, including sodas, quenchers and other sweet drinks)

What is a snack?

extra foods between meals that are easy to prepare•these extra foods are in addition to the meals—they do not replace meals•good snacks provide energy and nutrients (not to be confused with sweets)•most snacks can be eaten as finger foods such as pieces of ripe mango, pawpaw, banana •and vegetables

Notes to the trainer (T2.S3):



MANAGEMENT OF SOME HIV-RELATED SYMPTOMS AND ILLNESSES

TOPIC

3

Purpose: Participants will learn the importance of nutrition in managing some HIV and ART related symptoms and how to manage common HIV-related symptoms and complications using nutrition and dietary methods

Learning objectives: By the end of this session participants should be able to:

Identify the common nutrition-related problems associated with HIV/AIDS and the use of •ARV’s or other medicines.

Describe how these illnesses and symptoms can be managed •Counsel on management of these symptoms using the nutrition care and support national •counselling cards


Present an overview of learning objectives (listed below) and time allocated for the topic. At the end of this topic, refer back to the objectives and ensure that they have been met.


Contents

Introduction:

Session 1: The common symptoms and illnesses associated with HIV/AIDS and ARV’s, which can affect nutritional status

Session 2: Reachings an agreement using nutrition care and support national counselling cards

10

40

40


Note to the trainer: Introduction to this topic: (10 minutes)

Introduce this topic to the participants by explaining to them that PLHIV often develop certain symptoms and illnesses which can prevent them from ‘eating well’ and getting enough food.These symptoms and illnesses can be as a result of the HIV itself or can be caused by the ARV’s a PLHIV is taking.

Therefore it is very important that these symptoms and illnesses are managed fast because they can affect a person’s nutritional status and adherence to ARV’s. (Adherence to ART means: Sticking to taking anti-retroviral (ARV’s) medicines every day in the right amount (dose), at the right time and following the health worker’s instructions on how to use ART.

This is meant to be a short introduction to the topic. Community volunteers are not expected to know the key interactions between nutrition and ARV, it is important for them to be aware that ARV can affect the way food works, food can affect how ARV’s work and certain effects of the ARV’s can prevent a PLHIV from eating well, thus leading to malnutrition.

Refer participants to Card 6 of the Nutrition care and support national counselling cards and explain to them that this card shows the importance of nutrition in increasing adherence to ART. READ out the notes on the interactions between ARVS and food and make sure that participants understand the relationship between ARV’s and food

The community volunteer should always refer clients to the health facility/ health workers if these sympotoms and illnesses are severe or if they know that a PLHIV is not adhering to their ARV treatment.


The common symptoms and illnesses associated with HIV/AIDS and ARV’s, which can affect nutritional status (40 mins)

Session objective: By the end of this session participants should be able to identify common symptoms and illnesses associated with HIV/AIDS which can affect nutritional status of PLHIV.

Methodology: Brainstorm and studying cards in groups Role –Play

Materials needed: Prepared flipchart with the common symptoms and illnesses written out, markers, cards in nutrition care and support national counselling cards on managing symptoms, a ball

(The most common symptoms/ illnesses can be found in the national counselling cards #7-12)

ActivityINTRODUCE this session by EXPLAINING to participants that although there are many HIV related illnesses and symptoms, the focus of this session is on the particular symptoms and illnesses which can affect the nutritional status of a PLHIV

BRAINSTORM on illnesses and symptoms. After 5 minutes of brainstorming, HANG a prepared flipchart with the 9 symptoms written on it and compare these with the results of the brainstorm:

TELL• participants that these are the most common illnesses which can affect nutritional status of PLHIV.ASK• participants to refer to their Nutrition care and support national counselling cardssMAKE SURE• they have the cards in the national counselling cards on how to manage common symptomsGO THROUGH• each card and ASK a participant to interprete the images on the card. READ the text on the back of each card and MAKE SURE that the volunteers understand how to manage the common illnesess and symptoms.DISCUSS • any issues that may arise from reading the cards

Session 1


When all the cards are discussed, ASK participants to stand up and gather in a circle.

THROW • a ball to one participant and ASK him or her to mention one way of managing one of the symptoms or illnesses discussed.ASK • the participant to THROW the ball to another participant and CONTINUE the same way until all messages have been mentioned.SUMMARISE• the session by TELLING participants that they will now practise reaching an agreement using the cards in the national counselling cards


Practise reaching an agreement on managing HIV related symptoms and illnesses? (40 mins)


help clients on how to manage common symptoms and illnesses related to HIV using •basic communication skills

Methodology: Practise listening and learning skills, case studies

Materials needed: case studies, cards in national counselling cards on managing symptoms (Cards 7-12)

ActivityASK• participants to form buzz groups of threeREAD• the first case study and INSTRUCT a pair from each group to role play a client and a community volunteer using the national counselling cards. The third person acts as an observer and provides feed-back to the pair.MOVE• round and observe the exercise amongst the groups, the other trainers should also move round. There is no need to do a plenary presentation. After the first role play,READ• the second role play and REPEAT the excise. MAKE• SURE that group members shift roles. After the second role playREAD• the third role play and REPEAT the excise. MAKE SURE that group members shift roles so that every member has played the three roles.

Session 2


Case studies (T3.S2)

Case Study 1

John is a 40 year old brick maker in his village. He often does not like eating breakfast or lunch because the ARV’s which were given to him make him feel like vomiting. John says that when he does eat, he vomits some of his food and this is worrying him. You further discover that sometimes John drinks alcohol when he is depressed.

Activity: Demonstrate how you are going to help John through reaching-an-agreementGuide for the trainers:

What food is John eating?•Are there any food interactions with the foods the client is eating and the •medication he is taking?Discuss ARVs and food interaction•Explain need for increased energy intake and ways to increase energy•Reach-an-agreement on the use of alcohol•Manage symptoms of feeling like vomiting, decreased appetite•

Case Study 2:

Ann is a 20 year old woman who lives with her mother and sister in a small 2 bedroom house. The family collects their water from a village tap. Ann was started on ARV’s 5 days ago and has since had diarrhoea. She also noticed that she has pain in her mouth when she is eating food.

Activity: Demonstrate how you are going to help Ann through reaching-an-agreementGuide for the trainers:

What foods is Ann eating?•Explain the need for increased energy intake•Reach-an-agreement on importance of hygiene and clean water and help Ann to •manage her symptoms of diarrhoea and pain on swallowing

Case Study 3:

Christine is a 15 years old orphan, taking care of her 3 brothers and sisters. Since one month whe feels very tired which makes her life more difficult. She also does not have interest in food.


Activity: Demonstrate how you are going to help Christine through reaching-an-agreementGuide for the trainers:

What foods is Ann eating?•Explain the need for increased energy intake•Reach-an-agreement on importance of hygiene and clean water and help Ann to •manage her symptoms of diarrhoea and pain on swallowing



IMPORTANT BEHAVIORS TO IMPROVE AND MAINTAIN GOOD NUTRITION AND HEALTH FOR PLHIV

TOPIC4

Purpose: Participants will identify the key nutrition practices and messages for improving and maintaining good nutrition for PLHIV

Learning objectivesBy the end of this session participants will be able to:

Identify the important behaviors to improve and maintain good nutrition and healthfor •PLHIVIdentify key messages to communicate important behaviors for PLHIV using the nutrition •care and support national counselling cardsReach-an-agreement on the important behaviors using the cards in the nutrition care •and support national counselling cards


Present an overview of learning objectives (listed below) and time allocated for the topic. At the end of each topic, refer back to these to make sure they are met. At the end of each topic, refer back to these to make sure they are met.


Contents

Session 1: Important behaviors for PLHIV to improve and maintain good nutrition

Session 2: Key messages for communicating the important behaviors for PLHIV

Minutes

50

60



Important behaviors for PLHIV to improve and maintain good nutrition and health (50 minutes)


mention at least 5 of the 8 important behaviors for PLHIV•Identify key messages to communicate important behaviours for PLHIV.•

Methodology: Brainstorm, discussion

Materials needed: Prepared flipchart with the 8 important behaviors, markers, counseling Cards.

ActivityINTRODUCE this session by EXPLAINING to participants that the Ministry of Health recommends 8 important behaviours which can enable PLHIV to improve and maintain good nutrition and health.

