Training Module_Final_June_14_5Pm

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PREFACE

Diarrheal diseases are the second leading cause of death in children under five years old in the world. In India every year an estimated 3,00,000 under-5 children die due to diarrhea. Thus, it is evident that diarrheal diseases constitute a major public health problem particularly among children in India.

Diarrhea is mainly transmitted through contaminated water and food. Lack of proper sanitation further accelerates the process of transmission of diarrhea. Therefore, to prevent diarrhea, access to safe drinking water supply and improved sanitation are required. It is clear that improved access to WASH (Water, Sanitation & Hygiene) is critical to diarrhoea reduction, however, is not sufficient enough to effectively tackle diarrhoeal mortality and morbidity. Recognising this and the high magnitude of diarrhoea incidence in India, Save the Children has adopted the WHO-UNICEF ‘7-point plan’ for prevention and control of diarrhoea through Stop Diarrhoea Initiative (SDI), in order to showcase it as a scalable and sustainable diarrhoea reduction model.

Stop Diarrhoea Initiative is a signature programme of the organization with a focus on 6 rural districts and 3 urban locations in 4 states comprising West Bengal, Uttar Pradesh, Uttarakhand and Delhi that has started in April 2015. The Initiative aims at achieving the following objectives among children under-five by the end of the programme:

► At least 50 % reduction in the prevalence of childhood diarrhoea

► At least 50% reduction in the incidence of acute diarrhoea from 3-4 episodes to less than 2 per year

► An estimated 80% reduction in diarrhoea Case Fatality Rate (CFR) in clinics

► 13% reduction in diarrhoea related deaths

As a part of the initiative, it is envisaged to build the capacity of the district and below district level project staff for further training of the community health volunteers, on 7 point plan for diarrhea control. The present module was developed after an extensive review of the existing literature on diarrhea prevention and control, prepared by government departments, U.N. agencies and other international bodies along with peer reviewed journals. The purpose of the module is to facilitate the trainee in understanding the disease burden, causation of diarrhea and various prevention and control strategies for the same. Further, it would enable the facilitators to proceed with training in a systematic and organized manner so that the prime objective of making the staff and community health volunteers aware and equipped with necessary skills for diarrhea control is achieved.

The module has been designed in such a way that it is user friendly. The training module aims at discussing and applying the adult learning techniques. Besides, it also provides and strengthens their communication skills and the necessary community engagement skills.

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C O N T E N T SSessionsIntroduction of the participants and overview of the workshop .................................................9

Understanding the burden of diarrhea-Global & India ..............................................................15

Essential concepts of diarrhea ...................................................................................................19

Assessment of a case of diarrhea-diagnosis & treatment ..........................................................25

Prevention of diarrhea ...............................................................................................................33

Issues and Challenges in diarrhea prevention and treatment ....................................................39

A 7-point plan for comprehensive diarrhea control ...................................................................45

Effective communication-I (Ways and means, Dos and Don’t’s) ...............................................49

Specifics of IEC/BCC activities & Documentation .......................................................................59

Key messages for adults and children around diarrhea control .................................................67

Community level structures and their roles and responsibilities ...............................................71

Social mobilization and reaching the unreached ........................................................................79

Basics of Adult Learning Techniques ..........................................................................................87

Annexures ...................................................................................................................................93

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INSTRUCTIONS FOR USE OF THIS MODULE

This module has been visualized as a training of trainers’ module with many group activities, which can be used by the facilitator while training the staff at district and below district levels. The module deals with the basic understanding of the concept of diarrheal diseases, burden of the disease, its causation, prevention and control.

The training module is to be used for conducting a “three consecutive days training”. The various methodologies used in the module include case studies, dramatization, discussions and power point presentations with the purpose of making the learning experience more interactive, participatory and interesting.

For each session mentioned in the module an approximate time limit has been given. It is advisable for the facilitator to try and limit the time spent on each activity within plus 5 minutes of the approximate time given. This would ensure that the participants do not lose interest in the activity and the desired objective is achieved.

At the beginning of each activity, the facilitator can give a brief overview to what is to be expected from the activity. Even better if, the facilitator can opt for eliciting from the participants themselves, what they expect from the activity/exercise. This would help in maintaining the involvement of the participants in the activity by inducing curiosity among them.

The visuals and pictorials have been added for better understanding of the topic.

The module can be used for training 20-25 participants at a time.

Day 1

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INTRODUCTION OF THE PARTICIPANTS AND OVERVIEW OF WORKSHOP

Session

01Total time needed

30 minutes

OBJECTIVESAt the end of the session, the participants will be able to:

Know the other fellow participants and the resource person

Have a complete understanding and overview of the 3 day workshop

Material needed: ■ Power point slides based on the content of this

chapter

■ LCD projector

■ Laptop

■ Colored cards

■ Safety pins/tape

Key messages: ■ The participants will get to know and learn

from each other

■ The participants will build upon the expertise they and others have in the group.

■ They will set the ground rules of the workshop and will have a brief overview of the workshop

Instructional methodology: Games, Brain storming etc.

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Activity 1: Group introductions

■ Introduce yourself and your co-facilitator (s)

■ Welcome the participants to the training of trainers workshop on 7 point plan for prevention and control of Diarrhea.

■ Explain that before starting the program, some time will be spent on getting to know each other through a game.

■ Keep paired cards ready by writing on them words that form pairs – one word on a separate card e.g. ‘Day – Night’, write ‘Day’ on one card and ‘Night’ on another card. These two cards together become a pair. These pairs can also be prepared by writing names of persons, movies, diseases and causative factors, phrases and idioms. The number of paired cards should equal the number of participants so that each one gets one portion of the card. Include the facilitators also in this game.

■ Explain the game to the participants:

○ Each participant, including facilitator(s), will pick up a card when the facilitator(s) come to him/her with the bowl of cards.

○ Each participant will read the word on his/her card and move in the room to find his/her partner with the other word to complete the pair. These two participants, with a complete pair of cards, are partners for this game.

○ Tell the participants that they will be given 5 minutes to complete this game. ○ Tell the participants that each person will ask his/her partner for the following

information: Name, Designation, workplace and number of years of work experience. ○ After 5 minutes, ask each pair to come up to the front of the room and introduce each

other to the whole group. ○ Keep on noting and adding up the number of years of experience of everyone in the

room as you go along. ○ After the introductions, stress that there is a wealth of experience among the

participants present in the room. Mention the total number of years of experience that all the participants together have in the room. Clearly there will be much that every individual can share and learn from other in the group.

After the introduction, conduct the individual activity on expectations and contributions

Activity 2: Individual exercise

■ Take two different colored cards. On one (e.g. pink card) write “Expectations”/what would you like to take away and on other (e.g. blue card) write “Contributions/what you would like to share during the workshop. Paste these two cards on a wall at a distance of 2 feet from each other

■ Give the participants marker pens to write their responses within 2 minutes. As the participants complete writing their responses, ask them to come and paste the cards under each category on the wall.

■ When all the participants have pasted their cards on the wall, request two participants to volunteer to read the responses, first of expectations and then of contributions.

Facilitation notes:

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■ Thank the participants for their responses. Tell them that you will refer to these expectations when presenting the objectives of the program.

■ Also thank them for being ready to contribute to the workshop in their own way.

After the two activities, brief the audience about the overview of the workshop. Tell the participants that the objective of the training is that the field staff of stop diarrhea initiative (SDI) project at district and below district levels understand the 7 point plan for controlling diarrhea and are effectively able to deliver key messages pertaining to health, nutrition and WASH sectors, in the community.

Try to stress to participants that the focus of this workshop is to enable the participants to understand the basic concepts in diarrhea prevention and control and also acquire some skills to facilitate training for staff at block or sub-block levels. After this, display the agenda for three days training.

Time Session Topic Speaker

9:00-9:30 AM Registration

9:30-10:00 AM 1 Introduction of the participants & overview of workshop

10:00-10:30 AM 2 Understanding the burden of diarrhea-Global & India

10:30-11:00 AM 3 Essential concepts of diarrhea-I

11:00-11:30 AM TEA BREAK

11:30-12:00 PM 3 Essential concepts of diarrhea-II & Group exercises

12:00-1:00 PM 4 Assessment of a case of diarrhea-diagnosis & treatment of Diarrhea

1:00-2:00 PM LUNCH

2:00-3:00 PM 4 Assessment a case of diarrhea-diagnosis & treatment of diarrhea (group exercises)

3:00-3:30 PM TEA BREAK

3:30-4:00 PM 5 Prevention of diarrhea

4:00-4:30 PM 6 Issues and challenges in diarrhea prevention and treatment

4:30-5:00 PM Wrap up and feedback

Agenda: Day 1

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Agenda: Day 2


9:00-9:30 AM Welcome and recap of Day 1

9:30-10:00 AM 7 A 7-point plan for comprehensive diarrhea control

10:00-10:30 AM 8 Effective communication-I (Ways and means, Dos and Don’t’s)

10:30-11:00 AM 8 Effective communication-II (Mode of delivery of the key messages)

11:00-11:30 AM TEA BREAK

11:30-12:00 PM 9 Specifics of IEC/BCC activities

12:00-12:30 PM 9 Documentation of IEC/BCC activities

1:00-2:00 PM LUNCH

2:00-2:30 PM 10 Key messages for adults and children around diarrhea control

2:30-3:00 PM 11 Community level structures and their roles and responsibility-I


3:30-4:00 PM 11 Community level structures and their roles and responsibility-I

4:00-4:30 PM 12 Social mobilization and reaching the unreached


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Agenda: Day 3


9:00-9:30 AM Welcome and recap of Day 2

9:30-10:00 AM 13 Basics of Adult learning techniques-I

10:00-10:30 AM 13 Basics of Adult learning techniques-II

10:30-11:30 AM 14 Participants work together and plan for conducting sessions with the field staff


12:00-1:00 PM 15 Mock Session conducted by Group 1-feedback sharing and discussion

1:00-2:00 PM LUNCH

2:00-3:00 PM 15 Mock Session conducted by Group 1-feedback sharing and discussion


3:30-4:30 PM 15 Mock Session conducted by Group 1II-feedback sharing and discussion


Explain that the program is tightly structured, requiring everyone’s uninterrupted presence and active participation. Tell the participants that during the workshop everyone will be asked to share their views and perspectives with others. In this way, everyone (including the facilitators) will be equal participants. Tell them that in this workshop there are no teaching sessions; we all learn from each other.

Explain briefly the methodology and process of the training program. Explain the “participatory learning process”. The teaching and learning methods used throughout the training program are participatory and appropriate to working with adults who always bring a wealth of personal experience to any learning event.

The program uses a range of methods and approaches, from direct input in the form of short mini lectures to problem-solving in small groups and role-play sessions.

Emphasize that there are some basic ground rules that would be followed throughout the workshop. Ask the participants to brainstorm and then decide the ground rules for the workshop. The facilitator may note down the suggestions on a chart which can be displayed towards the end of the activity and be displayed for all the 3 days of the workshop.

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Put up a slide to display the ground rules, which may be as follows:

■ Treat everyone with respect at all times, irrespective of sex or age

■ Ensure and respecting confidentiality

■ Agree to respect and observe time-keeping and to begin and end the sessions on time

■ Speaking one by one - make sure that everyone has the opportunity to be heard

■ Accept and give critical feedback taking care not to hurt anyone’s feelings

■ Keep mobile phones on silent mode

■ Draw on the expertise of facilitators and the participants in difficult situations

Ask one of the participants to read out the list of ground rules. Once the list of ground rules is complete, write the list on the slide and paste it on the wall. These can then be referred to throughout the workshop.

End the session by stressing that we all learn best when we take an active part in finding out things that are new to us.

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UNDERSTANDING THE BURDEN OF DIARRHEA-GLOBAL & INDIA

Session

02Total time needed

30 minutes

OBJECTIVESAt the end of the session, the participants will be able to

Know the global burden of diarrhea

Know the burden of diarrhea in India

Material needed: ■ Power point slides prepared based on the

content of this chapter

■ LCD projector

■ Laptop

Key messages: ■ Diarrheal disease is globally the second leading

cause of death in children under five years old.

■ The number of child deaths from pneumonia and diarrhea is almost equal to the number of child deaths from all other causes.

■ Africa and South Asia are home to more than 80 percent of child deaths due to diarrhea.

■ India is leading in accounting for child deaths due to diarrhea (almost 13%).

Instructional methodology:Group discussion, lecture (power point slides)

Facilitation notes: Show the first slide and ask the participants if they have heard about diarrhea. Invite thoughts and definitions. Encourage participants to share their thoughts. After many

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of them have said something, share the correct definition of the term and emphasize on important points. Then highlight the slide showing the global burden of disease.

Then project the graph and ask the participants what the graph shows. Ask them what according to them are the key factors responsible for neonatal mortality. Then focus on deaths caused by diarrhea. Say that diarrhea and pneumonia together causes majority of deaths.

Then highlight the slide showing the burden of disease in India. Restate the gender wise and region wise variation of diarrhea.

End the session by asking one of the participants to summarize the session.

IntroductionDiarrhea is defined as the passage of three or more loose or liquid stools per day. It is major public health problem world over. Diarrheal disease is the second leading cause of death in children under five years old, and is responsible for the deaths of around 760 000 children every year.1 It accounts for 1 in 9 child deaths worldwide.2 Globally, there are nearly 1.7 billion cases of Diarrheal disease every year.1 On average, children below 3 years of age in developing countries experience three episodes of diarrhea each year.3 In 2010, the number of child deaths from pneumonia and diarrhea was almost equal to the number of child deaths from all other causes after the neonatal period-that is, acquired immunodeficiency syndrome (AIDS), malaria, measles, meningitis, injuries and all other post neonatal conditions combined.4 (Figure 1)

Figure 1: Global distribution of deaths among children less than 5 years of age by cause, 2010 5

(Source: Black, R, Allen, LH, Bhutta, ZA et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008; 371: 243–260)5

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Sesson 2: Understanding the burden of Diarrhea-Global & India

Africa and South Asia are home to more than 80 percent of child deaths due to diarrhea.6 Just 15 countries, with India leading all, account for almost three quarters of all deaths from diarrhea among children under five years of age annually.6

Diarrhea is the third most common cause of death in under-five children, responsible for 13% deaths in this age-group, killing an estimated 300,000 children in India each year7,8. The proportionate mortality due to diarrhea in children aged 0-6 years is 9.1%. Average estimated incidence of diarrhea in children aged 0-6 years was 1.71 and 1.09 episodes/ person/year in rural and urban areas.9 According to Million Death Study, diarrhea as a cause of death in children aged 1-59 months was 8.9 per 1000 live births amongst boys and 13.4 per 1000 live births among girls.8 Further, diarrhea accounted for a greater proportion of total child deaths in lower income than in higher income states. Region wise variation also exists in mortality rate due to diarrhea. The mortality rate from diarrheal diseases in central India was three times that in the west.8

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References:1. WHO. Factsheet: Diarrheal disease [Internet] 2013 [Accessed on 2016, Feb 2]. Available from:

http://www.who.int/mediacentre/factsheets/fs330/en/

2. CDC. Global Diarrhea Burden [Internet] 2015 [Accessed on 2016, Feb 2]. Available from: http://www.cdc.gov/healthywater/global/diarrhea-burden.html

3. WHO. The treatment of Diarrhea. A manual for physicians and other senior health workers. [Internet] 2005 [Accessed on 2016, Feb 2]. Available from: http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf

4. UNICEF, WHO. Ending preventable child deaths from pneumonia and diarrhea by 2025. The integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD). Switzerland: Geneva; 2013. Available from: http://apps.who.int/iris/bitstream/10665/79200/1/9789241505239_eng.pdf?ua=1

5. Black, R, Allen, LH, Bhutta, ZA et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008; 371: 243–260

6. UNICEF, WHO. Diarrhea: Why children are still dying and what can be done. Switzerland: Geneva; 2009. Available from: http://www.unicef.org/media/ files/Final_Diarrhea_Report_October_2009_final.pdf.

7. Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: Current scenario and future perspectives. J Nat Sci Biol Med. 2015;6(1):24-8.

8. Million Death Study Collaborators. Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, et al. Causes of neonatal and child mortality in India: A nationally representative mortality survey. Lancet.2010;376:1853–60.

9. New Delhi, India: National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Govt. of India; 2005. Report of the National Commission on Macroeconomics and Health. Estimation of burden of diarrheal diseases in India. In: NCMH Background Papers: Burden of Diseases in India; pp. 182–7.

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Sesson 2: Understanding the burden of Diarrhea-Global & India

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ESSENTIAL CONCEPTS OF DIARRHEA

Session

03Total time needed

60 minutes


Understand the concept of diarrhea-definition and clinical types

Know the causes and modes of transmission of diarrhea

Know who all are vulnerable to diarrhea



■ LCD projector

■ Laptop

■ Blackboard, chalk/white board and marker pen

■ Videos/CD

■ Handouts for exercises (group work)

Key messages: ■ Diarrhea is defined as the passage of three or

more loose or watery stools per day.

■ There are three clinical types of diarrhea: acute watery, acute bloody and persistent diarrhea

■ During a diarrheal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost which can cause dehydration.

■ Diarrhea is transmitted by faeco-oral route.

■ Diarrhoea is caused by both infectious and non-infectious agents.

■ Viral diarrhea is more common in childhood.

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Sesson 3: Essential concepts of Diarrhea

Instructional methodology: Group discussion, lecture (power point slides)

Facilitation notes: Show the first slide and ask the participants if they have heard about diarrhea. Invite thoughts and definitions. Encourage participants to share their thoughts. After many of them have said something, share the correct definition of the term and emphasize on important points by projecting the slide. Then project the slide on various types of diarrhea.

