Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.) Module One: Climate setting and assesment Session 1 - Diarrhea dialogue: Assessing our knowledge, needs and skills (introduction...) Handout 1A: Pre-test Handout 1B: Training objectives Trainer Attachment 1A: Pretraining questionnaire for volunteers Trainer Attachment 1B: Pretraining questionnaire for counterparts Trainer Attachment 1C: Trainer pretest guide Trainer Attachment 1D: ORT Pretest answer sheet Session 2 - Training program evaluation (introduction...) Handout 2A: Training evaluation

Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)

Module One: Climate setting and assesment

Session 1 - Diarrhea dialogue: Assessing our knowledge, needs and skills

TOTAL TIME

2 hours

OVERVIEW

Participants in this training course bring different skills, experiences, knowledge and perspectives about diarrhea, oral rehydration and ways to prevent diarrhea. In this opening session, an icebreaker activity sets the climate for friendly group relations and enables individuals to share experiences and interests. Participants assess their knowledge of the training course content through a pretest. They also discuss country and community health problems related to diarrhea. Participants and trainers exchange expectations about the training course and review the training schedule.

OBJECTIVES

· To assess knowledge, skills and experience in diarrheal disease control, particularly oral rehydration therapy.
(Steps 1-4)

· To describe the kinds and extent of the country's health problems related to diarrhea.
(Steps 3, 4)

· To list expectations about the activities and outcomes of the training course.
(Steps 4, 5)

RESOURCES

Handouts:

- 1A Pre-Test
- 1B Training Objectives
- 1C Training Schedule (to be prepared by the Trainer)

Trainer) Attachment:

- 1A Pretraining Questionnaire for Volunteers
- 1B Pretraining Questionnaire for Counterparts of Trainees
- 1C Trainer) Pretest Guide
- 1D Pretest Answers

Materials

Newsprint, markers, pencils and notebooks for ail participants.

PROCEDURES

Trainer Note

Prior to the training, if communications allow, send out the pre-assessment forms:

- Trainer Attachment 1A (Pretraining Questionnaire for Volunteers).
- Trainer Attachment 1B (Pretraining Questionnaire for Counterparts or Trainees).

Use this information to adapt the training design to fit the needs and interests of the Trainees and the health problems on their worksites.

Send the adapted training schedule and objectives to the participants prior to the training, if possible. Adapt the pretest (Handout 1A) according to the training schedule and background of the participants.

Locate visual aids on ORT and arrange them in the training room before the training course. Also, set up a "library" of primary health care and ORT reference books and articles for use during the training.

Translate the pretest into the appropriate language for Counterparts.

Step 1 (30 Min)

Coming Together

Welcome the group and use an icebreaker to make sure everyone has a chance to greet and learn about each other. Ask each individual to briefly describe their work in their community and to share one recent health-related experience. Ask someone to record these experiences on newsprint. Note any similarities or differences in experiences as a reference for the range of backgrounds they are bringing to the training.

Trainer Note

If there are any counterparts in the group, make sure that the Volunteers who invited them introduce them in a culturally appropriate way. Make sure the group includes them in dialogue and discussion throughout the training.

See the Training of Trainers Module in Combatting Communicable Childhood Diseases Training Manual (Peace Corps) for more ideas about setting the climate for the training. See Helping Health Workers Learn, "Getting off to a Good Start," Chapter 4, pp. 4-14, for ideas about specific icebreaker activities.

The length of time required for the step will vary with the type of icebreaker selected and the number of participants.

Step 2 (10 Min)

Introducing the Pretest

Introduce and distribute Handout 1A (Pretest). Explain that it is an "outline" of the main concepts to be covered in the training on ORT and other aspects of the control of diarrheal diseases.

Ask participants to read through the pretest and allow time for questions. Tell them to write "don't known, whenever they cannot provide the information requested.

Trainer Note

Emphasize that the pretest is intended to enable individuals to assess their own skills and knowledge of diarrhea and ORT. Explain that they will receive the pretest answers at the end of the session in which each particular topic is covered. They can use the pretest as a basis to decide what they want and need to learn about ORT in this training. Suggest that at the end of each session they refer back to the pretest to make sure they have mastered the main concepts and to assess how well the training is covering the important topics.

Emphasize that they will also be learning and practicing skills needed to apply the concepts in community work.

Step 3 (20 min)

Knowledge Assesment

Give participants 20 minute to complete the pretest.

Trainer Note

If some of the Counterparts have difficulty in reading the vocabulary in the pretest, an alternative approach is to ask Volunteers to work together with their Counterparts to answer the questions

Step 4 (45 min)

Diarrhea Dialogue

Have small groups use the pretest experience as a starting point to discuss the following points:

- What local community-based experiences have you had with ORT or other aspects of control and prevention of diarrhea?