HANG• the flipchart with the 8 important behaviors where all the participants can see itBRAINSTORM• for each important behavior: “what does it mean?” and “why is it an important practice for PLHIV?” DO NOT write the responses, this is a quick brainstorm.POINT OUT• that a good message addresses the benefits and/or barriers of implementing the behaviour and whyINFORM• participants that in the following session, they will learn the key messages for communicating these behaviours to PLHIV using the cards in the national counselling cards.

•

THE 8 IMPORTANT BEHAVIORS (T4.S1)Have periodic nutrition status assessments1.

Increase energy intake through a balanced diet2.

Drink plenty of clean, safe water3.

Practise positive living behaviours4.

Maintain high levels of sanitation and food hygiene5.

Carry out physical activities or exercise6.

Seek prompt treatment for all opportunistic infections and manage diet-related 7. symptoms

Manage HIV and ART related symtpoms and illnesses8.

Session 1


Key messages for communicating the important behaviors for PLHIV (60 mins)

Session objective: By the end of this session participants should be able to give key messages for communicating the important behaviors and identify different cards in the national counselling cards on the important behaviors.

Methodology: Studying cards in nutrition care and support national counselling cards

Materials needed: cards in nutrition care and support national counselling cards

ActivityINTRODUCE• this session by TELLING participants that they are going to look at the key messages for communicating the 8 important behaviours for PLHIV using the cards in the nutrition care and support national counselling cards. EXPLAIN• to participants that some cards communicate more than one message or behaviour. ASK• participants to refer to the cards in their nutrition care and support national counselling cards and look for a card which shows Number 1 of the important behaviours. When they find the appropriate card, ASK• one participant to read the key messages on the back of the card. CLARIFY• any questions.REPEAT• the exercise until all the 8 important behaviours have been identified and key messages discussed.TELL• participants that they will now be given a simple exercise whereby the trainer will read out some case studies. The participants should then determine what important behaviours they would communicate to the cases in each study.READ• each of the case studies below on the flip chart and ASK• the groups to identify the important behaviour related to each case study.

Session 2


Case Studies for identifying important behaviours for PLHIV (T4.S2):

Case study 1: Maria was weighed 4 months ago, when she went to the health facility for treatment. She is not sure if her weight has improved. (KEY BEHAVIOUR 1)

Case study 2: John is worried that he is not getting enough energy, yet he eats three meals a day. He works long hours as a casual labourer and often feels thirsty (KEY BEHAVIOUR 2 & 3)

Case study 3: Kato has been on ARV’s for 3 weeks, when he is depressed he buys some alcohol and a packet of cigarettes to make himself feel better. Kato also has very little appetite and complains of sores in the mouth (KEY BEHAVIOUR 4 & 8)

Case study 4: When you visit Maria at home, you notice her son throwing rubbish behind the house where there a lot of flies. Also Maria serves both herself and her son food and proceeds to eat without washing hands (KEY BEHAVIOUR 5)

Case study 5: Jane spent a few days in bed when she was ill and weak. She only went to the health facility when she felt worse and was diagnosed with Malaria. Now Jane is better but feels tired and does not like to do much round the house (KEY BEHAVIOUR 6 and 7)



IDENTIFYING MALNUTRITION IN THE COMMUNITY

TOPIC

5

Purpose: Partciants will learn how to identify malnutrition using MUAC and checking for oedema (swelling of both feet).

Learning objectiveBy the end of this topic participants should be able to:

Identify people with malnoutrition in the community•Assess swelling on both feet•Measure using MUAC tapes . •

Contents

Session 1: Identifying malnutrition in the community

Session 2: Checking for swelling of both feet

Session 3: Demonstration of using MUAC tapes

Session 4: Practise measuring MUAC

Minutes

15

30

40

60

Duration: 2 hours, 25 minute


Present an overview of, learning objectives (listed below) and time allocated for the topic. At the end of each topic, refer back to these to make sure they are met.


Identifying malnutrition in the community (15 mins)

Session objective: By the end of this session participants will be able to:

summarise the signs of malnutrition (as identified earlier) and to describe the importance •of identifying malnutrition for PLHIV

Methodology: studying pictures, brainstorm, Role-Play

Materials: Pictures of malnourished individuals, 2 ripe Bananas if available (used in topic 1)

Activity

• HANG up the pictures on a wall or hold them high for participants to study for a few minutes

• RE-CAP signs of malnutrition with a quick BRAINSTORM and showing the pictures of malnourished individuals

• ASK participants to recall the first important behaviour for PLHIV to improve and maintain good health and nutrition (Have periodic nutrition status assessments)

. • ASK ‘Why do we need to identify who is malnourished?”

• SAY “In the community there are two ways of identifying malnutrition: “measurement of MUAC and checking for swelling of both feet”

• BRAINSTORM with the participants what opportunities they would use in the community to identify malnoursihed individuals, to find malnourished children, adolescents, adults, pregnant and lactating women.

• REMIND participants to ALWAYS seek permission from clients to measure MUAC and check for swelling of both feet. It is better not to go into a separate room, and rather measure MUAC in the open.

• EXPLAIN to participants that they will now learn how to determine the nutritional status of community members using a simple tool called a MUAC tape as well as how to check for swelling of both feet

Session 1


Note to the trainer :Importance of nutritional assessment in the care and support of PLHIV (T6.S1)::

Importance of identifying malnourished people

dentification of malnutrition aids in the detection of potential health and nutrition •problemsIdentification of malnutrition provides information on the current nutritional status of •the client. If assessment is done periodically, the weight changes of the client can be trackedIdentification enables one to identify any risky behaviours or factors that might •contribute to the development of ill health or poor nutritional statusIdentification of malnutrition provides opportunities for providing correct and •appropriate nutrition information

Different methods of identifying malnourished people in the community

Measurement of MUAC•Checking for swelling of both feet•

Opportunities for identiying malnourished children, adolescents, adults, pregnant and lactating women:

During home- and follow- up visits•During mass campaign days •Child health days •Outreach clinics •Schools and community programmes. •During community gatherings•


Checking for swelling of both feet (30 minutes)

Objective: By the end of this activity participants will be able to”

identify swelling of both feet in malnourished individuals•

Materials: Picture of patient with swelling of both feet, the 2 cards showing the pressing and the pitting of feet

ActivityREMIND participants that they have already looked at malnutiriton with and without swelling under topic 1.

EXPLAIN to participants that swelling of both feet is a sign of severe malnutrition and that patients with swelling of both feet should ALWAYS be referred to the health facility for care.

(Note that for adults pregnant and post partum women, it is hard to determine if it is nutrition related therefore ALL cases of swelling should be referred to the health facility)

SHOW participants the images of oedema assessment

ASK them to describe what they see. Explain them that they have the same images on Card 7 in their job aids.

ASK for a volunteer from the participants

DEMONSTRATE how to check for swelling of both feet as follows:

Hold both feet with your thumbs on top.

PRESS gently and count ‘one thousand one, one thousand two, one thousand three’ (3 seconds). The patient has swelling if dents (pits) remain when you lift your thumbs

Use two ripe bananas to demonstrate pitting

ASK participants to practise the “checking for swelling of both feet” with their neighbor.

Session 2


Besides practising on each other, it is very important that participants practise checking for swelling of both feet on a person with swollen feet. Therefore try to arrange a visit to the nearest health center (preferrably with a nutrition unit), or for an oedematous adult or child to come to the place of training. If this is not possible, ask participants to practise cheking for swelling of both feet on a roasted plantain.


Reference T6.S2: Illustrations on how to check for oedema

Card 7

How to Check for Swelling of Both FeetSwelling of the feet caused by malnutrition occurs on both feet:

• it starts on both feet and can spread to the rest of the body

• when the feet are firmly pressed with the thumbs for 3 seconds, and then removed, pits are left in the skin as shown below

Notes to the trainer on oedema (T6.S2):

Recognising oedema:

Swelling usually occurs first in both feet and then in the lower legs. If a patient has been lying down, you may see swelling over the back. Oedema can quickly spread to the hands, lower arms and face.

It may be mistaken for ‘fatness’

Malnourished children with oedema often have:

Skin changes over swollen limbs. Changes include abnormally dark, cracked, peeling •patches (like flaky paint), with pale skin underneath which is easily damaged and infected.