Then project the stages of dehydration and describe them in detail. Then demonstrate video showing the child with dehydration.

Ask the participants about causes of diarrhea. Write all the responses on the blackboard/chart/whiteboard. Then add on the content which may not have been given in responses. Even if the participants state viruses, bacteria and parasites as causes, it can be taken as correct responses (as it may be difficult for them to spell the exact organism). Display the complete list of organism.

Assess the participants’ knowledge about mode of transmission of diarrhea. Project the slide on the same. Also highlight the risk factors and vulnerability to development of childhood diarrhea.

At the end of the session, ask any participant to summarize the session in terms of epidemiological triad and then display the key messages of the session

After the session, conduct the group exercises. (These exercises can be done as group work comprising 4-5 participants in each group).

What is diarrhea?Diarrhea is defined as the passage of three or more loose or liquid stools per day.1 However, it is the consistency of the stools rather than number that is more important.2

Diarrhea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms.

What are various types of diarrhea?There are three clinical types of diarrhea:

■ Acute watery diarrhea – lasts several days, and includes cholera;

■ Acute bloody diarrhea – also called dysentery; and

■ Persistent diarrhea – lasts 14 days or longer.

What is not diarrhea?1. Frequent passing of

formed stools.

2. “Pasty” stools passed by babies who are breastfed.

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Complications of diarrheaThe main danger associated with acute watery diarrhea is dehydration. Weight loss may also occur if feeding is not continued. Damage of intestinal mucosa, sepsis and malnutrition may additionally occur in acute bloody diarrhea. Persistent diarrhea may lead to malnutrition. Dehydration may also occur sometimes.2

Diarrhea associated with dehydrationDuring a diarrheal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced.

The degree of dehydration is graded according to signs and symptoms that reflect the amount of fluid lost:

■ Early stages of dehydration-no signs and symptoms

■ Moderate dehydration-thirst, restless or irritable behavior, decreased skin turgor, sunken eyes and sunken fontanelle (in infants)

■ Severe dehydration- shock, with diminished consciousness, lack of urine output, cool, moist extremities, a rapid and feeble pulse, low or undetectable blood pressure, and pale skin.

(Show a video of a dehydrated child with diarrhea).

Death can follow severe dehydration if body fluids and electrolytes are not replenished.

What are causes of diarrhea?Infectious agents are by far the most common cause for sporadic or endemic episodes of acute diarrhea in children.

Infectious causes include: 3

■ Viruses

○ Rotavirus ○ Norovirus ○ Calcivirus ○ Astrovirus ○ Enteric type adenovirus

■ Bacteria

○ Campylobacter Jejuni ○ Salmonella ○ E coli ○ Shigella ○ Yersinia enterocolitica

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○ Clostridium difficile ○ Vibrio parahaemolyticus ○ Vibrio cholera ○ Aeromonas hydrophila

■ Parasites

○ Cryptodporidium ○ Giardia lamblia

Besides, there are other non-infectious causes of diarrhea as well. These include: drug induced, food allergies or intolerances, malabsorption disorders, chemotherapy or radiation induced enteritis, heavy metal ingestion, vitamin deficiencies.

Modes of transmission of diarrheaMost pathogens that cause diarrhea share a similar mode of transmission – from the stool of one person to the mouth of another. This is known as faecal-oral transmission. Acute diarrhea usually occurs by ingestion of contaminated food or water. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning.

Food is another major cause of diarrhea when it is prepared or stored in unhygienic conditions. Water can contaminate food during irrigation.3 Fish and seafood from polluted water may also contribute to the disease.

Vulnerability to childhood diarrheaVarious studies across the world indicate that low level of maternal education, working status of mother, absence of toilet facility, lack of hand washing before feeding, inadequate breastfeeding, improper child stool disposal methods, not improved source of drinking water, poor socio-economic status, having more than two under five children, higher birth order and the age of the child are some of the risk factors associated with childhood diarrhea.4,5,6 Incidence of diarrheal diseases is observed to be maximum during the summer months followed by rainy or winter months.6


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ExerciseQ1. A 1 month old child on breast milk is passing pasty stools 3-4 times a day in last 2 days. The mother says that he has history of passage of such stools. What is your diagnosis?

Ans. Normal

Q2. A 4 month old is passing loose watery stools for last 3 days. The child is not being breastfed. The child is top-fed and taking water also since birth. The child is 5 birth order living in a family of seven. There is no toilet in the house. The mother is illiterate. But she works as housemaid in neighbouring colonies. Kindly enlist the risk factors in the history for this child.

Ans. Young age (4 months); Not breastfed; Taking water; Birth order 5; no toilet facility; illiterate mother; working mother.

Q3. A 3 year old child is passing loose watery stools for last 1 day. The child openly defecates near the house and does not wash hands before eating food. Describe the mode of transmission of infection in this case.

Ans. Faeces contaminating water and food, poor personal hygiene, ingestion of contaminated food.

References:1. WHO. Factsheet: Diarrheal disease [Internet] 2013 [Accessed on 2016, Feb 2]. Available from: http://www.who.int/mediacentre/factsheets/fs330/en/

2. WHO. The treatment of Diarrhea. A manual for physicians and other senior health workers. [Internet] 2005 [Accessed on 2016, Feb 2]. Available from: http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf

3. Medscape. Diarrheal Clinical Presentation [Internet] 2015 [Accessed on 2016, Feb 2] Available from: http://emedicine.medscape.com/article/928598-clinical#b5.

4. Mihrete TS, Alemie GA, Teferra AS. Determinants of childhood diarrhea among underfive children in Benishangul Gumuz Regional State, North West Ethiopia. BMC Pediatrics 2014;14:102

5. Mengistie B, Berhane Y, Worku A. Prevalence of diarrhea and associated risk factors among children under five years of age in eastern Ethopia: a cross-sectional study. Open Journal of Preventive Medicine 2013;3(7):446-53.

6. Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: Current scenario and future perspectives. J Nat Sci Biol Med. 2015;6(1):24-8.

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ASSESSMENT OF A CASE OF DIARRHEA-DIAGNOSIS AND TREATMENT

Session

04Total time needed 120 minutes


Acquire the skills for eliciting history from sick child with diarrhea

Classify the child for signs related to diarrhea

Know the treatment of child suffering from diarrhea



■ LCD projector

■ Laptop

■ Videos

■ Dummy or simulated models for eliciting signs

■ Charts, sketch pens

■ Ingredients for making home made ORS

Key messages: ■ Ask, look and feel for relevant signs and

symptoms related to diarrhea.

■ Assessment of dehydration in a case of diarrhea is must.

■ A case of diarrhea can be classified into 3 categories based on general condition, eyes, skin pinch and thirst.

■ Treatment Plan A is given as Home therapy to prevent dehydration; Treatment Plan B is for children with some dehydration whereas Treatment Plan C for children with severe dehydration and have to be managed in hospital inpatient department.

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■ For a breastfed child, continue breastfeeding even during the episode of diarrhea.

■ In absence of ORS, home made ORS can also be given to child.

■ Viral diarrhea is more common in childhood.

Instructional methodology: Group discussion, lecture (power point slides), demonstration, case studies

Facilitation notes: Show the first slide and discuss the points to be taken in history. Then demonstrate the clinical signs through video or dummy. After completion of history and assessment ask one of the participants to summarize the important history and examination. Then highlight the slide showing the categorization of a case of acute diarrhea. Then ask the patients about definition of persistent diarrhea (diarrhea lasting for 14 or more days) and dysentery (acute diarrhea with blood). Note down the responses and then project the respective slides. After this, divide the participants into 4 groups and give the exercises on classification to them (one exercise to two groups). Give 10 minutes for group work and then discuss the two cases.

Then discuss the management of acute diarrhea with the participants through slides. After each treatment plan, reinforce the important points. After discussing the management, again distribute the same cases and ask the groups to work on their management. Give 10 minutes for group work. Ask the groups to discuss the points on chart paper and display it. Discuss the management of the two cases in detail (20 minutes)

Demonstrate the making ORS solution using WHO recommended low osmolarity solution and homemade ORS. Ask two participants to demonstrate it again both ways. End the session by asking one of the participants to summarize the session. Then project the summary box.

IntroductionA child with diarrhea should be assessed for dehydration, bloody diarrhea, persistent diarrhea, malnutrition, serious non-intestinal infections, so that an appropriate treatment plan can be developed and implemented without delay.1

History1,2

Ask the mother or caretaker about:

■ Age of the child

■ Duration of diarrhea

■ Frequency of diarrhea

■ Presence of blood in stool

■ Presence of fever, cough or other important problems (e.g. recent measles)

■ Pre-illness feeding practices

Sesson 4: Assessment of a case of Diarrhea-Diagnosis and Treatment

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■ Presence and frequency of vomiting

■ Type and amount of fluids (including breast milk) food taken during illness

■ Immunization status

■ Drugs or other remedies taken

Clinical assessmentLook for signs and symptoms of dehydration:

■ Child’s general condition. Assess if the child is alert or lethargic or unconscious or restless/irritable

■ Are the eyes normal or sunken?

■ Child’s reaction when offered to drink: When water or ORS solution is offered to drink, is it taken normally or refused, taken eagerly, or is the child unable to drink owing to lethargy or coma?

Feel the child to assess:Elasticity of the skin: Check elasticity of skin using the skin pinch test. When released, the skin pinch goes back either very slowly (longer than 2 seconds) or slowly (skin stays up even for a brief instant), or immediately.

Then check for signs of other important problems.

Look for:

■ Does the child’s stool contain red blood?

■ Is the child malnourished? Check for visible severe wasting of the shoulders, arms, buttocks and legs, with ribs easily seen. Look at the child’s hips. They may look small when compared to chest and abdomen. This indicates presence of marasmus. Look at the child from the side to see if the fat of the buttocks is missing. When wasting is extreme, there are many folds of skin on the buttocks and thigh. However, the face of a child with visible severe wasting may still look normal. Look also for oedema of feet. If possible assess child’s weight for age using growth chart.

■ Is the child coughing? If so, count the respiratory rate to determine whether breathing is abnormally rapid and look for chest in drawing.

Take the child’s temperature

Table 1: Assessment of diarrhea patients for dehydration

Note: a. Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child’s mental state is dull and the child cannot be

fully awakened; the child may appear to be drifting into unconsciousness.b. In some infants and children, the eyes normally appear somewhat sunken. It is helpful to ask the mother if the child’s eyes are normal or

more sunken than usual.c. The skin pinch is less useful in infants or children with marasmus or kwashiorkor, or obese children.

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Classification of Dehydration1,2

Based on a combination of the above clinical signs, children presenting with diarrhea are classified into 3 categories:

Categories A B CLook at: • Condition • Eyes • Thirst

Well, alert Normal Drinks normally, not thirsty

Restless, irritable Sunken Thirsty, drinks eagerly

Lethargic/unconscious Sunken Drinks poorly, or not able to drink

Feel: skin pinch Goes back quickly

Goes back slowly Goes back very slowly

Decide The patient has NO SIGNS OF DEHYDRATION

If the patient has two or more signs in B, there is SOME DEHYDRATION

If the patient has two or more signs in C, there is SEVERE DEHYDRATION

Treat Use treatment plan A

Weigh the patient, and use treatment plan B

Weigh the patient, and use treatment plan C URGENTLY

Classification of persistent diarrhea2

All children with diarrhea for 14 days or more should be classified based on the presence or absence of any dehydration

� If dehydration is present, children are classified as having severe persistent diarrhea. Such children require special treatment and should not be managed at outpatient health facility.

� If no signs of dehydration are present, children are classified as having persistent diarrhea. Such children can safely be managed at outpatient health facility.

Classification of dysentery2

A child is classified as having dysentery if mother or caretaker reports blood in child’s stool. Bloody diarrhea is usually a sign of invasive enteric infection that carries a substantial risk of morbidity and death.

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ExerciseQ1. Case: Fatima is 18 months old. She weighs 11.5 Kg. Her temperature is 37.5 degree Celsius. The mother brought the child to the physician and complained that the child is having diarrhea for 3 days. She said, “there was no blood in the stool.” The general condition of the child was poor. Child looked lethargic. Fatima’s eyes looked sunken. The physician asked “Do you notice anything different about Fatima’s eyes?” The mother said “Yes”. He gave the mother some clean water in a cup and asked her to offer it to Fatima. When offered the cup, Fatima would not drink. When pinched, the skin of Fatima’s abdomen went back slowly.

Classify the child with diarrhea

Ans. The child is having diarrhea with severe dehydration

Q2. Case: Jatin is 6 weeks old. He weighs 4.5 Kg. His temperature is 37 degree Celsius. The physician asks the mother about Jatin’s diarrhea, the mother replies that it began 3 days ago, there is no blood in the stool. Jatin is crying. He stopped once when his mother put him to the breast. He began crying again when she stopped breastfeeding. His eyes look normal, not sunken. When the skin of his abdomen is pinched, it goes back slowly.

Classify the child with diarrhea

Ans. The child is having diarrhea with some dehydration

Management of acute diarrheaThe objectives of treatment are to:

■ Prevent dehydration, if there are no signs of dehydration;

■ Treat dehydration, when it is present;

■ Prevent nutritional damage, by feeding and during diarrhea;

■ Reduce the duration and severity of diarrhea and the occurrence of future episodes by giving supplemental zinc.

Treatment Plan A: Home therapy to prevent dehydration and malnutritionChildren with no signs of dehydration need extra fluids and salt to replace their losses of water and electrolytes due to diarrhea. Mothers should be taught how to prevent dehydration at home by giving the child more fluid than usual, how to prevent malnutrition by continuing to feed the child, and why these actions are important. There are 4 rules of Home treatment: give extra fluid, zinc supplement, continue feeding, when to return.

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1. Give extra fluid (as much as the child will take)

� If the child is exclusively breastfed: Breastfeed frequently and for longer at each feed. If passing frequent watery stools:

○ For less than 6 months age give ORS (oral rehydration solution) and clean drinking water in addition to breast milk.

○ If 6 months or older give one or more of the home fluids in addition to breast milk.

� If the child is not exclusively breastfed: Give one or more of the following home fluid: ORS solution, food based fluid (such as soup, rice water, and yoghurt drinks, coconut water) or clean water.

� It is especially important to give ORS at home when: ○ The child has been treated with Plan B or Plan C during this visit. ○ The child cannot return to a clinic if the diarrhea gets worse.

� Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at home.

� Show the mother how much fluid to give in addition to the usual fluid intake:

Up to 2 years 50-100 mL after each loose stool2 years or more 100 to 200 ml after each loose stool

2 months to 6 months ½ tablet daily for 14 days6 months or more 1 tablet daily for 14 days

� Tell the mother to: ○ Give frequent small sips from a cup ○ If the child vomits, wait 10 minutes. Then continue, but more slowly. ○ Continue giving extra fluid until the diarrhea stops.

2. Give Zinc (age 2 months upto 5 years)

� Tell the mother how much zinc to give (20 mg tab):

� Show the mother how to give zinc supplements

○ Infants- dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup.

○ Older children- tablets can be chewed or dissolved in a small amount of water.3. Continue feeding (exclusive breastfeeding if age less than 6 months)

4. When to return: follow up in 5 days if not improving

Treatment Plan B: Oral rehydration therapy for children with some dehydrationChildren with some dehydration should receive oral rehydration therapy (ORT) with ORS solution in a health facility following Treatment Plan B.

In the clinic, give recommended amount of ORS over 4-hour period.

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■ Determine amount of ORS to give during first 4 hours

Weight <6 Kg 6-<10 Kg 10-<12 Kg 12-19 KgAge* Upto 4 months 4-12 months 1-2 years 2-5 yearsIn ml 200-450 450-800 800-960 960-1600

○ If the child wants more ORS than shown, give more. ○ For infants under 6 months who are not breastfed, also give 100-200 ml clean

water during this period if you use standard ORS. This is not needed if you use low osmolarity ORS.

■ Show the mother how to give ORS solution

○ Give frequent small sips from cup. ○ If the child vomits, wait 10 minutes. Then continue, but more slowly. ○ Continue breastfeeding whenever the child wants.

■ After 4 hours:

○ Reassess the child and classify the child for dehydration ○ Select the appropriate plan to continue treatment. ○ Begin feeding the child in clinic

■ If the mother must leave before completing the treatment:

○ Show her how to prepare ORS solution at home. ○ Show her how much ORS to give to finish 4-hour treatment at home. ○ Give her enough ORS packets to complete rehydration. ○ Explain her 4 rules of home treatment.

Treatment Plan C: for patients with severe dehydrationThe preferred treatment for children with severe dehydration is rapid intravenous rehydration, following Treatment Plan C. If possible, the child should be admitted to hospital.

■ Start IV fluid immediately. If the patient can drink, give ORS by mouth until the drip is set up. Give 100 ml/Kg Ringer Lactate solution (or if not available, normal saline), divided as follows:

*Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying child’s weight (in Kg) times 75.

Age First give 30 ml/kg in: Then give 70 ml/kg in:Infants (under 12 months) 1 hour 5 hoursChildren (12 months upto 5 years) 30 minutes 2.5 hours

■ Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly.

■ Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children).

■ Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment.

Note: Antibiotics should not be used routinely for treatment of diarrhea. Most diarrheal episodes are caused by agents for which anti-microbials are not effective, e.g. viruses.Anti-diarrheal drugs-including anti-motility agents (e.g. loperamide, diphenoxylate, codeine, tincture of opium), adsorbents (e.g. kaolin), live bacterial cultures (e.g. lactobacillus, streptococcus faecium), and charcoal-do not provide practical benefits for children with acute diarrhea.

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ExerciseQ1. For the above mentioned 2 cases, kindly discuss the suitable treatment plan in detail.

Ans. Treatment Plan B, Treatment Plan C

ExerciseQ1. Ask the participants to demonstrate the use of WHO recommended ORS and making of home-made ORS.

Demonstration: WHO ORS Preparing one litre Oral Rehydration Soultion (ORS): Take 5 cups of water (each cup of 200 mL). Boil the water and then cool it. Mix the WHO recommended low osmolarity solution in one litre of water. Keep giving this ORS at regular interval over 24 hour period.

Demonstration: Home made ORS Preparing one litre Oral Rehydration Solution (ORS) using salt, sugar and water at home. Mix an oral rehydration solution using one of the following recipes; depending on ingredients and container availability3:

References:1. WHO. The treatment of Diarrhea. A manual for physicians and other senior health workers. [Internet] 2005 [Accessed on 2016, Feb 2]. Available from: http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf

2. MoHFW, GoI. Student’s Handbook IMNCI: Integrated Management of Neonatal and Childhood Illness. India: New Delhi; 2009.

3. Oral Rehydration Solutions: made at Home [Internet] 2012 [Accessed on 2016, Feb 10]. Available from: http://rehydrate.org/solutions/homemade-ors.pdf.


PREVENTION OF DIARRHEA

Session

05Total time needed

30 minutes


Know the preventive strategies for diarhoea

Reflect upon the preventive measures for diarrhea



■ LCD projector

■ Laptop

■ Soap

■ Water

Key messages: ■ Diarrhea is a preventable disease

■ Proper treatment of diarrheal diseases prevents the death

■ There are various preventive strategies for diarrhea control that include: safe drinking water supply, storage and use, improved sanitation, hand washing, exclusive breastfeeding, food hygiene, health education, immunization and micronutrient supplementation.

Instructional methodology: ■ Group discussion, lecture (power point slides),

demonstration

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Facilitation notes: Begin the session by asking the participants whether they know of any preventive measures against diarrheal diseases. Note the response on the blackboard/whiteboard and then project the slide showing all the preventive measures.

After this, discuss each preventive measure in detail. Begin the discussion by asking what is safe drinking water? How does unsafe water affect the health? Note down the responses and add on the missing points. Then discuss about various household and other methods of purification (Please refer to in Annexure II). First ask whether they have toilet facility at home and whether they use it or not. Then ask them the reasons for using particular type of toilet facility in daily life. Note the responses. Then ask the participants what are the different types of toilet facility they are aware of. Show them pictures of common toilet styles. Then explain how sanitation plays important role in diarrhea control.

After this, ask the participants whether they wash their hands after toilet and before cooking and eating meals. Then ask how they wash their hands-with just water, or water and soap, or water and ash. Washing hands with only water is considered improper hand hygiene. Ask how improper hand hygiene leads diarrhea. Then ask whether anyone in the audience knows the steps of hand washing. Demonstrate the steps of hand washing while discussing hand hygiene. Then ask one of the participants to demonstrate it again.

Then the discussion will focus on good personal hygiene. Ask the participants what constitutes good personal hygiene- cut nails, trimmed hairs/tied hairs, bathing daily with soap and water, brushing teeth etc.

After this, ask the participants what is exclusive breastfeeding and what are the advantages of it. Then discuss the importance of good personal hygiene and food hygiene. Then ask the participants how immunization and micronutrient supplementation prevents diarrhea. Discuss in detail.

End the session by asking one of the participants to summarize the session and then display the key messages.

IntroductionProper treatment of diarrheal diseases is highly effective in preventing death, but has no impact on the incidence of diarrhea.1 However, there exists a range of preventive strategies for reducing the burden of morbidity associated with diarrhea. The key measures include2:

■ Access to safe drinking water;

■ Use of improved sanitation;

■ Hand washing with soap at critical times

■ Exclusive breastfeeding for the first six months of life; and continued breastfeeding for two years.1

■ Good personal and food hygiene;

■ Health education about how infections spread;

■ Measles and Rotavirus vaccination

■ Micronutrient supplementation

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Sesson 5: Prevention of diarrhea

Access to safe drinking waterSafe drinking water is water with microbial, chemical and physical characteristics that meet WHO guidelines or national standards on drinking water quality (Indian standards for drinking water IS 10500 See the Annexure I); and access to safe drinking water means that the source is less than 1 kilometer away from its place of use and that it is possible to reliably obtain at least 20 litres per member of a household per day (WHO).3 In India, as per Ministry of Drinking Water & Sanitation (MDWS), India, in rural context safe water requirement is 55 lpcd within the household premises or at a horizontal or vertical distance of not more than 100 metres from their household without barriers of social or financial discrimination (Purpose and quantity (in lpcd): Drinking -3, Cooking- 5, Bathing 15, Washing utensils and house 10, Ablution/Toilets 10 Washing of Clothes and other uses 12=Total 55). Interventions to improve water quality at the source, along with treatment of household water and safe storage systems, have been shown to reduce diarrhea incidence by as much as 47 per cent.4 Household water treatment options that are currently being promoted include chlorination, filtration, disinfection, boiling, and solar disinfection.4 (See Annexure II)

Further, families should: ■ Collect water from the cleanest available source.

■ Not allow bathing, washing, or defecation near the source. Latrines should be located more than 15 metres away and downhill.

■ Keep animals away from protected water sources.

■ Collect and store water in clean containers; empty and rinse out the containers every day; keep the storage container covered and take out water with a long handled laddle that is kept especially for the purpose so that hands do not touch the water.

■ Use filtered and boiled water for drinking and making food for young children. Water needs only to be brought to a rolling boil

The amount of water available to families has as much impact on the incidence of diarrheal diseases as the quality of water. In simpler terms it means that if the amount of water is less, it will impact the personal as well as environmental hygiene, thereby leading to infections. Also if the quality of water is poor, it leads to diarrhea

Use of improved sanitationIn India, around 595 million people, which is nearly half the population of India, defecate in the open.5 Open defecation poses a serious threat to the health of children in India. The practice is the main reason India reports the highest number of diarrheal death of children under-five in the world. Children weakened by frequent diarrhea episodes are more vulnerable to malnutrition, stunting, and opportunistic infections such as pneumonia.

Improving sanitation facilities has been associated with an estimated median reduction in diarrhea incidence of 36 per cent. This is due to the fact that improved sanitation prevents the transmission of pathogens that cause diarrhea by preventing human faecal matter from contaminating environment.4 Every family needs access to a clean, functioning latrine. (See Annexure III)

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(To accelerate the efforts to achieve universal sanitation coverage and to put focus on sanitation, the Prime Minister of India launched the Swachh Bharat Mission on 2nd October, 2014. The Mission Coordinator is Secretary, Ministry of Drinking Water and Sanitation (MDWS) with two Sub-Missions, the Swachh Bharat Mission (Gramin) and the Swachh Bharat Mission (Urban), which aims to achieve Swachh Bharat by 2019)

Hand washing with soapAll diarrheal disease agents can be spread by hands,, that have been contaminated by fecal material. The risk of diarrhea is substantially reduced when family members practice regular hand washing. All family members should wash their hands thoroughly after defecation, after cleaning a child who has defecated, after disposing of a child’s stool, before preparing food, and before eating. Good hand washing requires the use of soap or a local substitute, and enough water to rinse the hands thoroughly.1

Demonstrate: 6 steps in hand washing6

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Exclusive breastfeedingDuring the first 6 months of life, infants should be exclusively breastfed. This means that the healthy baby should receive breast milk and no other foods or fluids, such as water, teas, juice, cereal drinks, animal milk or formula. Exclusively breastfed babies are much less likely to get diarrhea or to die from it than babies who are not breastfed or are partially breastfed. Breastfeeding also protects against the risk of allergy early in life, aids in child spacing and provides protection against infections other than diarrhea (e.g. pneumonia). Breastfeeding should continue until at least 2 years of age. The best way to establish the practice is to put the baby to the breast immediately after birth and not to give any other fluids.1

If breastfeeding is not possible, cow’s milk (diluted with water if given to infants younger than 6 months as the digestive system of the child is not developed at that age) or milk formula should be given from a cup. This is possible even with very young infants. Feeding bottles and teats should not be used because they are very difficult to clean and easily carry the organisms that cause diarrhea. Careful instructions should be given on the correct hygienic preparation of milk formula using water that has been boiled briefly before use.1

Take home message: In cases where breast feeding is not possible (such as death of the mother, HIV positive mother, infection of the breast, thyroid disorders etc.), milk given from outside must be diluted with clean boiled water and for making milk formula also, clean water should be used.

Good personal and food hygienePersonal hygiene requires the cleaning of all parts of the body (face, hair, body, legs and hands). The hands and finger nails have to be cleaned because the germs in between the fingers and finger nails cause contagious diseases such as diarrhea, worms, etc.

Food can be contaminated by diarrheal agents at all stages of production and preparation and storage. Following precautions should be taken to endure food safety1:

■ Do not eat raw food, except undamaged fruits and vegetables that are peeled and eaten immediately;

■ Wash hands thoroughly with soap after defecation and before preparing or eating food;

■ Cook food until it is hot throughout;

■ Eat food while it is still hot, or reheat it thoroughly before eating;

■ Wash and thoroughly dry all cooking and serving utensils after use;

■ Keep cooked food and clean utensils separately from uncooked food and potentially contaminated utensils; and

■ Protect food from flies by means of fly screens.

Health education about how infection spreadsThe family members of the patient suffering from diarrhea should be educated about mode of transmission of diarrhea. They should be motivated and emphasized to adopt appropriate preventive measures.

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Measles and Rotavirus immunizationImmunizations help reduce deaths from diarrhea in two ways: by helping prevent infections that cause diarrhea directly, such as rotavirus, and by preventing infections that can lead to diarrhea as a complication of an illness, such as measles.4 (See Annexure IV)For details of rotavirus (See Annexure VI)

Micronutrient supplementationAdequate zinc intake among children is critical for normal growth and development. Recent supplementation trials have shown that adequate zinc leads to a substantial reduction in childhood diarrhea cases.4 It reduces the duration and severity of diarrhea episodes, decrease stool output, and lessen the need for hospitalization. It may also prevent future diarrhea for upto three months. It has been determined that the use of both zinc and ORS for diarrhea can dramatically reduce the need for unscheduled IV therapy and, more importantly, reduce the number of diarrheal disease-related deaths.7

Vitamin A supplementation has also been shown to reduce the duration, severity and complications associated with diarrhea.4 Vitamin A maintains the physical and functional integrity of epithelial tissues that serve as a barrier against infection. Further, Vitamin A also plays a role in the production of cell glycoprotein and in the regulation of cell division in the intestine, which has a bearing on intestinal epithelial renewal during and after acute enteric infections and thereby on the absorption of water, electrolytes, and other nutrients.8

References:1. WHO. The treatment of Diarrhea. A manual for physicians and other senior health workers. [Internet] 2005 [Accessed on 2016, Feb 2]. Available from: http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf

2. WHO. Factsheet: Diarrheal disease [Internet] 2013 [Accessed on 2016, Feb 2]. Available from: http://www.who.int/mediacentre/factsheets/fs330/en/

3. WHO. Water Sanitation and Health (WSH) [Internet] 2002 [Accessed on 2016, Feb 10]. Available from: http://www.who.int/water_sanitation_health/mdg1/en/

4. UNICEF, WHO. Diarrhea: Why children are still dying and what can be done. Switzerland: Geneva; 2009. Available from: http://www.unicef.org/media/files/ Final_Diarrhea_Report_October_2009_final.pdf.

5. UNICEF. Eliminate open defecation [Internet] 2015 [Accessed on 2016, Mar 15]. Available from: http://unicef.in/Whatwedo/11/Eliminate-Open-Defecation

6. WHO. Hand hygiene: Why, How and When? [Internet] 2009 [ Accessed on 2016, Feb 10]. Available from: http://www.who.int/gpsc/5may/Hand_Hygiene_Why_ How_and_When_Brochure.pdf.

7. Center for sustainable development. Zinc & Vitamin A: Mitigating Diarrhea in Children [Internet] 2015 [Accessed on 2016 Feb 17]. Available from: http://www.csd-i.org/zinc-vitamin-a-mitigating-dia/

8. Bhan MK, Bhandari N. The Role of Zinc and Vitamin A in Persistent Diarrhea Among Infants and Young Children. Journal of Pediatric gastroenterology & Nutrition 1998;26(4):446-53.

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ISSUES AND CHALLENGES IN DIARRHEA PREVENTION AND TREATMENT

Session

06Total time needed

30 minutes


Know the issues and challenges in diarrhea prevention

Know the issues and challenges in diarrhea treatment



■ LCD projector

■ Laptop

■ Chart paper

■ Pens

Key messages: ■ Challenges in diarrhea prevention include- lack

of proper sanitation and safe water supply, lack of knowledge about benefits of exclusive breastfeeding, socio-cultural, administrative barriers and logistics and supply chain related barriers for low coverage of measles

■ Challenges in diarrhea treatment- availability and correct use of ORS, compliance to zinc therapy and irrational use of antibiotics in childhood diarrhea.


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Facilitation notes: Begin the session by asking the participants about what they feel are the issues and challenges in prevention and control of diarrhea. Note the response on the chart paper. Ask one of the participants to read the responses once again.

After this, discuss each challenge in prevention and treatment of diarrhea in detail by means of Power Point presentation.


Issues and challenges in prevention of diarrheaMeasures for prevention of diarrheal diseases include the use of safe water, hand-washing, food safety, safe disposal of excreta, promoting exclusive breastfeeding, micronutrient supplementation and immunization against measles and rotavirus.

As per estimates, inadequate sanitation cost India almost $54 billion or 6.4% of the country’s GDP in 2006 and 70% of this economic impact is health related with diarrhea followed by acute lower respiratory infections accounting for 12% of the health related impacts.1 Lack of toilets remains one of the leading causes of illness and death among children. According to United Nations Children’s Fund report (UNICEF), 626 million people in India practice open defecation.2 Though the sanitation coverage in India is 59%, there is a huge disparity in terms of use of toilets in the rural-urban areas (34% and 80%, respectively). However, there have been significant improvements in households using toilets in rural areas during the last 10 years.2 Yet the greatest challenge remains in sustainable use of sanitation facilities rather than construction of infrastructure. Thus, to make all communities free of open defecation, there is need to focus on social and behavior change and propagate the use of affordable and appropriate technologies.

India has reached the Millennium Development Goal (MDG) 7 target on improved drinking water sources with 86% coverage, however, piped water as a drinking water source has remained at 24%.3 Further, the issue remains of insufficient supply of water in poor urban areas. The possibility of faecal contamination hence, remains high there as sanitation coverage is also poor and overcrowded conditions prevail. Therefore, particular attention should be devoted to extending services to slums and informal settlements.3

Hand washing before preparing food is a particularly important opportunity to prevent childhood diarrhea and it works best when it is part of a package of behavior change interventions. Washing hands after defecating or handling children’s faeces and before handling food entails an average of 32 hand washes a day and consumes 20 l of water.4 A survey conducted by UNICEF in 2005 on well-being of children and women had shown that only 47% of rural children in the age-group 5-14 wash hands after defecation.3 This shows the need to promote hand-washing with soap before eating and after defecation, among children in India through the school hygiene program and mass media campaigns on “the Global hand-washing day.” Further it also requires that enough water is available for hand washing and that too with soap.

Evidence suggests that exclusive breastfeeding (EBF) is another cost-effective preventive intervention for diarrhea. However, according to National Family Health Survey-3 (NFHS-3), 20 million are not able to receive exclusive breastfeeding for the first six months of their life

Sesson 6: Issues and challenges in diarrhea prevention and treatment

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and about 13 million do not get good timely and appropriate complementary feeding after six months along with continued breastfeeding. The rate of early initiation of breastfeeding within one hour following the delivery is of only 23.4% and exclusive breastfeeding up to the age of six months is of 46.3%.5 The main stumbling block for this low breastfeeding rate among Indian women is the lack of support for mothers from the family, society, medical fraternity and also their work places. Lack of awareness about benefits of breastfeeding among pregnant and lactating mothers also remains a challenge. Further, prevailing myths and misconceptions about colostrum and breast milk also, are responsible for low breastfeeding in the country.

The country has an excellent law in the form of “The Infant Milk Substitute, Feeding Bottles and Infant Food (Regulation of Production, Supply and Distribution) Act, 1992.” The Act while not banning the products under its scope, regulates marketing of breast milk substitutes, which the Act calls infant milk substitutes, to children under the age of two, clearly in consonance with the World Health Organisation (WHO) recommendation of breastfeeding till 2 years. However, the deficiency lies in the legislation implementation and formation of support structures.

Several studies focusing on the constraints to EBF concluded that; breastfeeding problems, delivery by caesarean section, perceived or real breast milk insufficiency, inadequate weight gain of the infant, resumption of official work by the mother, are the other factors influencing mothers’ decision for continuation of breastfeeding.6

The virus reduces immunity in children who have had measles – especially those who are undernourished – may die of pneumonia, diarrhea and encephalitis later on. Thus, vaccination against measles becomes an important strategy for prevention against diarrhea. The Indian District Level Health Survey–3 (DLHS-3) reported that only 30% of vaccinated infants received the measles vaccine at the recommended age of 9 months. The barriers in low measles immunization coverage includes socio-demographic parameters (e.g. higher birth order, low family income, lower parental education, religion, poor knowledge of measles and the measles vaccine, limited public demand for and confidence in vaccines, etc.); challenges faced by difficult-to-reach areas; inadequate infrastructure, manpower, and communication; faults in vaccine storage, transport, and cold chains; defective surveillance activities for reporting of adverse events following immunization and for outbreak response;.7

On the other hand, rotavirus vaccine is yet to be introduced in the national immunization program of the country. (See Annexure IV)

Issues and challenges in treatment of diarrheaCurrent guidelines for management of diarrhea by the Ministry of Health and Family Welfare, Government of India, recommend low osmolarity oral rehydration salt solution (ORS) (refer to session 7; page 32), zinc and continued feeding of energy dense feeds in addition to breastfeeding.