Thin hair that can be easily puled out. It may be paler and less curly than normal•A poor appetite and are miserable•

Source: Ashworth and Burgess (2007), Caring for Severely malnourished children


Demonstration of using MUAC tapes (40 minutes)

Session Objectives: By the end of this activity participants should be able to

recognise the different MUAC tapes to be used for each category•use the instructions in the job aids to measure MUAC•interpret the MUAC measurements and colours in order to determine what action to take•

Methodology: Study MUAC tapes and cards in job aids, individual exercise Role-paly

Materials needed:Job aids•4 MUAC tapes for adults, pregnant/lactating women, children and adolescents (pregnant •adolescents will use the tape for pregnant women)Simple tool for interpreting MUAC and actions to be taken•

ActivityASK• participants to individually study all the MUAC tapes for 5 minutes, and to compare them with Card 3 of the job aids.EXPLAIN • the numbers, colours and window on the tapeASK • the participants to form buzz groups of 2, and to study and read Card 5 showing how to use a MUAC tape After 5 minutesASK• a few participants to describe what they see on the cardMAKE SURE• that they see how the length of the upper-arm is measured and the Mid-point is determined by folding the tape in halfThe MUAC is measured and the result is written down•MAKE SURE• that you TELL the participants that the left arm is used for measuring MUACDEMONSTRATE• the measurement of MUAC on one volunteerEXPLAIN• all the steps aloud (e.g. I am now feeling the tip of the shoulder, which is a bone and placing the 0-point of the tape on that tip…..etc.)ASK• if there are any questionsASK• what they think the colours on the MUAC tapes meanEXPLAIN• that only individuals who have a yellow (bad malnutrition) or red MUAC (very bad malnutrition) will be referred to the health facility for nutrition care and treatmentASK• the categories of people who can be measured with MUAC EXPLAIN• that the following group of people :

children from 6 months up to 18 years,•adolescents and adults (Both men and women)•pregnant and lactating and women with infnats up to 6 months old;•women with infants up to can be measured with MUAC. Refer them to Card 4 •showing all categories.

Session 3


EXPLAIN• the meaning of the cut-off using the flipchart as well as the colour–coding.GIVE• each participant a task sheet and EXPLAIN• that this is individual work. REFER• them to their reference on MUAC category and action to take (see reference T6.S3.3, EXPLAIN• that the table on the task sheet shows each category of person measured for MUAC, what the colour of the tape was when measured. Participants’ task is to: decide whether to refer the person to the facility or not and action to take•TELL• the group that they have 5 minutes to complete the taskMOVE• round to provide guidance, using reference T6.S3.3 as a referenceASK• a few members if they expercienced any problems filling out the task sheetASK• if there are any questions

• Mid-upper arm circumference (MUAC) is the circumference of the middle of the left upper arm using a special circumference measuring tape. The point of measurement is between the tip of the shoulder and the elbow.

• MUAC is measured in centimetres. MUAC is recommended for assessing malnutrition in adults and children more than six months old. Because it is easy to measure MUAC, it is used to assess the nutritional status of people whose weight can not be taken, e.g. because they are bed ridden.

Steps for taking MUAC:Step 1:

Bend left arm at angle of 90 degrees1.

Locate the tip of the shoulder2.

Locate the tip of the elbow3.

Place tape measure at 0 cam at tip of shoulder4.

Pull tape past tip of bent elbow and read length of upper arm5.

Step 2:

Determine mid-point by:6.

-Folding the tape in half from ‘0’ to the measured length OR

-Calculating

Mark the mid-point using your finger or a pen7.

Step 3:

Straighten the arm and place the MUAC tape around the mid-point8.

Place the MUAC tape through the window of the tape9.

Make sure the tape is neither too loose nor too tight10.

Read the cm measurement in the window at arrow11.

Record the measurement and the colour zone observed12.

Note to the trainer: Refer participants to their handbooks for further reading on identifying malnutrition using MUAC and oedema (reference T6.S3).Note to the trainer: The community volunteer is not expected to know the cut-off points in terms of cm, rather emphasis should be put on interpreting the colours on the tape and the action to be taken.

Notes to the trainer: use of MUAC tapes (T6.S3:1):


Task sheet (T6.S3:2): MUAC category and action to take

Category Colour of MUAC tape Refer Do not

refer Action taken

Pregnant woman, 20 years old Yellow

Boy, 15 months old Red

Girl, 14 years old Green

Girl, 6 years old, has swelling of both feet Yellow

Man, 40 years old Red

Woman, has swelling of both feet Yellow

Boy, 7 months Green

Reference T6.S3:3: MUAC criteria to identify malnutrition in the community and action taken

INDIVIDUALS ASSESSED COLOUR OF TAPE ACTION TO TAKE

Children from 6 months •oldAdolescents •Adult men and women •aged 18 years and olderpregnant and lactating •womenWomen with children up •to 6 months old.

GREEN

Counsel on eating well and importance of maintaining good nutrition.

Refer for treatment if he/ she has infections or any complications.

Counsel on preventing infections through food and water hygiene.

YELLOWRefer to health facility for nutrition care.

Counsel on importance of eating well.

REDRefer urgently to health facility for nutrition care.

Counsel on importance of eating well.

Notes to the trainer:

Refer participants to reference T6:S3:3: Interpreting MUAC and action to take.


Practise measuring MUAC (60 mins)

Besides practising on each other, it is very important that participants practise measuring MUAC on less well-nourished adults and/or children. Therefore try to arrange a visit to the nearest health center (preferrably with a nutrition unit), or for some people/children to come to the place of training. If this is not possible, ask participants to measure some community members as homework, and share their expericnces the following day.

Objective: By the end of this activity participants should be able to measure MUAC using the coloured MUAC tapes

Materials: MUAC tapes, sticks for measuring (if the sticks are not available, make sure to have some children present on who you can practise measuring MUAC)

ActivitySHOW• the participants s set of MUAC tapes with 4 tapes.

EXPLAIN• to them the different MUAC tapes are for the for the different age groups and MUST not be interchanged else they will give wrong readings.

DIVIDE• the participants into groups of 3

GIVE• each group a MUAC tape for adults

ASK• each participant to measure the MUAC of a fellow group member and to write the results in their notebooks

Have 3 group members first measure the MUAC of one individual while the rest of the •group observe

MOVE • around and to check if they are following correct procedures.

RE-DO• the measurement and correct the measurements If measurements between 2 participants are more than 0.2 cm apart,

MAKE SURE• that all the participants are conversant with the procedure

GIVE• each participant a stick (to represent children’s arms) and EXPLAIN that the marks on the stick represent the elbow and shoulder (E- elbow, S-shoulder)

ASK • the participants to measure these “children’s” arms.

ASK• them to share their results and COMPARE with the trainer’s measurements

DISCUSS• the exercise

SUMMARIZE• by stressing the importance of doing this exercise accurately as people will be referred to the health facility based on these measurements.

Session 4




TREATMENT AND CARE FOR MALNOURISHED INDIVIDUALS

TOPIC

6

Purpose: Participants will learn the use, storage of RUTF for malnourished people. And their role in ensuring that they use it as prescribed by health workers

Learning objectives: By the end of this topic participants should be able to:

Describe what RUTF is and what it is made up of.•Explain the benefits/ importance of RUTF•Explain how to use and store RUTF at home•Know their role as community volunteers in monitoring use of RUTF by the individual ( •adherence) Describe the feeding practices for specific illnesses. infants and young children •


Present an overview of, learning objectives (listed below) and time allocated for the topic. At the end of each topic, refer back to these to make sure they are met.


Contents:

Session 1: RUTF and its benefits

Session 2: How to use and store RUTF at home

Session 3: Ensuring that RUTF is used as advised by the health worker

Session 4: Feeding Practices for Specific Illnesses in sick infant and young child

Minutes

15

30

35

60

Duration: 2 hours, 40 minutes


RUTF and its benefits (30 minutes)

Session objective: By the end of this session participants should know what RUTF is and what its benefits

Methodology: Brainstorm, participatory lecture, demonstration

Materials needed: Job aids, packets of RUTF, flipcharts, markers

Activity:BRAINSTORM• “What is your understanding of ready-to-use food (RUTF)?”

Read • Card 8 of the job aids together.

PASS• around packets of RUTF for participants to have a look at and feel

ASK• participants to describe the packet they are looking at

ALLOW • time for answers

ENCOURAGE• participants to open the packet and taste the RUTF

ASK• them what it tastes like or if they recognise any of the ingredients

EXPLAIN• to the participants that a Ready-to-Use-Therapeutic-Food (RUTF) is a food

which has more energy-giving, body-building and protective substances which are

needed to treat malnutrition in both adults and children

TELL• participants that the aim of using RUTF is to treat malnutrition

EXPLAIN• further that RUTF is made of peanut butter,powdered milk, oil, sugar and a

mixture of protective and body-building substances

Session 1


How to use and store RUTF at home (40 minutes)

Session objective: By the end of this session partcipants will be able to:

describe how to use and store RUTF at home•

Methodology: Interactive lecture & Brainstorm and role play, small working groups

Materials needed: Flipcharts, markers, RUTF packets, role play, job aids, OTC ration cards

Activity:

Activity 1: Storage, disposal and use of RUTF at home (20 minutes)

Objective:

By the end of this activity participants should be able to describe how to store RUTF at home

Materials:

Job aids

Activity

ASK• participants to study Card 11 in the job aids: on storage and disposalREFER • to Cards 9 and 10 in the job aids showing how to use RUTF, stressing the importance not to share the RUTF with other family members because this is a special medicine for the malnourishedExplain • that these cards will be used in the following session, to help a client who is on RUTF.

Session 2


The RUTF packet should be put out of reach of people, rodents, insects and sun. This could be in a covered basket hanging on the beams of the roof, in a covered pot, in a covered bucket or in a closed cupboard.


SHOW card 11 in the job aids and explain that these can be used to help clients

TELL them that RUTF should be kept :

in a secure place.•out of reach of others.•in a clean place, safe from cockroaches and rats•out of the sun to keep the nutrients.•

Activity 2: Role play with the OTC ration card (20 minutes)

Objective:

By the end of this activity participants should be able to use the cards in the job aids on RUTF to help clients use and store the RUTF

Materials: J

ob aids (cards on use and storage of RUTF), example OTC ration cards

Activity

GO THROUGH• the two example OTC ration cards with the whole group

MAKE SURE• everybody understands

ASK • two other trainers to prepare for the role play. One trainer will take on the role of community volunteer and the other the role of a caregiver with a malnourished child.

USE• the listening and learning skills we learned in the earlier session, demonstrate to the caregiver about how to use RUTF using the appropriate card(s) from the job aids

ASK• participants to give feedback on the listening and learning skills.

CORRECT• any information that has to be corrected and SUMMARISE the session


Instructions for role play (T5.S3.2):

To the community volunteer: You are doing a home visit in your community to a mother whose child has malnutrition. They were previously referred to the health facility and given RUTF for the young child. The mother is not sure how to use this RUTF. Your role is to help the mother understand how to use the RUTF. Demonstrate using the listening and learning skills we learned.

Be sure to include the following information in your session:

Teach the caregiver how to open the packet of RUTF—(tear at one corner and eat paste from packet or on a spoon)

How to use RUTF

Describe to caregiver the dosing of RUTF. Define how much should be given to the patient •every day and at each dose (ask to look at the patient card).The RUTF should be given in small amounts and frequently (e.g. ½ packet * 8 times per •day), provided that the daily amount is according to the instructions from the health worker.Always have safe drinking water nearby whenever the patient is eating RUTF. Provide at •least a cup of safe drinking water while or after giving RUTF. If the patient wants more, let him/ her drink as much clean water as he/she wantsMake sure that all severely malnourished patients, including older children, pregnant •women and other adults, consume and finish the RUTF before eating anything else.If a child is breastfeeding, the caregiver must first breastfeed and give RUTF immediately •after breastfeeding.Individuals should be supervised while they consume their RUTF and meals.•RUTF must not be shared with other members of the family or community who may be •hungry. RUTF is a special food for the malnourished patient.

How to store RUTF

The RUTF packet should be rolled after every use.•Remaining RUTF in the packet should be put in sealed plastic bag until next dosing.•The RUTF packet should be put out of reach of people, rodents, insects and sun. This could •be in a covered basket hanging on the beams of the roof, or in a covered pot or bucket.

How to dispose of RUTF

Always dispose of the empty packets of RUTF safely, either by putting them in a latrine or •by burning them.Always counsel on hygiene and sanitation•


Refer participants to the notes on key messages for using RUTF in their handbooks.


Ensuring that RUTF is used as prescribed by the health worker (15 min)


identify ways of monitoring adherence to RUTF in the community•mention at least 5 signs that require referral to the health facility for care•

Methodology: Brainstorm, participatory lecture

Materials needed: Flipcharts, markers, prepared flipchart showing the roles of the volunteer written on it, flipchart with signs that require referral, reference on the signs requiring referral

ActivityBRAINSTORM• on how they would monitor adherence to RUTF in their communities WRITE their responses.EXPLAIN• that treating malnourished individuals requires adherenceTELL• them that possible ways of monitoring adherence include: Ask the caregiver to show you the number of packets remaining, calculate to know •whether it amount left correctAsk the caregiver to give the patient some RUTF while you are there (observe if hand •washing, secure place, patient likes it, safe drinking water)ASK• participants to brainstorm about possible reasons why clients do not adhere to prescribed RUTF.MAKE• a note of these responses on a flipchartEXPLAIN• that certain symptoms like diarrhoea and vomiting can cause clients not to follow advice on how to use RUTF.TELL• participants that if they are doing a home visit they must ask for syptoms the client relates to the eating of the RUTF and advice them to go back for review or to the nearest health facility.

Session 3


Refer participants to reference T5:S4:1 (Signs requiring referral) and reference T5:S4:2 (The Role of the Community volunteer in ensuring that RUTF is used as advised by the health worker).


Feeding Practices for Specific Illnesses in sick infant and young child (15 minutes)


describe feeding practices for specific illnesses.•

Methodology: Observe/reflect on practices/messages on Feeding the Sick Infant and Young Child using Counselling Cards #11 and 12 and the “How to Feed a Sick Child” leaflet.

Materials needed: Leaflet “How to Feed a Sick Child”

Activity:Ask participants to take their leaflet “How to Feed a Sick Child”.•Let participants describe the image they see on the “back 1” of leaflet.•

Sore mouth and throat•Difficulty breathing and cough•Fever•Vomiting and Diarrhoea•

Read the feeding messages on “back 1” together.•Discuss and summarise.•Explain that the other messages in the leaflet have been discussed when looking at the •Counselling Cards.

Session 4


ROLE OF COMMUNITY VOLUNTEERS IN THE CARE & SUPPORT OF MALNOURISHED INDIVIDUALS IN THE COMMUNITY

Theme 2



PurposeParticipants will learn their roles in the care and support of malnourished individuals in the community.

Learning objectives: By the end of this topic participants should be able to:

Explain the importance of involving the community in the care of malnourished •individuals and nutrition support activities

Describe the specific roles of community volunteers in the IMAM, and nutrition support •Identify other stakeholders in their community /catchment area who are involved in •nutrition care and support activties

Describe the roles and responsibilities of the various stakeholders in the care and support •of malnourished individuals

Describe the link between community and facility in the care for manourished •individuals

Prepare an activity plan •Learn how to fill the regester and reporting tools •

THE ROLES OF COMMUNITY VOLUNTEERS

TOPIC

7


Present an overview of, learning objectives (listed below) and time allocated for the topic. This topic covers all the roles and responsibilities of the communiy volunteers in the care of malnourished individuals and nutrition care and support for PLHIV.

Because this is a very long topic, with various sessions, at the end of each session refer back to each session’s objectives make sure they have been met.


Contents:

Introduction

Session 1: Why and how should the community be involved in nutrition care and support for PLHIV?

Session 2: Describe the specific roles of community volunteers in the nutrition Care and support

Session 3: Identifying other support services in the community

Activity 1: The Networking modelActivity 2: Case studies and mapping support services

Session 4: The roles and responsibilities of stakeholders in the community

Session 5: Planning your activities as a community volunteer and mobiliser

Session 6: Practice filling the community register and reporting tool

Session 8: Referral of malnourished individuals to the health facility

Activity 1: What is referral to the health facility?

Activity 2: Using referral tools

Session 9: Follow-up and support of individuals referred from the health facility back to the community

Session 10: The Link between the community and facility and other stakeholders in the care and support of malnourished clients

Minutes

15

35

40

45

1530

30

50

55

60

3030

60

30

Duration: 7 hours


Note to the trainer: Introduction to this topic: (15 mins)

Introduce this topic to the participants by explaining the following: “Besides identifying malnutrition, community volunteers have many other roles in the care of malnourished individuals. All these roles will be discussed in this topic, which will take many hours. To be able to follow where we are in the topic, we will hang two cards from the job aids on the wall (now hang Cards 1 and 2 showing “Your role as a community volunteer”, preferably enlarged cards).