Knowledge of ORS/ORT among mothers of under-five children in India is good (73%), but there is a big gap between knowledge and practice as reflected in poor ORS usage rates (43%).5 Further, very low coverage of zinc prescription has been documented, due to lack of knowledge and awareness among the care providers. Compliance with the use of zinc for 14 days and scaling up of zinc use in communities need to be assessed.2

References:1. Kumar GS, Kar SS, Jain A. Health and environmental sanitation in India: Issues for prioritizing control strategies. Indian J Occup Environ Med 2011;15(3):93–96.

2. Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: current scenario and future perspectives. J Nat Sci Biol Med. 2015;6(1): 24–28.

3. UNICEF. The situation of children in India – A profile. [Accessed on 2016 Feb 11]. Available from:http://www.unicef.org/india/health.html .

4. Graeff JA, Elder JP, Booth EM. Communication for Health and Behavior Change: A Developing Country Perspective. San Francisco, CA: Jossey Bass; 1993.

5. Government of India. National Family Health Survey-3, 2005-06. India (Volume1). Mumbai: IIPS and Macro-International.

6. Sureash S, Sharma KK, Saksena M, Thukral A, Agarwal R, Vatsa M. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Ind J Pub Health 2014;58(4):270-73.

7. Ram S, Shrivastava BL. Measles in India: Challenges & recent developments. Infection Ecology and Epidemiology 2015;5:27784- http://dx.doi.org/10.3402/iee.v5.27784

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Unwarranted use of antidiarrheal drugs and injections in the community for diarrhea as reported in NFHS-3 survey, where 16% and 30% children were treated with antibiotics and “unknown” drugs, respectively in cases of diarrhea.5 Appropriate case management of diarrhea is important for preventing mortality from the disease.

ConclusionsDespite gains in controlling mortality relating to diarrheal disease, the burden of the disease remains unacceptably high. Focus on comprehensive diarrheal disease control strategy through improved case management, addressing social determinants of health like environmental sanitation and clean drinking water, health promotion regarding preventive practices like breastfeeding and research in the field of cost-effective interventions is crucial to reduce the burden of diarrhea among children in India.

Sesson 6: Issues and challenges in diarrhea prevention and treatment

Day 2

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A 7-POINT PLAN FOR COMPREHENSIVE DIARRHEA CONTROL

Session

07Total time needed

30 minutes


Know a 7-point plan for comprehensive diarrhea control

Know the action needed to reduce child deaths from diarrhea



■ LCD projector

■ Laptop

■ Note pad

■ Pens

Key messages: ■ A 7 point plan consists of 2 treatment and 5

prevention strategies

■ Treatment package includes fluid replacement and zinc treatment.

■ Prevention package includes immunization, exclusive breastfeeding, handwashing, safe water supply, sanitation.

■ Action needed to control the disease involves:

○ Mobilizing resources; ○ Implementing high impact interventions ○ Social and behavior change communication ○ Monitoring progress ○ Strengthening health systems

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Facilitation notes: Begin the session by asking the participants about whether they have heard about 7 point plan. Note down the responses. Then project the slides on 7 point plan and explain them the said plan. After discussing the strategies, conduct the exercise on individual basis. Ask any one participant to discuss the exercise.

After this, ask the participants what according to them are the actions needed to prevent and control childhood diarrhea. Note down the responses on blackboard. Then discuss all the point by power point presentation. Then divide them into 4 groups and ask them to work on exercise.


IntroductionA plan for comprehensive diarrhea control-a 7 point plan has jointly been advocated by WHO and UNICEF for improving child survival in developing countries in particular. The 7-point plan includes two treatment and five prevention strategies.

■ Treatment Package

The treatment package focuses on two main elements:

1. Fluid replacement to prevent dehydration2. Zinc treatment.

Oral rehydration therapy is the cornerstone of fluid replacement. New elements of this approach include low-osmolarity ORS, which are more effective at replacing fluids than the previous ORS formulation, and zinc treatment, which decreases diarrhea severity and duration.

Comparison of standard and low osmolarity ORS solutions in terms of composition

Composition Standard ORS solution (mEq or mmol/l)

Reduced Osmolarity Solution (mEq or mmol/l)

Glucose 111 75Sodium 90 75Chloride 80 65Potassium 20 20Citrate 10 10Osmolarity 311 245

The original ORS was found to be hyperosmolar and may risk hypernatremia (high plasma sodium concentration) and increase in stool output especially in infants and young children. The low-osmolarity ORS reduce stool output by 25%, reduces vomiting by 30% and reduces the need for unscheduled intravenous therapy by more than 30%. Zinc is a vital micronutrient

Sesson 7: A 7-point plan for comprehensive diarrhea control

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essential for protein synthesis, cell growth and differentiation, immune function, and intestinal transport of water and electrolytes. Zinc deficiency is associated with an increased risk of gastrointestinal infections, adverse effects on the structure and function of the gastrointestinal tract, and impaired immune function. Important additional components of the package are continued feeding, including breastfeeding, during the diarrhea episode and use of appropriate fluids available in the home if ORS is not available.

■ Prevention Package

The prevention package focuses on five main elements to reduce diarrhea in the medium to long term:

3. Rotavirus and measles vaccinations4. Promotion of early and exclusive breastfeeding and vitamin A supplementation5. Promotion of hand washing with soap. 6. Improved water supply quantity and quality, including treatment and safe storage of

household water7. Community-wide sanitation promotion.

It is important that implementation of the prevention package is approached in a concerted way, since single interventions alone are likely to result in lesser overall impact. For example, diarrhea caused by rotavirus cannot be prevented solely by improvements in water and sanitation. And rotavirus vaccine does not prevent other pathogens (such as E. coli and Shigella) from causing diarrhea. The package should be accompanied by clear, targeted and integrated behavior and social change communication strategies to improve uptake by families and communities.

ExerciseA 3 month child living in a village X has suffered from 3 episodes of diarrhea since his birth. He is not being exclusively breastfed. Many children in his village also suffer from similar illness. The village does not have a toilet facility and there is no supply of piped water. Kindly discuss the strategies to prevent and control diarrhea in this setting

Ans. A 7-point plan for comprehensive diarrhea control.

Action needed now to reduce child deaths from diarrhea ■ Mobilize and allocate resources for diarrhea control: New resources for child survival

must include funding for diarrhea prevention and treatment. And global initiatives must keep the management of diarrhea high on the list of priorities for public health resource allocation, including rotavirus vaccination. At the same time, national and district health planners should include diarrhea control in program targeting childhood malaria, pneumonia and HIV, and ensure support to accelerate coverage of proven interventions.

■ Reinstate diarrhea prevention and treatment as a cornerstone of community-based primary health care: To effectively control diarrhea, treatment and prevention measures should be integrated into the training of health workers

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■ Ensure that low-osmolarity ORS and zinc are adopted as policy in all countries: Clear policy guidance is needed to ensure that the latest recommendations for treating childhood diarrhea are adopted and promoted, using effective delivery strategies. One way of facilitating the delivery of low-osmolarity ORS and zinc is by combining these life-saving remedies in a single treatment kit.

■ Reach every child with effective interventions: Community-based approaches are needed to ensure high coverage of health, nutrition and water and sanitation interventions, rather than relying solely on the public sector for these services.

■ Accelerate the provision of basic water and sanitation services: This can best be accomplished through partnerships between the health sector and other agencies responsible for water and sanitation, and the use of community-based approaches. Eliminating open defecation must be a priority, along with promoting the construction of basic sanitation facilities by households and providing safe water facilities close to people’s homes that can be operated and maintained by the community.

■ Use innovative strategies to increase the adoption of proven measures against diarrhea: All available options should be exploited to reach every household with a package of high-impact interventions against diarrhea which could include, for example, the development of flavoured ORS formulas or systems for treating and safely storing household water. Other types of innovations include alternative delivery strategies, such as Child Health Days, to reach a high proportion of the target group. Consumer research to improve packaging, marketing and product positioning will be essential for greater acceptance of ORS, soap and household water treatment.

■ Change behaviors through community involvement, education and health-promotion activities: Clear and targeted health promotion and behavior change communication programs must accompany the delivery of interventions to ensure that caregivers understand the simple actions they can take at home to prevent and manage diarrhea.

■ Make health systems work to control diarrhea: These include meeting the need for human resources, reducing staff turnover, improving training programs and seeking creative ways to motivate community health workers.

■ Monitor progress at all levels, and make the results count: As national programs accelerate their diarrhea control activities, it will become increasingly important for countries to collect, analyze and report quality data in a timely manner to monitor programs and increase accountability and performance.

Exercises:Q1. Based on the above suggested measures, discuss in your respective groups what are the important actions that need to be taken in Indian settings?

References:1. UNICEF, WHO. Diarrhea: Why children are still dying and what can be done. Switzerland: Geneva; 2009. Available from: http://www.unicef.org/media/files/ Final_Diarrhea_Report_October_2009_final.pdf

Sesson 7: A 7-point plan for comprehensive diarrhea control

EFFECTIVE COMMUNICATION

Session

08Total time needed

60 minutes


Know the ways of communicating effectively

Know the different modes of delivery of key messages

Know the do’s and don’t of effective communication

Equip themselves with effective communication skills



■ LCD projector

■ Laptop

■ Blackboard

■ Chalk

■ Flip charts, posters, handouts, pamphlets, charts

Key messages: ■ Communication is a process which involves

sharing of information between people through a continuous activity of speaking, listening and understanding.

■ There are various types of communication: one way-two way; verbal-nonverbal; formal-informal; tele-communication

■ There are various barriers which are needed to be overcome for effective communication-physiological, psychological, environmental and cultural

■ Listening is different from hearing

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■ There are different modes of delivery of key messages in community settings like flip charts, poster, pamphlets, handout, wall paintings, community talks, meetings, folk media

■ One should S(smile). O(open posture). F(forward lean). T(touch). E(eye contact). N (nod) for effective communication

Instructional methodology: Group discussion, lecture (power point slides), role plays

Facilitation notes: Begin the session by asking the participants about “what do they understand by communication?” Note down the responses. Then project the slide on concept of communication. Explain the process of communication to the audience.

After this, invite 2 participants for activity 1 and discuss the process of communication through it in 10 minutes.

Then ask the participants about various types of communication. Note down the responses on blackboard and then project the slide on various types of communication. Then conduct the activity 2. Then ask the participants to write barriers in communication which they encounter in their day to day work. Discuss the barriers. Then conduct the individual exercise on barriers in effective communication.

Ask the audience what do they understand by hearing and listening. Enlist the responses on blackboard and then add on the missing concept. Also tell the participants about how to be good listener as it is important component of effective communication. Then conduct the activity 3. Take about 10 minutes in it.

After this project the do’s and don’t of effective communication.

Ask the participants to detail out the do’s and don’t. Keep writing the responses on blackboard and then complete the list.

After this briefly discuss the modes of delivery of key messages in community settings.


Defining communicationCommunication is the art of expressing and exchanging ideas, thoughts and feelings in speech, writing and or by body language.1 It is the act of being understood. It is a process which involves sharing of information between people through a continuous activity of speaking, listening and understanding.2

Communication process: Communication process involves the following2:

1. Idea: Information exists in the mind of the sender/source. This can be information, concept or feelings.

2. Encoding: The source initiates a message by encoding the idea (or a thought) in words or symbols and sends to a receiver. When we speak, the speech is the message, when we write, the writing is the message, when we gesture, the movements of our arms and the expressions of our faces are the message.

3. The channel: The channel in the communication process is the medium that the sender uses to transmit the message to the receiver. Care needs to be exercised in selecting the

Sesson 8: Effective Communication

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most effective channel for each message. Even though both an oral and a written medium may be appropriate to transmit a particular message, one medium may be more effective than the other.

4. Decoding: It is the act of understanding messages (words or symbols). During the transmitting of the message, two processes will be received by the receiver. These are: Content and Context. Content is the actual words or symbols of the message which is known as language – i.e. spoken and written words combined into phrases that make grammatical and semantic (meaning) sense. Context is the environment in which communication takes place. It can be formal or informal.

5. Feedback: This feedback will tell the sender that the receiver understood the message, its level of importance, and what must be done with it. So the feedback loop is the final link in the communication process. Feedback is the check on how successful we have been, in transferring our messages as originally intended. It determines whether understanding has been achieved or not.

Activity 1:

Invite 2 participants. Ask one of the participants to tell the other to “leave the room” in 3 different ways (respect, anger, affection). Then ask the second participants how the message was interpreted in three different situations.

Types of CommunicationThere are different types of communication3:

1. One-way communication (didactic method): The flow of communication is “one way” from the communicator to the audience. Example: lecture method Advantages: It is fast, saves time & money. The sender is satisfied because there is no way of questioning his information Disadvantages: knowledge is imposed, learning is authoritative, little audience participation, no feedback, may or may not influence human behavior.

Source Encoding Channel Decoding Receiver

The Communications Process

Msg Msg Msg Msg

FeedbackContext

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2. Two-way communication (Socratic method): The Socratic method is a two way method of communication in which both the communicator and audience take part. The audience may raise questions, add their own information, ideas and opinions to the subject. The process of learning is active. Example: Workshop Advantages: It is more efficient method of communication than one way as it involves feedback and ensures clarity of information Disadvantages: It is time consuming and slow.

3. Verbal communication: The traditional way of communication has been by word of mouth. It may be loaded with hidden meanings. Advantages: Time saving, easy, cost saving, more powerful-speech is more powerful means of persuasion and control. With the help of variations in tone, pitch and intensity of voice, the speaker can convey shades of meaning, thus making it more effective means of communication. Disadvantages: Not suitable for lengthy messages, no legal validity of oral message as they are not recorded.

4. Non-verbal communication: Communication can occur even without words. It includes a whole range of bodily movements, postures, gestures, facial expressions. Advantages: Complementary to verbal communication, helpful to illiterate and handicapped people, quick expression of message. Disadvantages: vague and imprecise, culture bound, sometimes difficult to understand.

5. Formal and informal communication: Formal communication follows line of authority. Informal communication includes gossip circles. Advantages: Formal communication increases efficiency of system, use as reference, permanent record. Informal communication covers the gap not overcome by formal system. Disadvantages: Formal communication is costly, involves authoritarian attitude. Informal communication sometimes distort meaning, spread rumor, can create mis-understanding, reveals secrecy.

6. Visual communication: It comprises charts, graphs, pictograms, tables, maps, posters etc. Advantages: Very fast, more impactful, retained in memories for longer time, makes message more clear Disadvantages: costly, time consuming, only small amount of information can be conveyed.

7. Telecommunications and internet: It is the process of communicating over distance using electromagnetic instruments. Examples: radio, television, internet, telephone, telex etc. Advantages: Flexible, reduction of travelling costs and time. Disadvantages: security risks, accessibility issues

Activity 2:

Invite 2 participants for role-play. Give the scenario of one enacting as health worker and other will act as the mother of a child affected with diarrhea. The setting is of a health facility. The health worker has to enact ‘approach to patient’ with diarrhea.


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After the role play, discuss critically the process of inter-personal communication. Note the responses on blackboard.

The health worker will assess the child as described in chapter on approach to patient with diarrhea (session 4). The role play will continue upto 7-10 minutes. The mother of the child will give the history according to the questions asked. After assessment, the worker will find the child as case of diarrhea with no dehydration. Then the health worker counsel the mother and teach her home therapy. The health worker will assess the understanding of mother in the last. This activity will demonstrate the process of inter-personal communication i.e. sender, message, medium, receiver & feedback

Barriers in effective communicationIn the process of communication, caution needs to be exercised as barriers to communication are either consciously or unconsciously erected by the sender or the receiver.

The barriers may be3:

1. Physiological- difficulties in hearing, expression

2. Psychological- emotional disturbances, neurosis, levels of intelligence, language or comprehension difficulties.

3. Environmental-noise, visibility, congestion

4. Cultural- illiteracy, levels of knowledge and understanding, customs, beliefs, religion, attitudes, economic and social class differences, language variations, cultural differences between foreigners and nationals, between urban education and rural population

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ListeningOne of the most powerful tools for effective, two-way communication is active listening.2 Listening goes beyond hearing. Hearing is a physiological activity that occurs when sound waves hit our eardrums. Listening is far more complex than hearing or otherwise.

Listening refers to the interpretative process that takes place with what we hear.

Tips for good listening4

■ Stop talking and don’t interrupt

■ Don’t let yourself get mentally distracted by your next task or the fact that you are in a hurry, concentrate on the individual.

■ Encourage the person speaking to continue and not to feel rushed or time pressured

■ Don’t fidget, scribble or appear to be disinterested, they may stop talking

Exercise1. Sheela is a 4 year old girl who is brought to the Primary Health center by her

mother with the complaints of loose stools for 4 days accompanied with blood and mucus. The medical officer calls the mother into his room and asks the mother about child’s complaint. He did not ask the mother to sit on a stool or chair and did not even look into her eyes while taking history. There is a lot of noise outside the clinic room. The mother tells that the child is passing loose stools, but she forgets to tell about passage of mucus and blood. An adult patient comes in to ask about how to take his medicines. The conversation between the mother and the doctor gets interrupted. The doctor then again turns towards mother and write the prescription without telling what he has prescribed. He then calls upon next patient.

a. what are the communication barriers in this case

Ans. Lack of eye contact, no privacy, environment not friendly, lack of understanding, time constraint

b. What could have been done to avoid or overcome these barriers?