Ask the participants to study the cards individually and describe what they see. Discuss briefly, explaining that the details will be discussed in the following sessions.

During this topic, make sure to frequently refer to the card hanging on the wall, showing which role is being discussed.


Why and how should the community be involved in nutrition care and support for PLHIV? (35 minutes)

Session objectives: By the end of this session participants should be able to:

explain the importance of involving the community in the care of malnourished •individuals and nutrition support for PLHIV

Methodology: Small group work and brainstorm


ActivityEXPLAIN• to participants that you will read a task which they will have to think about.READ• the task (see below) and ASK each group to focus on the following points:

-What is the role of the community in improving nutrition for PLHIV?•-How can community and health facility be linked in order to integrate nutrition •services into HIV/AIDS care?

GIVE• participants 5 minutes to think about how to defend their case

Task: Defend your case:

A local NGO has just received some funds to be used in improving the nutritional status of people living with HIV in your community and in the care of malnourished individuals. The new project manager feels that it is a waste of money and time to involve the community in the project and would rather spend the money equiping the health facilties and training only health workers.

If you were to make a presentation to the project manager, making a case for involving your community in the care of malnourished individuals and nutrition care for people living with HIV, what would you present to him.

ASK• a few participants for ideas on how they would defend their caseFACILITATE• a DISCUSSION and SUMMARISE a presentation on a flipchart. The notes to the trainer can be used as guidance.

1 Uganda HIV/AIDS Sero-Behavioural Survey, 2004-2005. Ministry of Health, STD/AIDS Control Program

Session 1


Some of the roles of the community in improving nutrition for PLHIV

Identify PLHIV who may be ill or malnourished and take/ refer them to a health facility•Participate in activities which can lead to improved nutrition status for PLHIV such as •community gardening, attending health education sessions and implement other nutrition activities

Support PLHIV at household and community levels through psycho-social support•Support adherence to RUTF and ARV’s•Giving nutrition messages•

How should the community and health facility be linked:

Through community awareness raising activities on how to identify and manage •malnutrition (which creates understanding and awareness about the need for care)

Through referral of malnourished individuals from the community to the health facility •for care and treatment

Through referral of malnourished individuals from the health facility to the community •for support and care by trained community volunteers

Through the use of trained community volunteers to identify malnutrition, referral, follow •up and reporting

Through the outreach teams doing health education and counselling, and sometimes •providing other nutrition services.

Through supporting malnourished individuals who have been given ready-to use- •therapeutic food at the health facility to adhere and use it according to the instructions

Notes to the trainer: The Role of the Community in

improving nutrition for PLHIV (T7.S1):


Describe specific roles of a community volunteer in nutrition care and support

Session objectives: By the end of this session participants should be able to the specific roles of community volunteers in the IMAM, and nutrition support

Methodology: Small group work and brainstorm


Activity

EXPLAIN• to participants that they have to think of specific roles as community volunteers in nutrtion care

-What is the role of the community in improving nutrition of PLHIV?•

Ask participants to read from their handbook what their roles are

The roles of the a community volunteerCommunity mobilisatiion1.

Counseling on nutrition2.

Identification of malnourished individuals in the community3.

Referral of malnourished indivdiuals to health facility 4.

Follow up of malnourished individuals on RUTF5.

Link individuals who have completed treatment to sustainable livelihood and 6.other services

Record and report cases of malnutrition.7.

Session 2



Activity 1: Ways to raise awareness of community members (15 minutes)

Session objective:

By the end of this session participants will be able to:

identify some ways to raise awareness of community members about the nutrition program

Methodology:

Brainstorm

Materials needed:

Flipcharts, markers

Activity• ASK participants whether it would be appropriate to go to the community and start

identifying for malnutrition, without first informing the community about the program

• BRAINSTORM with participants about ways of raising awareness about the nutrition program

• WRITE down the answers. ADD any missing information using the notes to the trainer

• EXPLAIN that creating awareness is a very important role of the communtiy volunteers. This will prevent misunderstanding and enable full participation of the community members

Ways to raise awareness in the community:

Talking about the program to community leaders •Talking about the program to other community members•Talking about the program in public meetings and gatherings•Health education•Home visits•



Identifying other support services in the community (45 minutes)


understand the importance of networking with other support services in their •communitiesdescribe available networking support for PLHIV•map the support services in their communities, guided by the case studies •

Methodology: Brainstorm, case studies and mapping, participatory lecture

Materials needed: Case studies, flipcharts, markers, prepared flipchart with reference T7.S2:1.

Activity 1: The Networking model (15 minutes)

ASK• participants whether PLHIV require additional support besides the community and the health facility, especially if they are on treatment or at risk of malnutrition.ASK• : “Why do they need further support?”ASK • them what kind of support they think that PLHIV may needEXPLAIN• to to them that through partnership and networking different organisations are able to provide support for PLHIV, therefore it is important for community volunteers to be aware of the organisations which offer support services in their communitiesUSE• the diagram below to EXPLAIN that the networking model plays a key role in supporting health facilities and community volunteers whilst putting malnourished clients at the centre of the networking modelBRAINSTORM• on the roles that all sides can play in ensuring that formerly and currently malnourished people will not be malnourished again.INTRODUCE• the next activity by SAYING “we are going to explore the support systems present in your own community through case studies and mapping”

Session 3


Transitioning clients off RUTF is made more difficult by poverty, reduced productivity, •and dependency on RUTF. Clients who have been on RUTF should be referred to or linked to existing income-•generation or other sustainable livelihood programmes for PHA and OVC in their communities.

Therefore it is important for community volunteers and health workers to be aware of other stakeholders in their community and catchment area who provide or are involved in the HIV/AIDS prevention, care and mitigation

Reference T7.S2:1: Figure: The Networking Model

Malnourished PLHIV in your community


NGO’s, CBO’S & FBO’s which offer further

support services

Community volunteers

Government departments, health

facilities etc.


Activity 2: Case studies and mapping support services (30 minutes)

Activity

DIVIDE• the participants into as many groups as we have regions or communities, and GIVE each group the group work references for this activity. 2 groups will work on case study 1 and the other 2 groups will work on case study 2.

ASK• each group member to read their case study for 5 minutes and then the group should DISCUSS the appropriate responses for each case study for 10 minutes.

GO• from time to time round the groups to provide assistance and follow-up;

ASK• one member from one group doing case study 1 to PRESENT their group work for 5 minutes

GIVE• participants time after each presentation to comment and enrich the work

ASK• one member from one group doing case study 2 to PRESENT their group work for 5 minutes

GIVE• participants time after each presentation to comment and enrich the work

RESPOND• to any questions and THANK the participants for their collaboration and announce the coming session.


Case studies for discussion (T7.S2.2)

Use local names for the individuals in the case studies.

Case Study 1:

Paul is a 45 year old man, married with 6 children. 4 months ago he developed constant fevers and a persistent cough but never went to see a health worker. He has had diarrhoea on and off for the past year and has lost a lot of weight. Paul has no stable job or source of income but has a small garden, 2 goats and some hens. He and his wife get very little money from selling some of the food they grow in the small garden and from selling some of eggs from the hens. Only 2 of Paul’s children are in school as he has no money for school fees for the other 4 children. Paul is very worried about his illness but will not seek help from a health worker.

Activity:

In your small groups, think about and discuss Paul’s problems and how you think you could help him.Also think about the other service providers in your community and catchment area who may be able to support Paul. Generate a list of these stakeholders showing their target beneficiaries and draw a map showing where these services are located

Case Study 2:

Maria is a 35 year old woman whose husband died after being bed ridden for 6 months. He left Maria with a 3 month old baby. However, during her pregnancy, Maria did not attend any ante natal care (ANC) and therefore did not receive routine counselling and testing for HIV. Maria breastfeeds her baby, but when she goes to the garden, she leaves the baby at home with a caretaker who gives her some milk and soft-mashed foods. Maria noticed that her baby only gained very little weight in the last few months.

Activity:

Discuss amongst yourselves how best you can support MariaWhat kind of support might Maria need?Are there any organisations or service providers in your community or catchment area to whom you could refer Maria for some form of support?How are you going to put Maria in contact with these service providers?

Refer participants to Reference T7.S2:1: Figure: The Networking Model.




At the end of the case studies, INFORM participants that they are going to generate or update a list of all the service providers in their respective communities to whom they can refer PLHIV for support.