Ans. Make the clinic setting environment friendly, ensure privacy, and maintain eye contact with patient.

2. Ramesh is a health worker in village. He is organizing a community meeting in the village on diarrhea. Only 10 mothers of under five children have come to attend the meeting. He talks about prevention and control of diarrhea, but does not discuss danger signs of diarrhea amongst children. After delivering his lecture he ends the meeting. He sometimes speaks in Hindi and some words in English. Few mothers leave the meeting in between only

a. What are the various barriers in this communication process

b. Suggest some measures to overcome these barriers and make his communication effective


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■ Have an open mind to what the person is saying-don’t let how you feel and believe affect what you hear

■ Don’t be afraid of silence whilst the other person may be thinking and preparing what to say next, give them time to talk

■ Be sensitive to the person’s situation, they may be nervous or shy and talk very quietly or shout, don’t let this affect what you hear.

■ Listen to how the person is talking, what they emphasize or quickly gloss over, listen out for what is not being said and try to get the whole picture.

■ There may be physical signs; perhaps making eye contact; nodding, and leaning close enough to hear the person speaking well.

■ You may have noticed that a good listener checks that he or she understands what you are saying.

Activity 3:

Let all participants sit in a circle. Whisper a statement in first participant’s ear. The statement is “Hand hygiene is important for diarrhea control.” Let the participant murmur it out in the next participant’s ear. This will continue till last participant. Ask the last participant to say the statement he has heard aloud. Highlight the importance of listening carefully.

Do’s and Don’ts of effective communication

Do’s Don’ts(S.O.F.T.E.N.) Tap fingers, pens, pencilsSmile Crossing armsOpen Posture-this means no crossed legs, arms

Yawning or looking bored

Forward-lean forward… just a little Leaning away from the clientTouch-shake hands or greet in warm & friendly manner

Looking out of window or somewhere else

Eye Contact Tapping feetNod

Methods in health communicationCommunication in health takes place on many levels, including individual, group, organization, community or mass-media. Thus, communication methods can be divided into one of five categories: intrapersonal, interpersonal, organizational, community and public/mass communication.5

‘Intrapersonal’ incorporates internal communication. This includes what we think or listen to internally. Interpersonal communication is communication on a personal level. This includes one-to-one communication or small group communication. (e.g. emails, telephone, one to one counseling etc). ‘Organizational communication’ includes communication in an organization,

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both formal and informal (e.g. lectures, seminars, debates, meetings, workshops etc.). ‘Community’ communication includes mediums that are used in community settings, for example local radio and newspapers. ‘Public/Mass’ communication is large-scale and includes national and international communication (e.g. newspaper, television, radio etc.)

We will discuss in detail the common mode of delivery of key messages in community settings. They are as follows:

1. Flip charts3:

• This consist of series of charts or posters about 25 by 30 cm or more, each with an illustration pertaining to talk to be given

• Each chart is displayed before the group as the talk is being given.• The message on the chart must be brief and to the point• E.g. Flip chart can be used to stimulate community discussion about health sanitation

issues. They can be used for large group of people.

2. Posters6:

• The message to be communicated should be simple, easy to understand and artistic.• The title needs to be communicated from a distance of 5-10 m and text from 1.5 to

2 m. Block thick styles of letters no less than 23 mm for titles and 5 mm for text for legibility should be followed.

• Posters should be changed frequently.• They are usually displayed in visible public areas.• E.g. Posters can be used to display any health promotion issue-such as hand washing

can reduce diarrhea. They are meant for specific small groups.

3. Handouts:

• It is a single piece of paper where information is printed on one or both sides to promote a product or service or to provide information about an event or a social issue.

• They carry detailed information about the health issue.• They give the audience something to take away from your message or presentation.• Make it simple, readable type. • Organize and break out dense information into charts, graphs and other illustrations.• E.g. Handouts on safe water supply/how to make water safe for drinking purposes.

Handouts can also be given as summary of the session on diarrhea prevention and control. They can distributed widely

4. Pamphlets7:

• An unbound booklet without binding or a hardcover is also known as a pamphlet. • These pamphlets are made by folding the few pages in half and saddle stapling them

at the crease.


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• E.g. Pamphlets on management of diarrhea-various treatment plans can be made. They can be distributed widely.

5. Wall paintings8:

• It is a tool for communicating to people through writing text and drawing pictures on the wall.

• They are easily readable • They are a cheap medium • People from all age groups can be given messages through wall paintings• Size of the wall writing should be at least 6 x 4 feet.• It should be clearly visible from 100 m distance.• E.g. Wall paintings depicting safe water supply through pipes in a village. It reaches to

large audience.

6. Community talks:

• The talks cover basic health information and are delivered in easy-to-understand language, with plenty of time for questions and answers.

• They take place in community settings, such as places of worship, recreation centers, and libraries.

• E.g. community talks on importance of environmental sanitation in health. It also targets large audience

7. Mother meetings:

• Regular meeting for mother of under-5 children in the community provide counseling opportunities regarding infant feeding and hygiene.

• It involves informal discussion and supportive environment.• E.g. Mother meetings on importance of exclusive breastfeeding and immunization for

young children are highly useful.

8. Folk media:

• It involves keerthan, katha, songs, dances and dramas which have roots in our culture• E.g. Folk media can be used for spreading the message of immunization for children.

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References1. NHM, GoI. Facilitator’s Guide. Orientation of medical officers for adolescent friendly health services. New Delhi: India; 2014.

2. Mberia HK. Communication Training Module. International Journal of Humanities and Social Science 2011;1(20):232-55.

3. Park K. Park’s Textbook of Preventive And Social Medicine. 23rd ed. New Delhi: Banarasidas Bhanot Publishers; 2011.

4. NHS. Introduction to: communication skills. Student Training Module [Internet] 2015 [Accessed on 2016, Feb 15]. Available from: https://www.networks.nhs.uk/nhs-networks/medslearning/documents/commun ications-1

5. Corcoran N. Theories and models in communicating health messages [Internet] 2007 [Accessed on 2016, Feb 15]. Available from: http://www.corwin.com/upm-data/13975_Corcoran___Chapter_1.pdf

6. Davis M, Davis KJ, Wolf DC. Effective communication with poster displays. J Nat. Resour. Life Sci. Educ. 1992;21(2):156-60.

7. Difference Between.com. Difference between pamphlet and brochure [Internet] 2011 [Accessed on 2016, Feb 15]. Available from: http://www.differencebetween.com/difference-between-pamphlet-and-vs-brochure/

8. Educational series: Using health communication materials effectively [Internet] 2016 [Accessed on 2016, Feb 15]. Available from: http://elibrary-sbcc.org/images/How%20to%20use%20Wall%20Paintings%20Wall%20Writings.pdf


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INFORMATION EDUCATION COMMUNICATION/BEHAVIOR CHANGE COMMUNICATION (IEC/BCC) ACTIVITIES

Session

09Total time needed

60 minutes


Understand the concept of IEC/BCC activities and Know the how to plan IEC/BCC activities

Know how to document IEC/BCC activities



■ LCD projector

■ Laptop

■ Flip chart

■ Pens

■ Documentation formats

Key messages: ■ IEC is a process of working with individuals,

communities and societies to develop communication strategies to promote positive behaviors which are appropriate to their settings.

■ BCC includes IEC with providing a supportive environment which will enable people to initiate and sustain positive behaviors.

■ There are 5 stages in behavior change: unaware, contemplation, decision, action, maintenance

■ IEC/BCC strategy should be developed keeping target audience and program need in mind.

■ After implementation of IEC/BCC activity, it should be documented well.

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Facilitation notes: Begin the session by asking the participants about “what do they understand by IEC?” Note down the responses. Then project the slide on definition of IEC. Also ask the participant about IEC material they have seen in and around their vicinity.

After this, ask participants whether they have heard about BCC? Then explain them the concept of BCC and how it is different from IEC. Then explain the audience various stages of behavior change. Following this, conduct activity 1 (5 minutes). After this, tell the participants, that many people in target audience may be at varying stages of behavior change so we have to adopt multiple communication strategy for them. Then conduct activity 2 as case study. Divide the participants into 5 groups and ask each group to tell possible ways of BCC activities at one of each stage of behavior change (10 minutes). After this, discuss the steps in development of IEC/BCC strategy and project the slide on tips for developing quality IEC material. Then conduct the activity 3.

As a last step briefly discuss the process of documentation of IEC/BCC activities.

End the session by asking one of the participants to summarize the session and then display the summary box.

Information Education Communication (IEC)IEC is a process of working with individuals, communities and societies to:

� Develop communication strategies to promote positive behaviors which are appropriate to their settings.

Behavior Change Communication (BCC)BCC is a process of working with individuals, communities and societies to:

� develop communication strategies to promote positive behaviors which are appropriate to their settings; AND

� Provide a supportive environment which will enable people to initiate and sustain positive behaviors.

While providing information to help people to make a personal decision is a necessary part of behavior change, BCC recognizes that behavior is not only a matter of having information and making a personal choice. Behaviour change also requires a supportive environment.1 Community and society provide the supportive environment necessary for behavior change. IEC is thus part of BCC while BCC builds on IEC.

BCC involves IEC messages, IEC communication activities and the supportive environment needed to initiate and sustain behavior change. IEC only refers to communication messages and materials that form part of a BCC intervention.2

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Sesson 9: Information Education Communication/Behavior Change Communication (IEC/BCC) Activities

Stages of Behaviour Change ■ Unaware – Person is unaware of risks/issues and its application to them

■ Contemplation – Person is aware of risks but ambivalent about changing

■ Decision/determination – Person prepares to make a change

■ Action – A new behavior is put into action

■ Maintenance – New behavior is established, but not necessarily sustained

Stages of behavior change do not always happen sequentially. Community members are at different levels of the process, and at different times. Also, not everyone goes through all the stages. One person may go from unaware to action straight away, while another may vacillate between contemplation and decision/determination for a while before action is taken.

Fig 1: Stages of Behavior Change

Activity 1:

Ask participants to share a behavior they changed or intend(ed) to change and identify which stage of behavior change they were/are in. List responses on a flipchart.

A combination of BCC activities is usually the best approach for motivating and sustaining behavior change among a target group(s) because members of the target audience will be at different stages of behavior change.2

Change Continuum

Stages of Behavior Change Enabling Factors Channels of

Communication

Mass Media

Information on risks, benefits; effective Communication

Step-by-step action plan/information

Unaware

Contemplation

Decision/Determination action

Maintenance/sustained behavior change

Enabling environment – social support, services, policies, commodities

Mass & Interpersonal

Media

Interpersonal Communication

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Activity 2:

Divide the participants into 5 groups and ask each group to tell possible ways of BCC activities at one of each stage of behavior change.

Case study: A young lady of 23 years has just delivered a baby girl. Her first child is 2 years old and has not been breastfed. The last child is malnourished and has suffered from diarrhea very frequently. The mother has been counseled on nutrition for mother and child. Kindly discuss the BCC activities at various stages of behavior change.

Ans. Unaware- when the mother is unaware of the benefits of exclusive breastfeeding, Potential BCC activities include: print materials (posters, pamphlets, etc.), mass media (TV and radio ads), and community drama that have IEC messages to raise awareness on the same.

Contemplation-the mother is thinking about starting exclusive breastfeeding, but is apprehensive whether the breast milk will be adequate for the child. Potential BCC activities include: Interpersonal communication (IPC) with a dedicated health worker and other mother who are practicing exclusive breastfeeding.

Decision- The mother decides to breastfeed the child exclusively this time. Potential BCC activities include: print materials, mass media (TV and radio ads) and health education explaining how to practice correct way of positioning and attachment in breastfeeding.

Action & Maintenance-The mother starts practicing breastfeeding. Potential BCC activities include: IPC and Social support from family members, peers and health workers

Process of planning IEC/BCC activities for communityAs a community worker, you have to be involved in organizing various IEC/BCC activities in your community. But planning of any IEC/BCC event requires consideration of following points:

Step 1: Identify the problem based on the overall program goals- Determine the severity and causes of the health issue and notice differences by audience characteristics such as gender, age etc. Identify possible health related behavior that could be encouraged or discouraged. Identify social, economic, and political factors blocking or facilitating desired behavior changes. Develop problem statement that summarizes the above points to help identify what aspects of the health issue can be addressed through communication.3

Step 2: Identify the target audience- Before development of IEC/BCC strategy, we should identify the primary target audience. The primary audience(s) is the main group(s) whose behavior the project is seeking to influence. It should share similar characteristics, such as age range, gender, occupation, residence (rural vs. urban), number of children, as well as access to print, radio and/or TV media.2

For example, in diarrhea prevention and control, our target audience would mothers/parents of under-5 children of a particular socio-economic status.

Health workers involved in implementation of diarrhea control activities are referred to as “behavior change agents”. These behavior change agents actually form the part of your BCC intervention that helps the community initiate and sustain behavior change.

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Secondary target groups are those individuals or groups who are not the primary focus of the project, but who influence your primary target members. Examples of secondary audiences could include: Grandparents, Elders/village chiefs in the village and health care providers.

Step 3: Engage in formative research- Collect in-depth information about the audience: What are their knowledge, attitudes, and beliefs about health? What factors affect their health behaviors? What are their media habits? What access do they have to information, services, and other resources? Where do they currently stand in the stages of behavior change? Are there different groups of people who have similar needs, preferences, and characteristics (audience segments)? Will the BCC program need customized messages and materials to suit audience segments?3

Step 4: Identify behavior change goals- We have to define the behavior change goals which are referred to as intended changes in the audience’s actual behavior.

Step 5: Seek consensus from stakeholders- Involve audience members and other key stakeholders in the analysis of their own concerns. These may include nongovernmental organizations, professional associations, schools, faith-based groups, and the media.

Step 6: Design communication plan, including objectives, overall theme, specific messages and outlets for dissemination- Develop a conceptual framework to show how BCC program activities are expected to contribute to objectives and goals. Use relevant findings from formative research to guide the choice of channels. Develop a creative brief to share with people and organizations involved in developing messages and materials. Draw up an implementation plan, including activities, partners’ roles and responsibilities, timeline, budget, management plan, monitoring and evaluation plan.

Step 7: Pre-test and revise- Pretest messages and materials with audience members and revise messages and materials based on pre-testers’ reactions.

Step 8: Implement the plan: Mobilize a large number of stakeholders to help implement activities and develop a broad sense of ownership. Include audience members and other stakeholders in steering committees to oversee program implementation, make recommendations, and ensure action to improve activities.

Step 9: Monitor and Evaluate: Measure the outcomes and assess impact. Disseminate results to partners, key stakeholders, the news media, and funding agencies. Record lessons learned and archive research findings for use in future programs.

Step 10: Seek feedback and make appropriate revisions: Revise or redesign program based on evaluation findings

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Activity 3:

Divide the participants into 4 groups. Assign each group to design appropriate IEC material and mode of delivering message on diarrhea control and prevention for mothers in the community

Documentation of IEC/BCC activitiesDocumentation of the event/activity is not only required for show casing purpose, it is a prima facie requirement for evidence collecting and archiving purpose.4 It must start from ground zero as it is a constructive and accumulating process.

Two types of activities that can be documented i.e event and process. While event documentation need to be done on a regular basis, process documentation takes time. While event document captures fresh activities process; documentation captures the processes that have been undertaken and have impacted the success and failure of a particular event.

Important points to remember in documentation are:

■ Documentation is nothing but a systematic arrangement of facts, letters and pictures which together tells the story.

■ Documentation must be stakeholder specific and target oriented. What to write is only clearer when we know for whom we are writing. The language, content size as well as writing style etc. are made clearer only when we know for whom we are writing.

■ Writing can be in form of case studies, in form of best practices or in form of promising practices.

■ It can be of few lines or it can be a voluminous document,

■ For documentation one must try to follow an inverted pyramid approach while writing. The first few lines carry the introduction while the body should be the lengthiest part and must elaborate the process. Similarly, the concluding part must be written following summative approach.

IEC Material development Tips ■ Message should be short, simple and scientifically accurate.

■ Message should be in local language, easily understandable by the target audience.

■ Use illustrations to reinforce the text

■ Use bold or underline to emphasize the message

■ Limit the number of concepts per material

■ Avoid illustrating negative message

■ Leave plenty of white space.

■ The font of the message should be legible

■ Consider the socio-cultural background of the audience also.

■ Information should be presented in logical manner

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■ Each of the photographs used for the purpose must be having appropriate captions mentioned against it.

■ Photographs should be of high quality and must be clearly expressing the subjects in it.

■ Similarly, the data used in the subject, must be used from the authentic sources. If it is used from a primary source one must mention points from which it is obtained.

■ This documentation can be shared with individuals, institutions or visiting delegates as and when required. Reports or documents can also be shared with district and state officials. It can also be mentioned in different magazines and newspapers published from the district.

A sample format for documentation of event

Name of the district:Date of submission of report:PART-A Activity Report (within 150 words)PART-B Photographs (insert soft copy of

photos with caption)1. 2. 3.

PART-C Paper clippings (insert soft copy with paper name and date of publication)

1. 2. 3.