Roles and Responsibilities of stakeholders in the community (30 minutes)


identify the main stakeholders in their community as well as their roles and responsibilities

Methodology: Small group work

Materials needed: Prepared flipchart; markers; group work instruction; reference, a flipchart with the following instructions: list the roles of community volunteers, CBO’s and NGO’s and health workers in integrating nutrition into HIV/AIDS care

Activity:ASK• participants to mention the community based intervention key actors;TELL• them that they are going to work in 4 groups in order to identify some key actors’ roles and responsibilities;DIVIDE• the participants into 4 groups. Group 1) community volunteers, Group 2) health workers, Group 3) community leaders and Group 4) CBOs and NGOsGIVE• each group 3 cards and INSTRUCT them to come up with 3 roles and responsibiliities of their stakeholder and write them on their cards.GIVE• them time to ask for clarifications before working in respective groupsGO• from time to time, in the groups to provide assistance. After 5 minutesINVITE• one participant from the first group in turn to present the group findings in plenaryGIVE • them time after each presentation for comments to enrich their work.SUMMARISE• and REFER participants to the reference (T7:S3) on the roles and responsibilities of the stakeholders

Refer participants to reference T7:S3: The roles and responsibilities of stakeholders in the community. These roles are not exhaustive and can be expanded further.


Session 4


Planning your activities as a community volunteer and mobiliser (50 minutes)

Session objectives: By the end of this session, participants should be able to:

prepare a work plan for creating community awareness, reaching-an-agreement and health education in their communities

Methodology: Small working groups

Materials needed: Flipcharts, markers, sample activity plan (reference T7.S5)

Activity

Group • the participants by their community/ catchment area (if a person is alone, he/she works individually)

ASK them to plan the following using the reference:•Community awareness activities1.

Home visits/ group visits2.

Health education sessions3.

MOVE• round the groups and OBSERVE their work. The plan will not be shared in plenary, therfore it is important that all trainers go round to the groups.

Refer participants to reference T7.S5: Sample activity plan.

If time is limited, the activity plans can be drawn as homework, and revised by the trainers on an individual basis the following day.

Session 5



Getting acquainted with the adapted/new reporting tool(s) (55 minutes)


Identify the community reporting tools•correctly fill the reporting tools•

Methodology: Practise using reporting tools

Materials needed: Enough samples of community client Register, Referral Form, Monthly reporting forms. also to be found in references T7.S6.1 and T7.S6.2),

flipchart, markers

ActivityEXPLAIN• that each organisation has its own reporting system and tools and therefore participants will be grouped by organization

INTRODUCE (in turn) the three tools: the register book and the monthly register •books and show them how they look.

ORGANIZE• the participants in groups. A trainer should be assigned to each group during the exercise.

DISTRIBUTE• leaflets of the reporting register and monthly reporting tool to each participant

GIVE • all participants 5 minutes:

to study the tool(s), individually.-

Go• through each tool with them

ASK• if there are any questions and EXPLAIN where necessary.

EXPLAIN• that, any person with swelling of both feet must be referred for nutrition care, regardless of the MUAC measurement. SHOW in the tool where this information is captured.

EXPLAIN• that you will read 10 case studies and that all participants should fill out the relevant information on their tool (s). Explain that this is an individual exercise and that they are allowed to ask questions if there are any problems.

READ• the first case study completely. Then read it again, line by line, allowing participants to fill out their tool(s).

Session 6


ASK• if there are any questions. MAKE SURE each tool is checked (by the trainer in the groups). If there are any people with difficulties, assist them.

REPEAT• the process for the other 9 case studies.

DISCUSS AND SUMMARIZE• , keeping the participants grouped for the next activity.

Case Studies:

Use local names for the individuals in the case studies.

Case study1:

John is 28 years old and part of a support group. He looks very thin and his MUAC measurement falls in the yellow part. You reach-an-agreement on good important behaviors and refer him to the health facility.

Case study 2:

Sara is a 25 month old baby girl with swelling on both her feet. You refer her immediately to the health facility as it is still morning.

Case study 3:

Maria is about 5 months pregnant. She is 40 years old. When you measure her MUAC she falls in the red zone. You counsel her on maternal nutrition and refer her to the health facility.

Case study 4:

Jane is a 14 year old girl and looks very thin. She lost both of her parents two years ago. Her MUAC falls in the red zone. You counsel her about nutrition and refer her to the health facility.

Case study 5:

Ruth is a 35 year old mother of 8 children , 3 of whom died. She is very weak and unable to walk well because her feet are swollen. Counsel her on nutrition and refer her to the health facility.



Case study 6:

Moses is a 10 year old boy who looks very skinny. You measure his MUAC which falls in the green zone.

Case study 7:

Juma is a 45 month old boy, not very active for his age. His MUAC falls in the yellow part. Talk to the mother to find out what is wrong. Reach-an-agreement with her on complementary feeding and hygiene, and refer the boy to the health facility.

Note: 45 months is about 3.5 years. Have participants calculate themselves if they need the age in years.

Case study 8:

Jen is a 6 years old girl and thin. Her MUAC falls in the red part. Refer her to the health facility.

Case study 9:

Mary is 25 and breastfeeding her third baby. She is thin and her MUAC falls in the yellow part. Reach-an-agreement with her on maternal nutrition and family planning. Refer her to the health facility.

Case study 10:

Anne is a 16 years old girl and very thin. Her MUAC falls in the green part.

If participants wonder why someone can look very thin and still have a green MUAC explain that, especially children, sometimes grow very fast and therefore look thin but are actually healthy.

Refer the participants to their handbooks for the following figure.

Reference T5.S1: Figure: The Role of Community in the care of malnourished individuals




Number assessed for Malnutrition Total Number referred to Health Facility

MUACOedema (Swelling

on both legs)Green Yellow Red

Children 6 months to less than 18 years

Male

Female

Pregnant / mothers with children up to 6 months

Adults

Male

Female

Community Level Nutrition Monthly Report

Organization: _________________________

District:___________________ Subcounty:_____________

Name of Health Facility Attached to:____________________________

Month: __________Year: _______


Foo

d a

nd

Nu

trit

ion

Inte

rven

tio

ns

for

Ug

and

a C

om

mu

nit

y A

sses

smen

t fo

r M

aln

utr

itio

n C

lien

t’s R

egis

ter

Nam

e o

f Vo

lun

teer

: ___

____

____

____

____

Ye

ar: _

____

____

__M

on

th__

____

___

Nam

e o

f Hea

lth

Fac

ility

____

____

____

____

____

No.

N

ames

Ad

dre

ss

(Vill

age)

Sex

(M/F

)A

ge

Clie

nt

Cat

ego

ry

(Tic

k th

e ca

teg

ory

of t

he

clie

nt)

Id

enti

fy N

utr

itio

n S

tatu

s

(Tic

k th

e co

rrec

t c

olo

ur

of M

UA

C a

nd

ch

eck

for

swel

ling

of b

oth

leg

s)R

efer

red

b

y yo

u

to H

ealt

h

Faci

lity

(Y/N

)

Co

mm

ents

(Wh

at

hap

pen

ed?)

MU

AC

Oed

ema

(Sw

ellin

g

on

Bo

th

leg

s) (

Y/N

)

Ch

ild

(6m

th

-18

yr)

Ad

ult

Pre

gn

ant/

mo

ther

w

ith

ch

ild

up

to

6

mth

s

Gre

enYe

llow

Red

Tota

l


Session 7

Information on the frequency of reporting (10 minutes)

Session objective: By the end of this session, participants should understand the reporting system and the frequency with which they will be required to make reports

Methodology: Case studies

Materials needed: samples of reporting tools, flipcharts

ActivityEXPLAIN• that each organisation has its reporting system and data flow. Some require community volunteers to report monthly while others quarterly.

EXPLAIN• that NuLife is expect to receive the monitoring information from each implementing partner on a quarterly basis, i.e. every three months.

INFORM• participants that NuLife will work with each organization to develop a mechanism for reporting on nutrition indicators from the community.

DISCUSS and SUMMARIZE stressing:•The importance of reporting in time•The importance of each single piece of information•

The following information is the minimum information organisations need to report on. This information will be collected in the organisation-specific tools which will be adapted to collect this information.