Reported submitted by: Medical Officer-Primary Health Centre (Name):

Signature:

Reported verified by: Block Medical Officer: (Name):

Signature:

A sample format for documentation of process

Name of the Event:Event Period:District’s Name:General Description of the Event:

Major activities undertaken:How is the community responsive to the campaign?What are the major learning’s of the campaign?What are the shortcomings of the campaign?Are there any district or sub-district level initiatives undertaken?Attach photographs:Submitted by:Date of submission:

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References:1. Introduction to Behavior Change Communication [Internet] 2016 [Accessed on 2016, Feb 2] Available from: http://www.seesac.org/sasp2/english/publications/ 5/1_ Introduction_BCC.pdf.

2. USAID. The balanced project. Developing Behavior Change Communication interventions for Population Health & Environment Projects. Facilitator’s Guide. [Internet] 2013 [Accessed on 2016, Feb 16]. Available from: https://www.k4health.org/sites/default/files/PHE%20IEC%20workshop_Facilitators%20Guide_508.pdf

3. INFO Reports. Tools for Behavior Change Communication [Internet] 2008 [Accessed on 2016, Feb 16]. Available from: https://www.k4health.org/sites/default/files/BCCTools.pdf

4. Centre of Excellence, Directorate of state Institute of Health & Family Wlfare, Govt. of Odisha. Kartavya [Internet] 2012 [Accessed on 2016, Feb 16]. Available from: http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/Kartavya %20TRAINING%20MODULE%20.pdf

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KEY MESSAGES FOR ADULTS AND CHILDREN AROUND DIARRHEA CONTROL

Session

10Total time needed

30 minutes


Know key messages for adults and children around diarrhea control

Learn how to deliver key messages for adults and children around diarrhea control in the community settings



■ LCD projector

■ Laptop

■ Flip chart

■ Pens

Key messages: ■ A mix of communication media are used to

reach the target population

■ Key messages for prevention and control on diarrhea should focus on 7 point plan

■ Awareness should also be generated regarding healthy nutrition for child


Facilitation notes: Begin the session by asking the participants about “what media can be used to deliver the key messages for diarrhea prevention and control” Note down the responses. Then

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project the slide on media to reach target population. Explain the audience that type of media to be used would depend upon the reach and depth.

After this, ask participants what key messages they would like to give for prevention and control of diarrhea in the community. Note down the responses on flip chart. Complete the list after discussion for 10 minutes. Then ask the participants about importance of nutrition in children in prevention against illnesses. Then ask the key messages to be given regarding nutrition of children. Discuss it for 10 minutes and project the slide on the same.

End the session by asking one of the participants to summarize the session and then display the summary box.

IntroductionAs discussed previously also, an integrated IEC/BCC campaign should be propagated for prevention and control of diarrhea. A mix of three type of medium is required to reach the target population. These are:

1. Mass media (TV/Radio)

2. Mid Media (posters, wall paintings/street play)

3. Outreach interpersonal communication by Auxillary Nurse Midwife/Accredited Social Health Activist (ANM/ASHA) (home demonstrations)

REACH

DEPTH

Mass Media-TV/Radio

Mid Media- Posters, wall paintings

Outreach/IPC-ASHA/ANM

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Sesson 10: Key messages for adults and children around diarrhea control

Key action messages to be given to the community1

■ Household demonstration of ORS

■ Household demonstration of Zinc (both in liquid and capsule form)

■ Role of diarrhea in onset of malnutrition and deaths among children

■ Give extra fluids during diarrhea

■ Give ORS to all children with Diarrhea

■ Continue feeding, including breast feeding in those children who are being breast fed

■ Give zinc for 14 days, even if diarrhea stops

■ Use clean drinking water

■ Make a habit of regular hand washing with soap before preparation of food, before serving the food, before feeding the child and after cleaning stools of the child

■ Zinc decreases the chance of second episode of diarrhea in another 2-3 months

■ Does zinc also reduce the severity of the diarrhea in the existing cases?

■ Danger signs of diarrhea-many watery stools, repeated vomiting, thirst, child becomes lethargic or irritable, drinking poorly, fever, blood in stool

■ Immunization of the child against measles and rotavirus

■ Avoid open air defecation

Key messages to be given regarding prevention of under-nutrition among childrenUnder-nutrition in children is a major Public Health problem in our country. Under-nutrition increases the risk of illness and death associated with the illnesses. It also leads to compromised growth, impaired psychosocial and intellectual development in children, thus preventing children from attaining their fullest potential. For prevention of onset of under-nutrition in children, following key practices are to be ensured:

1. Early initiation of breastfeeding; immediately after birth, preferably within one hour.

2. Exclusive breastfeeding for the first six months of life i. e. 180 days (no other foods or fluids, not even water; but allows infant to receive ORS, drops, syrups of vitamins, minerals and medicines when required)

3. Timely introduction of complementary feeding (solid, semisolid or soft foods) after the age of six months i. e 180 days.

4. Continued breastfeeding for 2 years or beyond

5. Age appropriate complementary feeding for children 6-23 months, while continuing

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breastfeeding. Children should receive food from 4 or more food groups [(1) Grains, roots and tubers, legumes and nuts; (2) dairy products ; (3) flesh foods (meat fish, poultry);(4) eggs, (5) vitamin A rich fruits and vegetables (e. g carrot, orange, maize, mango etc) ;(6) other fruits and vegetables] and fed for a minimum number of times (2 times for breasted infants 6-8 months; 3 times for breastfed children 9-23 months; 5 times for non-breastfed children 6-23 months).

6. Continuous feeding for children during and after illness g. Active feeding for Children during and after illness.

References:1. Guideline for Control of childhood diarrhea through scaling-up zinc and ORS [Internet] 2015 [Accessed on 2016 Feb, 15]. Available from: http://www.nrhmhp.gov.in/sites/default/files/files/Diarrhea%20management%20guidelines.pdf

2. MoHFW, GoI. IDCF 2014: Intensified Diarrhea Control Fortnight [Internet] 2014 [Accessed on 2016, Feb 17]. Available from: http://www.wbhealth.gov.in/notice/IDCF%20Guidelines%20for%20States.pdf

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Sesson 10: Key messages for adults and children around diarrhea control

COMMUNITY LEVEL STRUCTURES AND THEIR ROLES AND RESPONSIBILITY

Session

11Total time needed

60 minutes


Understand the community level structures in India

Know the roles and responsibility of community level structures



■ LCD projector

■ Laptop

■ Flip chart

■ Pens

Key messages: ■ Community engagement is important to ensure

people’s participation in health.

■ ANM, ASHA and AWW are key functionaries involved in connecting community to health and nutrition services at the community level

■ Village Health Sanitation and Nutrition Committee is envisaged as a mechanism to promote community action for health, particularly for social determinants of health.

■ Rogi Kalyan Samiti (Patient Welfare Committee) / Hospital Management Society is a registered society, acts as a group of trustees for the hospitals to manage the affairs of the hospital.

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Instructional methodology: lecture (power point slides), quiz, group discussion

Facilitation notes: Begin the session by asking the participants about “what are the community workers” they know of. Note down the responses.

Divide the participants into 4 groups. Ask three group to work on ASHA, AWW and ANM each- their selection, their roles and responsibilities and their payment mechanisms. The fourth group will, briefly describe Village Health Nutrition Days and coordinated role of ASHA, ANM and AWW in it. Then project the slide on NHM and introduce the ASHA program. After this, introduce the concept of VHSNC. Highlight the roles and responsibilities of the same.

After this tell the participants about another management structure-Rogi Kalyan Samiti.

End the session by asking one of the participants to summarize the session and then display the key messages. After this conduct the quiz. Give small prize who correctly answers the questions.

IntroductionWith launch of National Rural Health Mission in 2005, a strong focus has been on community engagement to ensure people’s participation in health and to enable action on the social determinants of health.1 The key instruments in this regard are the ASHA and the Village Health, Sanitation and Nutrition Committees (VHSNC).

The ASHA Program:The ASHA program was introduced as a key component of the community processes intervention under NRHM in 2005. It has emerged as the largest community health worker program in the world, and is considered a critical contributor to enabling people’s participation in health.

Accredited Social Health Activist (ASHA) works as healthcare facilitator, a service provider and a health activist. ASHA is woman resident of the village, preferably married and aged 25-45 years. She has effective communication skills, leadership qualities and able to reach to the community. She should be a literate with formal education upto class eighth at least. One ASHA is for 1000 population.

Her roles and responsibilities are:

■ ASHA will take steps to create awareness and provide information to the community on determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living and working conditions, information on existing health services and the need for timely use of health services.

■ She will counsel women and families on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs) and care of the young child.

■ ASHA will mobilize the community and facilitate people’s access to health and health related services available at the village/sub-centre/primary health centres, such as Immunization, Ante Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other services being provided by the government.

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Sesson 11: Community level structures and their roles and responsibility

■ She will work with the Village Health, Sanitation and Nutrition Committee to develop a comprehensive village health plan, and promote convergent action by the committee on social determinants of health. In support with VHSNC, ASHAs will assist and mobilize the community for action against gender based violence.

■ She will arrange escort/accompany pregnant women & children requiring treatment/ admission to the nearest pre- identified health facility i.e. Primary Health Centre/Community Health Centre/First Referral Unit (PHC/CHC/FRU).

■ ASHA will provide community level curative care for minor ailments such as diarrhea, fevers, care for the normal and sick newborn, childhood illnesses and first aid. She will be a provider of Directly Observed Treatment Short-course (DOTS) under Revised National Tuberculosis Control Program. She will also act as a depot holder for essential health products appropriate to local community needs.

■ The ASHA will provide information on about the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the Sub-Centres/Primary Health Centre. She will promote construction of household toilets under Total Sanitation Campaign. (Now under Swacch Bharat Mission for rural and urban area)

■ ASHA should promote attendance at the monthly Village Health and Nutrition Day by those who need Aganwadi or Auxiliary Nurse Midwife (ANM) services and help with counseling, health education and access to services.

Village Health Sanitation and Nutrition Committee (VHSNC)It is envisaged to- act as leadership platform for improving awareness and access of community for health services, support the ASHA, develop village health plans, specific to the local needs, and serve as a mechanism to promote community action for health, particularly for social determinants of health.1

The VHSNC is to be formed at the level of revenue village. It should have minimum of about 15 members. Members of the committee are selected from: elected Gram Panchayat Members, ASHAs, frontline staff of government health related services such as ANM, AWW and the school teacher, pre-existing committees, representatives from community based organizations, service users.

Roles and responsibilities of VHSNC are as follows:

1. Monitoring and Facilitating Access to Essential Public Services- and Correlating Such Access with Health Outcomes- other than health services the VHSNC also records access to related public services, including the access to work under MNREGA, rations from public distribution system, midday meals, anganwadi services, safe drinking water, access to toilets, etc-

2. Organising Local Collective Action for Health Promotion- The VHSNC could motivate voluntarism by organization and serve as an inspiring village organization, or they could pay local village youth for the task, or contract labour for this purpose.

3. Facilitating Service Delivery and Service Providers in the Village-

a. Organization of the Village Health and Nutrition Day and support to the organization of immunization sessions is key part of facilitating service access in the village.

b. VHSNCs need to allow outreach workers and community service providers to articulate

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their problems in these meetings. The meeting should identify those individuals whom the ANM, Anganwadi worker, the school teacher and the ASHA are unable to reach and should help these providers in reaching these sections.

c. Sometimes there are important amenities missing in the Anganwadi center or Sub- center or School. The VHSNC can help provide these amenities

d. The committee can organize local tie-ups with vehicle owners to transport a patient to the hospital in time of need.

e. One specific type of service for VHSNCs to focus on is the registration of births and deaths.

4. Village Health Planning- One method of making a village health plan is to identify the problems in access to public services and close the gaps. This type of planning enables understanding on why some pockets or habitations have lower access and can suggest actions to close the gaps.

5. Community Monitoring of Health Care Facilities- In many districts VHSNCs have been oriented towards community monitoring of health care services in primary and secondary health care facilities in their area.

6. Monthly meetings (should be held once in a month)

7. Management of Untied Village Health Fund- Every VHSNC is entitled to an annual untied grant of Rs. 10,000 from the National Rural Health Mission (NRHM). The untied grant is a resource for community action at the local level. Nutrition, Education & Sanitation, Environmental Protection, Public Health Measures are key areas where these funds could be utilized

8. Maintenance of records-record of meetings, record of approvals, cash back, public services monitoring register, birth and death register.

Auxiliary Nurse Midwife (ANM)2

ANMs are regarded as the first contact person between people and organisation, between needs and services and between consumer and provider.2 ANM is expected to participate in Maternal Health, Child Health and Family Planning Services; Nutrition Education; Health Education; Collaborative Service for Improvement of Environmental Sanitation; Immunisation for Control of Communicable Diseases; Treatment of Minor Ailments and First Aid in Emergencies and Disasters.

In addition to these duties, the ANM would perform the following functions in guiding and training the female Accredited Social Health Activist (ASHA), as envisaged in the Guidelines on ASHA, under NRHM:

■ Holding weekly / fortnightly meeting with ASHA to discuss the activities undertaken during the week/fortnight.

■ Acting as a resource person, along with Anganwadi Worker (AWW), for the training of ASHA.

■ Informing ASHA about date and time of the outreach session and also guiding her to bring the prospective beneficiaries to the outreach session.

■ Participating and guiding in organising Health Days at Anganwadi Centre.

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■ Taking help of ASHA in updating eligible couples register of the village concerned.

■ Utilizing ASHA in motivating the pregnant women for coming to Sub-Centre for initial check-ups.

■ ASHA helps ANMs in bringing married couples to Sub-Centres for adopting family planning.

■ Guiding ASHA in motivating pregnant women for taking full course of iron folic acid (IFA) tablets and TT injections, etc.

■ Orienting ASHA on the dose schedule and side effects of oral pills.

■ Educating ASHA on danger signs of pregnancy and labour so that she can identify and help beneficiary in getting further timely treatment.

■ Informing ASHA about date, time and place for initial and periodic training schedule. ANM would also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training.

Anganwadi WorkerAn Anganwadi is the focal point for the delivery of Integrated Child Development Services (ICDS) Scheme services to children and mothers. An Anganwadi normally covers a population of 400-800 in both rural and urban areas and 300-800 in tribal areas.

Services at Anganwadi center (AWC) are delivered by an Anganwadi Worker (AWW) who is a part-time honorary worker. She is a woman of same locality, chosen by the people, having educational qualification of middle school or matric or higher. She is assisted by a helper who is also a local woman and is paid honorarium. Being the functional unit of ICDS programme which involves different groups of beneficiaries, the AWW has to conduct various types of job responsibilities.3

Role and responsibilities of AWW are as follows:

■ To elicit community support and participation in running the programme.

■ To weigh each child every month, record the weight graphically on the growth card, use referral card for referring cases of mothers/children to the sub-centers/Primary Health Centers (PHC) etc., and maintain child cards for children below 6 years and produce these cards before visiting medical and para-medical personnel

■ To carry out a quick survey of all the families, especially mothers and children in those families in their respective area of work once in a year.

■ To organise non-formal pre-school activities in the anganwadi of children in the age group 3-6 years of age and to help in designing and making of toys and play equipment of indigenous origin for use in anganwadi.

■ To organise supplementary nutrition feeding for children (0-6 years) and expectant and nursing mothers by planning the menu based on locally available food and local recipes.

■ To provide health and nutrition education and counseling on breastfeeding/Infant & young feeding practices to mothers. Anganwadi Workers, being close to the local community, can motivate married women to adopt family planning/birth control measures

■ AWWs shall share the information relating to births that took place during the month with the Panchayat Secretary/Gram Sabha Sewak/ANM whoever has been notified as Registrar/Sub Registrar of Births & Deaths in her village.

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■ To make home visits to enable mothers to plan an effective role in the child’s growth and development with special emphasis on newborn child.

■ To maintain files and records as prescribed.

■ To assist the PHC staff in the implementation of health component of the programme viz. immunisation, health check-up, ante natal & post natal check etc.

■ To assist ANM in the administration of IFA and Vitamin A by keeping stock of the two medicines in the Centre.

■ To share information collected under ICDS Scheme with the ANM.

■ To bring to the notice of the Supervisors/ Child Development Project Officer (CDPO) any development in the village which requires their attention and intervention.

■ To maintain liaison with other institutions (Mahila Mandals) and involve lady school workers and girls of the primary/middle schools in the village which have relevance to her functions.

■ To guide ASHA engaged under NRHM in the delivery of health care services and maintenance of records under the ICDS Scheme.

■ To assist in implementation of Kishori Shakti Yojana (KSY) and motivate and educate the adolescent girls and their parents and community in general by organizing social awareness programmes/ campaigns etc.

■ AWW would also assist in implementation of Nutrition Programme for Adolescent Girls (NPAG) as per the guidelines of the Scheme and maintain such record as prescribed under the NPAG.

■ AWW can function as depot holder for RCH Kit/ contraceptives and disposable delivery kits. However, actual distribution of delivery kits or administration of drugs, other than OTC (Over the Counter) drugs would actually be carried out by the ANM or ASHA as decided by the Ministry of Health & Family Welfare.

■ To identify the disability among children during her home visits and refer the case immediately to the nearest PHC or District Disability Rehabilitation Centre.

■ To support in organizing Pulse Polio Immunization (PPI) drives.

■ To inform the ANM in case of emergency cases like diahorrea, cholera etc.

Rogi Kalyan Samiti (RKS)Rogi Kalyan Samiti (Patient Welfare Committee) / Hospital Management Society is a registered society, acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from Government sector who are responsible for proper functioning and management of the hospital / Community Health Centre / First Referral Units (FRU’s). RKS / HMS is free to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services.4

The suggested composition of RKS / HMS is as follows:

■ Peoples representatives MLA / MP

■ Health officials (including an Ayush doctor)

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■ Local district officials

■ Leading members of the community

■ Local CHC/ FRU in-charge

■ Representatives of the Indian Medical Association

■ Members of the local bodies and Panchayati Raj representative

■ Leading donors

Roles and responsibilities of RKS:

■ Identifying the problems faced by the patients in CHC/PHC;

■ Acquiring equipment, furniture, ambulance (through purchase, donation, rental or any other means, including loans from banks) for the hospital;

■ Expanding the hospital building, in consultation with and subject to any Guidelines that may be laid down by the State Government;

■ Making arrangements for the maintenance of hospital building (including residential buildings), vehicles and equipment available with the hospital;

■ Improving boarding / lodging arrangements for the patients and their attendants;

■ Entering into partnership arrangement with the private sector (including individuals) for the improvement of support services such as cleaning services, laundry services, diagnostic facilities and ambulatory services etc.;

■ Developing / leasing out vacant land in the premises of the hospital for commercial purposes with a view to improve financial position of the Society;

■ Encouraging community participation in the maintenance and upkeep of the hospital;

■ Promoting measures for resource conservation through adoption of wards by institutions or individuals; and,

■ Adopting sustainable and environmental friendly measures for the day-to-day management of the hospital, e.g. scientific hospital waste disposal system, solar lighting systems, solar refrigeration systems, water harvesting and water re-charging systems etc.

Village Health Nutrition Day5

The VHND is to be organized once every month (preferably on Wednesdays, and for those villages that have been left out, on any other day of the same month) at the AWC in the village. This will ensure uniformity in organizing the VHND. The AWC is identified as the hub for service provision in the RCH-II, NHM, and also as a platform for inter-sectoral convergence. VHND is also to be seen as a platform for interfacing between the community and the health system.

On the appointed day, ASHAs, AWWs, and other will mobilize the villagers, especially women and children, to assemble at the nearest AWC. The ANM and other health personnel should be present on time On the VHND, the villagers can interact freely with the health personnel and obtain basic services and information. They can also learn about the preventive and promotive aspects of health care, which will encourage them to seek health care at proper facilities.

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QuizQ1. One ASHA is for how much population? Ans. 1000

Q2. ASHA is a member of Rogi Kalyan Samiti. True/False Ans. False

Q3. VHSNC is entitled to grant of how much money? Ans. Rs. 10,000

Q4. One AWW covers how much population in tribal areas? Ans 300-800

Q5. Who encourages community participation in the maintenance and upkeep of the hospital? Ans. Rogi Kalyan Samiti

Q6. Where are VHND organized usually? Ans. AWC

Q7. Who provides assistance in supplementary nutrition for children? AWW

Q8. RKS is present at Sub-Centre level. True/False Ans. False

Q9. ANM is an honorary worker. True/False Ans. False

Q10. VHND are held how many times in a month in a village? Ans. once

References:1. NRHM. Guidelines for Community Processes [Internet] 2013 [Accessed on 2016, Feb 15]. Available from: https://www.google.co.in/url?sa=t&rct=j&q=& esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ahUKEwjy3-nwqojLAhVC G44KHVexA98QFggwMAI&url=http%3A%2F%2Fnhsrcindia.org%2Findex. php%3Foption%3Dcom_dropfiles%26task%3Dfrontfile.download%26id%3D1173&usg=AFQjCNE5rWwrwtYlEnNYBT138oTj98-OpQ.

2. Malik G. Role of Auxillary Nurse Midwives in National Rural Health Mission. The Nursing Journal of India 2009; c(3). Available from: http://www.tnaionline.org/april-09/8.htm

3. Sandhyarani MC, Rao UC. Role and responsibilities of anganwadi workers, with Special reference to mysore district. International Journal of Science, Environment and Technology 2013;2(6):1277-1296

4. NHM, MoHFW, GoI. Constitution of Rogi Kalyan Samities [Internet] 2013 [Accessed on 2016, Feb 16]. Available from: http://nrhm.gov.in/nhm/nrhm/ guidelines/nrhm-guidelines/constitution-of-rogi-kalyan-samities.html

5. NHM, MoHFW, GoI. Village Health Nutrition [Internet] 2013 [Accessed on 2016, Feb 16]. Available from: http://nrhm.gov.in/communitisation/village-health-nutrition-day.htm

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SOCIAL MOBILIZATION AND REACHING THE UNREACHED

Session

12Total time needed

30 minutes


Understand the concept of social mobilization

Know how to reach the unreached



■ LCD projector

■ Laptop

■ Flip chart

■ Pens

Key messages: ■ Social mobilization is about people taking

action and making change for common good.

■ Social mobilization involves community to solve their own problems and initiate their own projects.

■ It is essential to reach the unreached-in geographic terms, economic terms, and cognitive terms.

■ Social mobilization involves health education, community organizing, advocacy and monitoring and evaluation

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Instructional methodology: lecture (power point slides), brain storming

Facilitation notes: Begin the session by asking the participants about “what do they understand by Social mobilization”. Note down the responses. Then project the slide on Social mobilization. Highlight the process of social mobilization. Then ask social mobilization techniques.

After this, ask the participants to work in group to develop social mobilization plan for diarrhea prevention and control and then discuss


What is Social Mobilization?Social mobilization is a process that engages and motivates a wide range of partners and allies at national and local levels to raise awareness of and demand for a particular development objective through dialogue.1 Members of institutions, community networks, civic and religious groups and others work in a coordinated way to reach specific groups of people for dialogue with planned messages. In other words, it’s about people taking action and making change for the common good. The societal mobilization strategy calls for partnership with all stake holders.

Steps to mobilize the communityWhen working with the community, it is advised to apply the Community Mobilization Cycle. This cycle is composed of 8 steps and can regularly be used when enabling the community to solve their own problems and initiate their own projects.

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Sesson 12: Social mobilization and reaching the unreached

Fig: Community Mobilization Cycle

Reaching the unreached

It is suggested that the unreached may be considered in three categories.3

■ First there are the under-served in geographically remote areas, sometimes referred to as the rural ghettos.

■ Then there are the under-served in the urban ghettos who may or may not be in close proximity to every kind of health care resource but still do not get the care they need.

■ And then there is a very large and generally overlooked group, the under-served among educated, economically self-sufficient persons who are quite capable of getting health care for themselves, but who; may feel they are perfectly healthy and not in need of care, or who for some other reason may not choose to avail themselves of it.

1. Getting to know the community, provide information & create interest.

2. Analysis-identification of resources, problem identification, identification solutions & projects

3. Decision making & selection of leaders by community

4. Identification of stakeholders

5. Planning and selection of implementing leaders

6. Project implementation by community

7. Follow up & monitoring

8. Evaluation

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Social mobilization componentsHealth education:

Information Education Communication- Appropriate messages should be designed for a particular audience based on a particular problem. Use of various mechanisms and forms of communication-both one way and two-way communication.

Fig: Hierarchy of effects

Target Audience

Exposed to message

Correctly understand the message

Agree with message

Intend to act Act

100 persons 80 persons 60 persons 40 persons 20 persons 3-7 persons

Training-

■ Develop competencies of the community, health sector workers and those of the other sectors.

■ In undertaking the identified tasks from resource sharing to provision of specific health procedures.

Community organizing:

■ Build the community’s capability for problem-solving, decision making and collective action while developing and strengthening its own networks.

■ Mobilization of communities should focus on building confidence, trust and respect, increasing knowledge base, and enabling community members to participate, and become more proactive with regard to their own health behavior.

Advocacy

■ Organization of information into arguments used to persuade or convince a specific group of people to take necessary action on a specific goal.

■ Involves the generation and utilization of reliable information to help national leaders, policy makers, and decision makers to help adopt necessary policies or programs.

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Monitoring and Evaluation

■ Improve the implementer’s efficiency in advocating and mobilizing action (Monitoring)

■ Determine the effectiveness of the program (Evaluation)

Social mobilization in diarrhea prevention and treatment4

■ Improvement in care-seeking and child-rearing practices; health education and promotion; social accountability and advocacy have been identified as the core components of the community mobilization strategy

■ Inter-sectoral collaboration within and outside the health sector

■ Community-based workers have to be trained not only in counseling skills to improve child care and feeding and care-seeking practices but also in community development facilitating skills.

■ Generating and presenting in the appropriate national and international forums the relevant data on the disease burden, the human and socioeconomic impacts arising from this burden and the available cost-effective interventions as a solution to this problem must be an integral part.

■ Besides reducing excess mortality, morbidity and disability, especially in poor and marginalized populations, mobilizing a unified response from national and international partners would also assist in framing an enabling policy and creating an institutional environment for implementing the programme.

ExerciseQ1. As a community health worker, how will you mobilize the community for prevention and control of diarrhea among children? (ask the participants to work in group and put it on charts)

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References:1. UNICEF. Communication for Development (C4D) [Internet] 2015 [Accessed on 2016, Feb 20]. Available from: http://www.unicef.org/cbsc/index_42347.html

2. Handbook “Steps and methods to mobilize the community” [Internet] 2003 [Accessed on 2016, Feb 20]. Available from: http://siteresources.worldbank.org/INTECAREGTOPCOMDRIDEV/34004326-1113591395520/20451886/smallgrantshighlight1.pdf

3. Watts MS. Editorial: reaching the unreached with health care. West J Med 1974;121(3):230-31.

4. WHO. Strategy for coordinated approach to prevention and control of acute diarrhea and respiratory infection in the South East Asia Region [Internet] 2010 [Accessed on 2016, Feb 15] Available from: http://www.searo.who.int/about/administration_structure/cds/Publication_SEA-CD-212.pdf

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BASICS OF ADULT LEARNING TECHNIQUES

Session

13Total time needed

60 minutes


Understand the concept of andragogy

Know the adult learning techniques

Equip themselves with skills of using adult learning techniques



■ LCD projector

■ Laptop

■ Flip chart

■ Pens

Key messages: ■ Adult learning is different from learning

techniques among children.

■ Andragogy focuses on adult learning strategies and centers attention on the process of engaging adult learners within the structure of learning experience.

■ Adult learning is active, problem centric, based upon previous experience, relevance, emotional connection, self-learning, alignment and fun.

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Instructional methodology: lecture (power point slides), fish bowl discussion

Facilitation notes: Begin the session by asking the participants about “difference between adult and child learning principles”. Note down the responses on flip chart. Then explain the difference. Introduce basic concept of andragogy and explain the principles of adult learning. Then tell the participants about type of learning styles prevalent among adults. Ask participants what techniques of learning could be used for adults or they have been using for adult training. Then discuss the adult learning techniques.

End the session by asking one of the participants to summarize the session and then display the key messages of the session.

After this ask the participants to work in groups for the exercise.

IntroductionAs a health provider, one has to enter into teaching learning relationship with the patient/community when transmission of information for their well-being is necessary. For the teaching to be as effective as possible, knowledge about adult- learning principles is essential. Understanding why and how adults learn and incorporating the learner’s preferred learning style will assist the health care provider in attaining the goals set.1

The reasons most adults enter any learning experience is to create change. This could encompass a change in (a) their skills, (b) behavior, (c) knowledge level, or (d) even their attitudes about things.1

Andragogy: Andragogy focuses on adult learning strategies and centers attention on the process of engaging adult learners within the structure of learning experience.2

Principles of Adult Learning1. Principle of Active Learning: Active participation through discussion, feedback and

activities creates more learning than passive listening or reading. As a presenter, find ways to reduce the amount of content covered and allow the participants to discuss the content with each other.

2. Principle of Problem Centric: Adults come to your presentation expecting to get their problems solved. They are not there just to get more information. If your presentation does not help them solve their pressing issues, it will be forgotten. Adults are problem-centric, not content-centric.

3. Principle of Previous experience: New information has to be linked to previous knowledge and experience or it will not be remembered.

4. Principle of Relevance: If the information being presented is not relevant to the listener’s life and work, it will not get their attention. As a speaker, your content must have meaning and immediate relevance.

Sesson 13: Basics of adult learning techniques

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5. Principle of Emotional Connection: Presentations that connect with a learner’s emotions are more likely to be remembered, recalled and learned. Fear is not a good motivating factor for learning as it causes the brain to react in a fight or flight syndrome.

6. Principle of Self-Learning: Adult learners have some strong beliefs about how they learn. As a speaker, always explain why the audience should participate in specific activity and how the process as well as content benefits their learning.

7. Principle of Alignment: Adults expect that a presenter’s content, learning outcomes and activities be aligned together. If the learning outcomes do not match the content, the learner feels disconnected and learning is hampered.

8. Principle of Fun: By all means, make learning fun, enjoyable and filled with laughter

What is active learning?Active learning occurs when the learner is involved in more than just listening to a lecture. It involves discussion with others (not just the presenter), structured note taking, problem solving and participation in some form. Active learning also stimulates cognitive learning and the use of higher level thinking skills like analysis, evaluation and synthesis.2

What is self-directed learning?Self-directed learning (SDL) is a “process in which individuals take the initiative, without the help of others” in planning, carrying out, and evaluating their own learning experiences.3

What is transformational learning?Transformative learning (TL) is often described as learning that changes the way individuals think about themselves and their world, and that involves a shift of consciousness.3

Adult learning techniquesTo encourage maximum learning, participation and retention among adults, following techniques can be used2:

1. Body Voting-This simple activity is great as an icebreaker or intro to a subject. It helps the presenter and attendees quickly gauge the experience or knowledge level of a group. Body voting is simply the process of asking the audience to take an action based on a series of questions. Example: Have everyone stand. Then ask the following questions: If you’ve been in this industry for more than one year, stay standing. Those that haven’t please take a seat. If you’ve been in this industry for more than five years, stay standing. Those that haven’t please sit. Repeat the process until only a few are standing. Use this process with industry or content specific questions. Why use this over audience response systems? Because people need the chance to move around, especially if they’ve been sitting for several hours at a conference.

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2. Case Studies-Case studies are written accounts of real or fictitious situations or problems. Some case studies are left unsolved so that participants can analyze situations and arrive at their own conclusions. They are designed to develop critical thinking and decision-making skills. Case studies may be from two to ten pages in length. For small groups, ask participants to discuss possible solutions and outcomes. Or provide a list of questions to help facilitate a conversation.

3. Critical Incidents Similar in design to case studies, critical incidents are much shorter, usually a paragraph in length.

4. Fishbowls-It involves forming a circle within a circle. The inner circle discusses an issue while the outer circle listens and takes notes on group dynamics, process or content. After a set time, the outer circle shares their observations. Then the groups switch and the process is repeated.

5. Human Spectagram-The presenter starts by making a statement. Attendees then stand along one wall where one corner represents strongly agree and the opposite corner represents strongly disagree. Attendees are asked to stand along the wall where they rate their level of agreement with the statement. Some may choose to stand in the middle. Some may stand closer to one corner. The presenter can pose a variety of statements with different variables to see how the majority of the audience feels about specific issues.

6. Jigsaw Grouping Brainstorming-The attendees are divided into separate groups each with a pre-established topic, facilitator and flip chart. The participants brainstorm the topic of their group while someone keeps notes on a flip chart. After a prearranged time, members of the group separate and go to other tables where that table’s topic is discussed and the flip chart shared. The facilitator at each table helps start the brainstorming where the previous group ended. At the end, all charts are shared with the attendees.

7. Lecturette- Short ten to fifteen minute lectures spoken or distributed via handouts that frame a conversation, situation or theory. Lecturettes are intended to establish some common language between presenters and attendees about a model, principle or process. They are a perfect fit before an activity or to segue into a different topic.

8. Mind Maps (sometimes referred to Mind Webs)- Often used to help individuals and groups to think globally and creatively, mind maps help attendees analyze, classify, evaluate, generate, list, structure and visualize important ideas. Attendees draw diagrams representing words, ideas, issues, tasks, etc., around a central idea.

9. Open Space Session- open space is an umbrella term describing a variety of meeting formats where participants define the agenda with a rigorous process. All attendees contribute to the scope of the session, the agenda, the groupings and the topics. Often used as problem solving tool or peer engagement process.

10. 1Pair-Squared Attendees are asked to form a pair, turn to a neighbor on their right or left and discuss a specific issue, question or topic. Each attendee is given a specific time period to speak while the other attendee listens. Then roles change and the process is repeated. After both attendees have played listener and talker, they find another pair. Then attendee A tells the other pair what attendee B said while the three listen. Then attendee B tells the other pair what attendee A stated while the three listen. The process repeats for the other pair.

11. 1Peer -To-Peer Round Table Discussions-A structured system to provide peer engagement around specific topics. Attendees enter a room and each table has an established topic and facilitator. The facilitator follows a set of instructions to allow each table participant to help guide frame the discussion on three important ideas.

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12. 1Role Plays- Role plays allow participants to create manageable versions of situations in which they can practice new behaviors and try on new forms of communication. Participants can make and correct mistakes in a safe environment while preparing them to be more effective in real world situations.

13. 1Structured Note Taking -Structure note taking is providing some type of graphical representation that frames the lecture, discussion or reading. Some presenters intentionally omit important words or phrases from handouts to allow attendee to write them in the spaces provided.