Refer participants to Reference T7:S6: The Sample Reporting tool



Session 8

Referral of malnourished individuals to the health facility for care and treatment (60 minutes)


understand the importance of referral and the two-way referral system•use the referral FORM to refer malnourished clients to the health facility•

Material: Flipcharts, markers

Methodology: Brainstorm, role play, small group work

Materials needed:Task cards, flipcharts, markers, sample of referral form

Activity

Activity 1: What is referral to the health facility? (30 minutes)

DIVIDE• participants into small working groups of 4-5

ASK • each group to discuss one of the following:

Group 1• : what does the term ‘referral’ in the context of nutrition care for PLHIV in the community meanGroup 2: • why is referral important in nutrition care for PLHIVGroup 3:• what are some reasons for referral Group 4:• at what levels are referrals carried out?

Once the group work is done,

INVITE• a participant from one group to present the group’s discussion

ASK• the other groups to make any contributions, WRITE these on responses on a flipchart

REPEAT• the procedure for the other groups


Referral:

Referral links malnourished individuals and those at risk of malnutrition in the community to:

The health facility for treatment and care of malnutrition and any related illnesses•Other services or service-providers with more skills, experience or better equipment who •are in a position to support PLHIV and improve their quality of life

Referral can be carried out at two levels:

The community level, whereby trained community volunteers, using specific nutrition assessment tool (e.g. MUAC, observation of swelling of both feet) screen individuals in their community and then refer those who are malnourished to the health facility for nutrition care.

The facility level where the trained health workers who do further nutrition assessment and determine wheter or not the referred individual can be enrolled into the RUTF/ nutrition support programme, and then refer individuals back to the community to be supported by volunteers through follow-up and home visits.

Both the facility and community levels can refer individuals to other support services in the community for more support (see one of the next sessions).

Two-way referral whereby the individuals are referred from the community to the health facility for nutrition care and treatment and then referred back to the community for continues support is important because it:

Enables early detection of individuals who are malnourished or at risk of malnutrition in •the community, thereby encouraging timely intervention.Enables health facilities to keep track of individual clients’ adherence to ART, RUTF and to •provide them with tailored health and nutrition messages

Notes to the trainer on referral (T7.S8.1):


Activity 2: Using referral tools (30 minutes)

Materials:

Referral tool (this should be the organisation/district-specific tool. If these are not available, then use the generic one displayed in T7.S8.2)

Activity:

TELL • the participants that they will now learn how to use the referral tools to refer individuals to the health facility

DIVIDE• the participants into small working groups of 4-5

DISTRIBUTE• a sample of the referral tool and ASK participants to study it

GO THROUGH• the tool together to ensure everybody uderstands it.

Explain• that the upper part of the tool will be filled by the community volunteers about the client being referred. While, the lower part will be filled by the health worker and will contain information that the health worker wants to share with the community volunteer. When the community volunteer visits the client, he or she should ask for this referral form.

When everybody is clear on the tool

READ• the task sheet for the whole group.

MOVE • round the groups to ensure that they are all filling out the tool correctly

At the end of the group work

ASK• for 2 participants to demonstrate the referral process using the role play instructions below


Task sheet for Role play:

Instructions: One participant takes on the role of community volunteer and the other the role of patient. The community volunteer gives relevant information and refers the client who then goes to the health facility with the referral form.

The client takes the referral form back to the community volunteer who will then support the client in the most appropriate way.

Community volunteer: You do a home-visit in your community and assess 24 year old John’s nutrition status using MUAC and find that he has a MUAC in the yellow zone of the MUAC tape. John’s mother tells you that John has not been taking his ARV’s as he is supposed to because he vomits every time he swallows the ARV’s.

Instructions:

Discuss as a group what sort of support John requires. If you think that he needs to be referred to the health facility, then fill out the referral tool.

When making a referral:

Fill the slip for the community volunteer but also the general information on the slip for •the health worker

Always remember to counsel the client using the listening and learning skills you have •learned

Inform the client that you will be referring him to the health facility and explain the •reason for referral (for further nutritional care and treatment )

Inform the client about where to take the referral form•


Sect

ion

Ret

ain

ed b

y C

om

mu

nit

y Vo

lun

teer

Clie

nt

Ref

. No

:___

____

____

____

____

Dat

e __

__/_

____

/___

____

Clie

nt

Nam

e __

____

____

____

____

____

_

Sex

(F/M

)___

___

Sub

Co

un

ty _

____

____

____

____

____

____

Pari

sh: _

____

____

____

____

____

____

____

Vill

age

____

____

____

____

____

____

____

_

MU

AC

: (T

ick

the

corr

ect

co

lou

r of M

UA

C )

Gre

en _

___

Yel

low

___

__

Red

___

__

Oed

ema

(Sw

ellin

g o

n B

oth

leg

s): Y

es__

_No

___

(Tic

k “Y

es”

if th

e cl

ient

has

sw

ellin

g of

bot

h le

gs a

nd

“No”

if th

ere

is n

o sw

ellin

g of

bot

h le

gs)

Clie

nt

Ref

. No

:___

____

____

____

____

D

ate

____

/___

__/_

____

__

Clie

nt

Nam

e __

____

____

____

____

____

__Se

x (F

/M)_

____

_

Sub

Co

un

ty _

____

____

____

____

____

____

__Pa

rish

: ___

____

____

____

__

Vill

age

____

____

____

____

____

____

____

____

____

____

__

Hea

lth

Fac

ility

Clie

nt

is re

ferr

ed to

: ___

____

____

____

____

____

____

_

MU

AC

: (T

ick

the

corr

ect

co

lou

r of M

UA

C )

Gre

en _

___

Yel

low

___

__

Red

___

___

Oed

ema

(Sw

ellin

g o

n B

oth

leg

s): Y

es__

___

No

____

_

(Tic

k “Y

es”

if th

e cl

ient

has

sw

ellin

g of

bot

h le

gs a

nd “N

o” i

f the

re is

no

swel

ling

of b

oth

legs

)

Volu

nte

er’s

Nam

e: _

____

____

____

____

____

___

Dat

e cl

ien

t w

as re

ceiv

ed _

____

/___

__/_

____

__

Clie

nt

adm

itte

d t

o: (

Tick

as

app

rop

riat

e)

[ ]

Ou

tpat

ien

t Th

erap

euti

c C

are

(OTC

) (f

ollo

w u

p o

n R

UTF

ad

her

ence

)

[ ]

In

pat

ien

t Th

erap

euti

c C

are

(ITC

)

[ ]

Su

pp

lem

enta

ry F

eed

ing

Pro

gra

m

[ ]

Do

es n

ot

qu

alify

for a

dm

issi

on

(Co

un

sel o

n e

atin

g w

ell a

nd

hyg

ien

e)

Feed

bac

k fr

om

Hea

lth

Wo

rker

to C

om

mu

nit

y Vo

lun

teer

(Fill

an

d re

turn

to t

he

clie

nt)

To b

e fil

led

by

Co

mm

un

ity

Volu

nte

er(F

ill a

nd

giv

e to

th

e cl

ien

t)

Gen

eric

Ref

erra

l Fo

rm (

T7.S

8.2

)


Follow-up and support of individuals referred from the health facility back to the community (60 min)


carry out follow-up and support visits using the community volunteers’ guidelines and the •home visit checklist.

Methodology: Brainstorm, role play in groups of 3

Materials needed: Prepared flipchart with the 2 case studies, “The home-visit follow-up guide” (reference T7.S9:1 or Card 12 in the job aids), flipcharts, markers, group instructions, nutrition care and support national counselling cards, OTC card, referral form

Activity

ASK• the participants what they understand by ‘follow-up” of clients and why it is important in nutrition care and support, especially for PLHIVASK• them to read “The home-visit follow-up guide” (reference T7.S9:1 or Card 12 in the job aids)CLARIFY• any issues that may arise from reading these referencesDIVIDE• the them into groups of 3 (triads) and ask them to READ their respective case study on the prepared flipchartASK• each group to role-play a follow-up home visit session (one participant acts as the client, another as the community volunteer, and the 3rd and 4th ones as observers. The community volunteer should use the home-visit guide. After 10 minutes•ASK • each group to switch roles and READ the second case studyASK• two groups to present their experiences (do not role play) and allow for comments

Session 9


-

CASE STUDY 1:

When you first visited Maria, she had poor eating habits and was not ‘eating well’. She had lost so much weight and you referred her to the health facility for treatment. You also noticed that Maria was depressed, had general body weakness and is on ARV’s. Maria came back from the facility with RUTF.

Do a follow-up home visit, use the home-visit guide and appropriate cards from the nutrition care and support national counselling cards.