Other training methods include: panel/guest expert, games, demonstration and use of technology (media, video, computer, interactive multi-media)

ExerciseQ1. Name three techniques that enhanced your own learning in present workshop

Q2. Practice fishbowl technique

Inner group- A meeting of all the stakeholder in a village regarding implementation of 7 point plan for prevention and control of diarrhea

Adults learn best when:1. They are in supportive environment

2. Learners are allowed to define their own needs

3. See personal growth opportunities in the training

4. Material presented is relevant to perceived needs

5. Participate actively in cooperative and individual exercises

6. Educator respects the life experience of the learner

7. Material can be immediately related to learner’s life experience

8. Direction of learning made explicit at the outset

9. Instructions for learning activities are clear

10. Experience a variety of training methods and media

11. Are empowered with learning skills

12. Receive timely feedback on practice activities

13. Learners receive positive reinforcement for accomplishments

14. Have their individual needs met

15. Are taught course content that is relevant and in integrated patterns

16. Learners feel free to question and challenge

17. Learner’s self-esteem and ego are respected

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References:1. Russell SS. An overview of Adult Learning Processes. Urol Nurs. 2006;26(5):349-352.

2. Corenet Global. Adult Learning Techniques [Internet] 2016 [Accessed on 2016 Feb 20]. Available from: http://www.corenetglobal.org/files/summits_events/ CallforContent/pdf/AdultLearningTips.pdf.

3. TEAL Center Factsheet No. 11: Adult Learning Theories. [Internet] 2011 [Accessed on 2016 Feb 20]. Available from: https://teal.ed.gov/sites/default/files/FactSheets/11_%20TEAL_Adult_Learning_Theory.pdf.

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. No. Test Parameter IS: 10500-2012 Method of TestDrinking Water Specification

(Indian Standard IS:3025 Methods of Sampling and Test for Water and Waste Water)

(Second Revision)Requirement (Acceptable limit)

Permissible limit In the Absence of alternate source

1 Odour Agreeable Agreeable IS:3025 Part 52 Taste Agreeable Agreeable IS:3025 Part 83 pH value 6.5 – 8.5 No relaxation IS:3025 Part 114 Turbidity, NTU, Max 1 5 IS:3025 Part 10

5 Total dissolved solids (TDS), mg/l, Max

500 2000 IS:3025 Part 16

6 Total alkalinity as CaCO3, mg/l, Max

200 600 IS:3025 Part 23

7 Total hardness as CaCO3, mg/l, Max

200 600 IS:3025 Part 21

8 Calcium as Ca, mg/l, max

75 200 IS:3025 Part 40

9 Magnesium as Mg, mg/l, Max

30 100 IS:3025 Part 46

10 Chloride as Cl, mg/l, Max

250 1000 IS:3025 Part 32

11 Residual Free Chlorine, mg/l, Min*

0.2 1 IS:3025 Part 26

12 Sulphate as SO4, mg/l, max

200 400 IS:3025 Part 24

13 Nitrate Nitrogen as NO3, mg/l, Max

45 No relaxation IS:3025 Part 34

14 Fluoride as F, mg/l, Max

1 1.5 IS:3025 Part 60

15 Total Iron as Fe, mg/l, Max

0.3 No relaxation IS:3025 Part 53

16

Coliform MPN/100 ml Shall not be detectable in any 100 ml sample

Indian Standard IS:1622, Methods of Sampling and Microbiological Examination of water.

17 Faecal Coliform, Presence/Absence

Shall not be detectable in any 100 ml sample

18 E.coli, Presence / Absence

Shall not be detectable in any 100 ml sample

*Applicable only when water is chlorinated

ANNEXURE I

INDIAN STANDARDS OF DRINKING WATER

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ANNEXURE II

WATER QUALITY MANAGEMENT

Purification of water on a large scaleThe method of treatment of water to be employed depends upon the nature of raw water, and the desired standards of water quality. For example, ground water (e.g. wells and springs) may need no treatment, other than disinfection. Surface water (e.g. river water) which tends to be turbid and polluted, requires extensive treatment

The components of a typical water purification system comprise one or more of the following measures:

1. Storage

2. Filtration

3. Disinfection

Storage: Water is drawn out from source and impounded in reservoirs. Storage provides a reserve of water from which further pollution is excluded. About 90% of the suspended impurities settle down in 24 hours by gravity. The water becomes clearer. This allows penetration of light and reduces the work of filters. Also, certain chemical changes take place during storage. The aerobic bacteria oxidize the organic matter present in the water with aid of dissolved oxygen. Consequently, the content of free ammonia is reduced. It is found out that when river water is stored, the total bacterial count drops by as much as 90% in the first 5-7 days.

The optimum period of storage of river water is 10-14 days, after which there is likelihood of development of vegetable growths such as algae which impart bad smell and color to water.

Filtration: It is the second stage in purification of water. 98-99% of the bacteria are removed by filtration. Two types of filters are in use the “biological” or “slow sand” filters and the “rapid sand” or mechanical filters.

Disinfection: It is the last step in purification process. An agent or chemical can act as disinfectant if it is capable of destroying pathogenic organisms, does not leave any products of reaction, have ready and dependable availability, possess the property of leaving residual concentration to deal with small possible re-contamination and is amenable to detection by simple analytical techniques. Examples-chlorine and ozone.

Purification of water on a small scaleThree methods are generally available for purifying water on an individual or domestic scale. These methods are:1. Boiling2. Chemical disinfection3. Filtration

4. Ultraviolet irradiation

5. Multi-stage reverse osmosis purification of water

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Boiling: It is a satisfying method of purifying water for household purposes. To be effective, the water must be brought to “rolling boil” for 10-20 minutes. It kills all bacteria, spores, cysts and ova and yields sterilized water. It also removes temporary hardness of water. However, it offers no “residual protection” against subsequent microbial contamination.

Chemical disinfection: Water is disinfected using bleaching powder, chlorine solution, hypochlorite solution, chlorine tablets, iodine.

Filtration: Water can be purified by filtering through ceramic filters such as Pastuer Chamberland filter, Berkefeld filter and “Katadyn” filter. The essential part of a filter is the “candle” which is either made of porcelain or infusorial earth. In the Katadyn filter, the surface of the filter is coated with silver catalyst so that bacteria coming in contact with the surface are killed. Filter candles of fine type usually remove bacteria found in drinking water, but not filter passing viruses.

Ultraviolet (UV) irradiation: UV irradiation is effective against most microorganisms known to contaminate water supplies like bacteria, yeast, viruses, fungi, algae, protozoa etc. This method of disinfection involves exposure of a film of water, upto 120 mm thick, to one or several quartz mercury vapour arc lamps emitting UV. The advantages are that exposure is for short period, no foreign matter introduced and no taste or odour produced. Over exposure does not result in any harmful effects.

Multi-stage reverse osmosis purification of water: It is used to make water both chemically and microbiologically potable by reducing total dissolved solids, hardness, heavy metals, and disease causing bacteria, virus, protozoa and cysts.

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ANNEXURE III

METHODS OF EXCRETA DISPOSALThere are number of methods of excreta disposal. Some are applicable to unsewered areas and some to sewered areas.

I. Unsewered areas

1. Non service type latrines (sanitary latrine)A sanitary latrine is one where:

a. Excreta should not contaminate the ground or surface water.b. Excreta should not pollute the soil.c. Excreta should not be accessible to flies, rodents, animals, and other vehicle of

transmissiond. Excreta should not create a nuisance due to odour or unsightly appearance.

Some well-known type of sanitary latrines are as follows:

i. Bore hole latrine: The latrine consists of a circular hole 30-40 cm in diameter, dug vertically into the ground to a depth of 4-8 m. A concrete squatting plate with central opening and footrests is place over the hole. For a family of 5-6 people, it serves well over a year.

ii. Dug well latrine or pit latrine: A circular pit about 75 cm in diameter and 3-3.5 m deep is dug into the ground for reception of nightsoil. A concrete squatting plate with central opening and footrests is place over the hole. The pit latrine last for about 5 years for a family of 4-5 persons.

iii. Water seal latrine or hand flushed “water seal” type: The squatting plate is fitted with water seal which prevents access by flies and odours and foul gases thereby eliminating the nuisance from smell. This type of latrine consists of pan that receives nightsoil, urine, and wash water. There is a uniform slope from front to back of the pan. It is connected to a trap which is bent pipe holding the water seal. A connecting pipe is required if the pit is dug away from the squat.

iv. Septic tank: It is water tight masonry tank into which the household sewage is admitted for treatment. A capacity of 20-30 gallons per person is recommended for household septic tanks. The minimum capacity should 500 gallons. The depth of the tank is 1.5-2 m and length is usually twice the breadth. The liquid depth should be 1.2 m. There should be minimum of 30 cm air space between the liquid in the tank and undersurface of the cover. There is an inlet and outlet pipe and bottom is sloping towards inlet. Newly built septic tanks are first filled with water upto the outlet level and then seeded with ripe sludge drawn from another septic tank, to provide the right type of bacteria for decomposition.

v. Aqua privy: The privy consists of water tight chamber filled with water. A short length of a drop pipe from latrine floor dips into the water. A capacity of one cubic ft. is recommended for small family, allowing 6 years or more for cleansing purposes.

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2. Latrines suitable for camps and temporary use:

i. Shallow trench latrine: The trench is 30 cm wide and 90-150 cm deep. Its length depends on the number of users: 3-3.5 m are necessary for 100 people. It is rudimentary arrangement for a short period (upto one week).

ii. Deep trench latrine: The trench is 1.8 to 2.5 m deep and 75-90 cm wide. This type of latrine is intended for camps of longer duration, from few weeks to a few months.

II. Sewered areas

1. Water carriage system and sewage treatment: It implies collecting and transporting of human excreta and waste water from residential, commercial and industrial areas, by a network of underground pipes, called sewers to the place of ultimate disposal.

A water carriage system consists of the following elements:

i. Household sanitary fittings (plumbing system of buildings)

ii. House sewers

iii. Street sewers

iv. Sewers appurtenances: manholes, traps etc.

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ANNEXURE II water quality management

ANNEXURE IV

NATIONAL IMMUNIZATION SCHEDULE

For Infants (0-1 year)

Vaccine & Dose Route

At Birth BCG (0.1 ml) IntradermalOPV 0 dose (2 drops) OralHepatitis B 0 dose (0.5 ml) Intramuscular

6 weeks Pentavalent Vaccine-1 (0.5 ml)

Intramuscular

OPV-1 (2 drops) Oral10 weeks Pentavalent Vaccine-2 (0.5

ml)Intramuscular

OPV-2 (2 drops) Oral14 weeks Pentavalent Vaccine-3 (0.5

ml)Intramuscular

OPV-3 (2 drops) OralIPV (0.5 ml) Intramuscular/subcutaneous

9-12 months Measles (0.5 ml) SubcutaneousVitamin A (1 ml) Oral

For children (1-5 years)

16-24 months Measles-2/MMR (0.5 ml) Subcutaneous18-24 months DPT Booster 1 (0.5 ml) Intramuscular

OPV Booster 1 (2 drops) OralVitamin A (2 ml) Oral

2 years Typhoid vaccine (0.5 ml) Intramuscular2-5 years Vitamin A (2 ml) after every

6 monthsOral

5-6 years DPT Booster (0.5 ml) IntramuscularOPV Booster (2 drops) Oral

For children (10-16 years)

10 years Tetanus Toxoid (0.5 ml) Intramuscular16 years Tetanus Toxoid (0.5 ml) Intramuscular

For pregnant womenAs soon as the women registers

for antenatal check upTetanus Toxoid-I (0.5 ml) Intramuscular

4 weeks after 1st dose Tetanus Toxoid-II (0.5 ml) Intramuscular

Note: Japanese Encephalitis vaccine has been introduced in 182 districts of 21 states in routine immunization schedule as two doses, first at 9-12 months and second at 16-24 monthsRotavirus Vaccine: to be given under UIP as a 3 dose vaccine along with DPT 1st, 2nd and 3rd dose in a phased manner, initially in four states i.e. Andhra Pradesh, Odisha, Haryana and Himachal Pradesh in first quarter of 2016. Subsequently, the vaccine will be scaled up in entire country.BCG=Bacillus Calmette Guerin; OPV=Oral Polio Vaccine; IPV=Inactivated Polio Vaccine; DPT=Diphtheria Pertussis Tetanus; Pentavalent vaccine=DPT+Hep B+Haemophilus Influenzae type b

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ANNEXURE V

TRAINING FEEDBACK FORM (FOR MOCK SESSIONS)

Date of the session:

Name of the session:

Presenter’s/ Trainer’s name:

Instructions: Please indicate your level of agreement with statements listed below:

S.no. Statements Strongly agree

Agree Neutral Disagree Strongly disagree

1. The objectives of the training clearly defined

2. Participation & interaction were encouraged

3. The topics covered were relevant to me

4. The content was organized and easy to follow

5. The materials distributed were helpful

6. The trainer was knowledgeable about training topics.

7. The training objectives were met.

8. The time allotted for training was sufficient

9. The trainer was well prepared.

10. The meeting room and facilities were adequate and comfortable

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Q11. What aspect of training you liked the most?

Q12. What aspects of the training could be improved?

Other comments:

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ANNEXURE VI

ROTAVIRUS VACCINATION

Rotavirus is the leading cause of severe diarrhea in Indian children under 5, and has been projected to cause 457,000 to 884,000 hospitalizations, 2,000,000 outpatient visits, and 122,000-153,000 deaths annually.1 Findings from various study support the introduction of rotavirus vaccine in India, particularly in states such as Bihar and Uttar Pradesh, where rotavirus-associated mortality rates are high.2

Brief description of rotavirus

Rotaviruses belong to the family Reoviridae, genus rotavirus. The virus measures 70 nm in diameter and has 3 shells-outer capsid, inner capsid and core which surround 11 segments of double stranded RNA.The rotaviruses are divided into seven groups A,B, C (human and animal viruses) and D, E, F, G (animal viruses). Group A rotaviruses are the most frequently identified pathogens. Based on structural glycoprotein VP7, group A rotavirus are classified into 15 genotypes/serotypes and based protease sensitive protein VP4, these are classified into more than 20 serotypes.In most of the studies from India the most common G types reported were G1 and G2 and P types wereP[4] and P[8].3

A novel neonatal strain P type 11 human rotavirus (116 E) was isolated from a newborn in a nursery of Delhi.4 The VP4 of this strain was closely related to that of the bovine serotype G10 P[11] of strain B223.Another neonatal strain G10 P[11] was reported from Bangalore.5 These unusual rotavirus strains which are natural re-assortants of human and bovine rotaviruses suggest that re-assortment may be an important mechanism for generation of rotavirus strains of newborns.3

Rotavirus vaccine in India

India’s first indigenous rotavirus vaccine has been launched in Mar, 2016 under the Universal Immunization Programme (UIP). The vaccine has been introduced initially in four States — Andhra Pradesh, Haryana, Himachal Pradesh and Odisha — and would be expanded to the entire country in a phased manner.

Rotavirus Vaccine-ROTAVAC (Live Attenuated, Oral) is a monovalent liquid frozen vaccine containing live rotavirus 116E strain [G9 P(11)] prepared in Vero cells for the prevention of rotavirus gastroenteritis.6 ROTAVAC should be administered as a 3-dose regimen, 4 weeks apart, beginning at 6 weeks of age and should not be administered to children older than 8 months of age. ROTAVAChas a shelf life of 5 years when stored at -20°C till the expiry date and can be stored for up to six months between 5°C ±3°C. Advantages of ROTOVAC over other rotavirus vaccine is that it is easy to administer (<10 seconds); requires reconstitution; each dose 0.5 ml (5 drops); requires less cold chain space; better compliance; sweet taste; can be safely given with other UIP vaccines; no interference with breast milk; and no vaccine related intussception.6

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References

1. Tate JE, Chitambar S, Esposito DH, Sarkar R, Gladstone B, Ramani S, et al. Disease and economic burden of rotavirus diarrhoea in India. Vaccine. 2009;27:F18-24.

2. Morris SK, Awasthi S, Khera A, Bassani DG, Kang G, Parashar U, et al. Rotavirus mortality in India: estimates based on a nationally representative survey of diarrhoeal deaths. Bull of WHO 2012;90:720-27.

3. Broor S, Ghosh D, Mathur P. Molecular epidemiology of rotaviruses in India. Ind J Med Res 2003;118:59-67.

4. Das BK, Gentsch JR, Hoshino Y, Ishida S, Nakagomi O, Bhan MK, et al. Characterization of the G serotype and genogroup of New Delhi newborn rotavirus strain 116E. Virology 1993; 197 : 99-107

5. Das M, Dunn SJ, Woode GN, Greenberg HB, Rao CD. Both surface proteins (VP4 and VP7) of an asymptomatic neonatal rotavirus strain (I321) have high levels of sequence identity with the homologous proteins of a serotype 10 bovine rotavirus. Virology 1993; 194 : 374-9.

6. Bharat Biotech. Rotavac [Internet] 2016 [Accessed on 2016, Jun 7]. Available from: http://www.bharatbiotech.com/products/vaccines/rotavac/

7. Bhandari N, Chandola TR, Bavdekar A, John J, Antony K, Taneja S, et al.Efficacy of a monovalent human-bovine (116E) rotavirus vaccine in Indian infants: a randomised, double-blind, placebo-controlled trial. Lancet 2013; 383(9985):2136-2143.

Rotavirus strain 116E isolated from asymptomatic neonates born during 1986-88 at the All India Institute of Medical Sciences, New Delhi, was developed into ROTAVAC by Bharat Biotech in collaboration with highly regarded national and international organizations.The vaccine efficacy of ROTAVAC for severe non-vaccine rotavirus gastroenteritis has been found to be 56.4% [95% Cl 36.6, 70.1] in the first year of life and the vaccine efficacy in the second year of the same study is 49% [95% Cl 17.5, 68.4].7

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NOTES

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NOTES

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