CASE STUDY 2:

At your initial visit, 6 year old Kato was severely ill, had no appetite and refused the food given to him. His mother told you that he had lost a lot of weight in the last 2 weeks. You assessed him with MUAC, it was red. So you helped the mother and referred her to the health facility where she took Kato. Kato was given 20 bags of RUTF.

Do a follow-up home visit, use the home-visit guide and appropriate cards from the nutrition care and support national counselling cards.

Notes to the Trainer: Follow-up (T7.S9:2):

Notes to the Trainer: Follow-up (T7.S9:2):

Follow-up is usually done to monitor a client’s well-being

Done continuously both in the facility and community•The frequency of follow-up home visits depends on the severity of the problem•Follow-up will be of benefit if nutrition issues are integrated into other care and •support activitiesInclude monitoring of health, nutrition and assessment of dietary intake during •follow-up visitsInclude reaching-an-agreement to address barriers to good nutrition (i.e. •implementing the important behaviors)Follow up helps to increase adherence to treatment such as RUTF and ARV’s•Offer support and encouragement•During follow-up, review some of the following:•

Meal plans•Exercise and physical activity regimens•Use of RUTF if prescribed by health facility, etc.•

Refer participants to reference T7: S8:1: Home-visit follow-up guide


The link between community and facility in the care for manourished individuals (30 minutes)

Session objective: By the end of this session participants be able to:

Know the role of the community in the care of malnourished individuals and have an •overview of the care of malnourished individuals

Methodology: Brainstorm, lecture

Materials needed: Diagram on the role of community in the care of malnourished individuals

ActivitySHOW• participants the simple diagram on the roles of community in the care of malnourished individuals and EXPLAIN to them the role of the community in the care of malnourished individualsEXPLAIN• to the participants the various components of the care of malnourished individuals such as outpatient care, special care and supplementary feeding:TELL• the assess, identify malnourished individual and refer to the health facility:The malnourished, found with serious medical conditions, will be referred for admission •to receive both nutritional and medical treatment till he/she is out of danger.Malnourished individuals if found with no life threatening condition, and only •malnutrition, will be managed from home using the RUTF and be required to report to the health facility on dates written on the clients card.

How can community and health facility be linked in order to integrate nutrition services into HIV/AIDS care?

GIVE participants 5 minutes to think about how to defend their case•ASK participants to refer to card 1 and 2 in the job aids explaining their roles as •community volunteersINTRODUCE the next session which is using RUTF in the community•

Session 10


Partner organizations

Community Volunteers

Mobilize community

Counsel on Nutrition

Identify Malnourished cases

refer malnourished cases to health facility

Follow-up

Link to sustainable livelihood and other services

Document

Health Facility

Re-assess•Categorize•Prescribe RUTF•Counsel•Document•Counter-refer•


REFFERENCE TOOLS & JOB AIDES

Appendix


THEM

ES 1

&2

: Bas

ic n

utr

itio

n c

are

and

su

pp

ort

for

PLH

IV &

th

e ro

le o

f co

mm

un

ity

in IM

AM

Ag

end

a: 4

Day

Tra

inin

g o

n in

teg

rati

ng

nu

trit

ion

into

HIV

/AID

S C

are

and

su

pp

ort

Pro

gra

mm

es: A

tra

inin

g o

f co

mm

un

ity

volu

nte

ers

DA

Y 1

DA

Y 2

DA

Y 3

DA

Y 4

8:3

0- 1

0:0

5 S

TAR

T U

P A

CTI

VIT

IES

Sess

ion

1: (

15 m

inu

tes)

Sess

ion

2: (

50

Min

ute

s)Se

ssio

n 3

: ( 2

0 M

inu

tes)

Sess

ion

4: (

10

Min

ute

s)

8:3

0- 1

0.0

5: R

E-C

AP

DA

Y 1

(5 T

OP

IC 1

C

ON

T’D

8:3

0-1

0:0

5Se

ssio

n 3

(30

min

ute

s)Se

ssio

n 4

(25

min

ute

s)Se

ssio

n 5

(50

min

ute

s)

8:3

0- 8

:45

: RE-

CA

P D

AY

2

TOP

IC 4

: IM

PO

RTA

NT

BEH

AV

IOU

RS

TO IM

PR

OV

E A

ND

M

AIN

TAIN

GO

OD

NU

TRIT

ION

& H

EALT

H F

OR

PLH

IV8.

45 –

10.

05Se

ssio

n 1

: (50

min

ute

s)Se

ssio

n 2

: (30

min

ute

s)

8:3

0- 8

:45

: RE-

CA

P D

AY

38

:45

- 10

:15

TO

PIC

7 c

on

tin

ued

Sess

ion

2 (4

5 m

inu

tes)

Sess

ion

3. (

45 m

inu

tes)

TEA

BR

EAK

10:3

5 –

11:0

5: S

TAR

T-U

P co

nti

nu

edSe

ssio

n 5

: ( 3

0 M

inu

tes)

11:0

5-11

:35:

VO

LUN

TEER

ING

11:3

5- 1

:15:

EFF

ECTI

VE

CO

MM

UN

ICA

TIO

N

SKIL

LSSe

ssio

n 1

: (60

min

ute

s)1S

essi

on

2: (

40 m

inu

tes)

10:4

5- 1

.00

Sess

ion

6 (2

5 m

inu

tes)

Sess

ion

7 (3

0 m

inu

tes)

Sess

ion

8 (8

0 m

inu

tes)

10.3

0-11

.00

Sess

ion

2 C

on

t’d (3

0 m

inu

tes)

11.0

0- 1

:00

TOP

IC 5

: ID

ENTI

FYIN

G M

ALN

UTR

ITIO

N IN

TH

E C

OM

MU

NIT

YSe

ssio

n 1

(15

min

ute

s)Se

ssio

n 2

(30

min

ute

s)Se

ssio

n 3

(40

min

ute

s)Se

ssio

n 4

: (25

min

ute

s)

LUN

CH

BR

EAK


8 0

2:15

– 3

:55

Sess

ion

3: (

40 m

inu

tes)

Sess

ion

4 (

60 m

inu

tes)

TOP

IC 1

BA

SIC

S O

F N

UTR

ITIO

N3:

55 –

5:0

0Se

ssio

n 1

(15

min

ute

s)Se

ssio

n 2

(50

min

ute

s)

TOP

IC 2

: TH

E R

ELA

TIO

NSH

IP

BET

WEE

N N

UTR

ITIO

N &

HIV

/AID

S2

.00

– 3

:45

Sess

ion

1: (

25 m

inu

tes)

Sess

ion

2: (

40 m

inu

tes)

Sess

ion

3: (

40 m

inu

tes)

3:45

- 5:1

5: T

OP

IC 3

:M

AN

AG

EMEN

T O

F SO

ME

HIV

R

ELA

TED

SY

MP

TOM

S &

ILLN

ESSE

SIn

tro

du

ctio

n (1

0 m

inu

tes)

Sess

ion

1 (4

0 m

inu

tes)

Se

ssio

n 2

(40

min

ute

s)

2: 0

0 –

2:35

Sess

ion

4 –

Co

nt’d

(35

min

ute

s)

2:35

– 4

:15

TOPI

C 6

: TRE

ATM

ENT

AN

D C

ARE

FO

R M

ALN

URI

SHED

IND

IVID

UA

LS

Sess

ion

1 (3

0min

ute

s)Se

ssio

n 2

(40

min

ute

s)Se

ssio

n 3

(15

min

ute

s)Se

ssio

n 4

(15

min

ute

s)

4:15

- 5

:05

TOP

IC 7

: RO

LES

OF

THE

CO

MM

UN

ITY

IN T

HE

CA

RE

OF

MA

LNU

RIS

HED

IN

DIV

IDU

ALS

.In

tro

du

ctio

n (1

5 m

inu

tes)

Sess

ion

1 (

35 m

inu

tes)

10:4

5 –

1:10

Sess

ion

4 (3

0 m

inu

tes)

Sess

ion

5 (5

0 m

inu

tes)

Sess

ion

6 (5

5 m

inu

tes

)Se

ssio

n 7

(10

min

ute

s)LU

NC

H2.

00 –

5:1

5Se

ssio

n 8

(120

min

ute

s)Se

ssio

n 9

(60

min

ute

s)Se

ssio

n 1

0 (1

5 m

inu

tes)

5:1

5- 5

:45

PO

ST T

EST

& T

RA

ININ

G

EVA

LUA

TIO

N

TEA

BR

EAK

AN

D D

AIL

Y E

VA

LUA

TIO

N



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