- Did your experience help you answer the questions in the pretest?

- What are the mayor health problems related to diarrhea in your community?

- What skills are available in the group to deal with the problems?

- Do the topics outlined in the pretest address these problems?

- What do you expect to gain from this training program?

- What hopes and doubts do you have about this training program?

- What rules should we follow for working together as a group?

Ask each group to select one member as recorder. Ask the recorder to Jot down comments, questions, impressions and experiences on newsprint to share later with the entire group. Make it clear the answers to these questions should provide a list of resources, expectations and rules for working together as a group during the rest of this training program.

Trainer Note

See Helping Health Workers Learn, Chapter 4, pages 11-13, for further descriptions of how to discuss hopes, doubts and other important topics in the first few days of training.

While the participants may not have a clear idea of exactly what they want or need to know at this point in the training, the opportunity to discuss their ideas will force them to reflect on their needs and expectations.

For preservice training modify the discussion questions to draw on participants previous experiences and provide information about health problems in the host country.

Step 5 (20 Min)

Sharing Resources and Expectations

Reconvene the group and ask each recorder to report on their group's discussion, using the newsprint they prepared.

Summarize by comparing impressions and experiences focusing on the resources available within the group. Draw on any unique perceptions of Counterparts in the group.

Make a list of participants" expectations about what they want to learn, and working rules for dally life as a group. Discuss these and get a consensus on the working rules and ideas about ways to deal with the doubts.

Trainer Note

Be prepared to provide accurate information about diarrheal disease particularly in the host country.

Examples of "working rules" from previous training courses include:

- starting and finishing sessions on tire
- not smoking in the training room
- stating complaints when they arise; not waiting until the end of the course.

Step 5 (45 min)

Reviewing Objectives

Distribute and discuss Handout 1B (Training Objectives). Explain each objective briefly by relating it to practical tasks in teching the community about ORT. Compare the objectives with the list of expectations for the training.

Distribute Handout 1C, (Training Schedule) and note that participants will be developing a plan for a health education project during this training and designing and conducting one session within the project plan. Encourage them to work with their Counterpart or another Volunteer to identify a topic and begin exchanging ideas for a project.

If necessary, modify the objective and schedule to fit the expectations expressed in the previous step.

Summarize by reviewing the objectives, and schedule. Encourage participants to express what is going well and what needs to be improved throughout the training, particularly during the dally review at the end of each day.

Trainer Note

If some expectations are outside the scope of this training course, discuss why that is the case. Depending on the teaching and language skills of the participants, ask them to help in preparing for and conducting at least one session now so they that have ample time to prepare. Those with technical or health education background may want to facilitate a session on their own. Such opportunities provide practice and feedback on health education skills. Participant facilitated sessions do require more of the Trainer's time because it is important to work with participants, to assure that their sessions will provide the other Trainees). with the experience and information needed to accomplish the objectives of the training course. In training programs where Counterparts are participating, the facilitator also needs good language skills unless the Counterparts speak English.

See Helping Health Workers Learn, Chapter 4, page 14 for additional ideas about forming trainee "committees"

Handout 1A: Pre-test

Name..................................

I. DIARRHEA, DEHYDRATION AND REHYDRATION

1) Name two mayor causes of childhood diarrhea in your country. (Session 3)

2) Explain the primary way diarrheal disease are transmitted. (Session 3)

3) List four health practices that would prevent and/or control the spread of diarrhea. (Session 3)

4) Cite four signs of severe dehydration. (Session 4)

5) List the two most important things to do when a child has some dehydration. (Session 5)

6) Write the recipe for preparing home made sugar-salt solution. (Session 5)

7) List the two ingredients in ORS packets that are usually not found in other rehydration solutions and explain what purpose each of these ingredients serve. (Session 5)

II. NUTRITION AND DIARRHEA

1) Describe the appropriate diet for a one year old child during and after diarrhea. (Session 7)

2) Explain the meaning of "the vicious circle" of diarrhea and malnutrition. (Session 7).

3) Describe four signs indicating a child under two is at high risk for malnutrition and illness. (Session 8).

4) List three kinds of anthropometric measures used in growth monitoring. (Session B).

5) Describe four strategies for preventing malnutrition. (Session 9) .

III. WORKING WITH THE HEALTH SYSTEM

1) Explain the host country national recommendations for the use of ORS packets and home-made sugar-salt solution (or rice-flour water) in the treatment of diarrhea and dehydration (Session 10)

2) List two areas in which Peace Corps Volunteers can collaborate with Host Country National and or other international organizations in the implementation of CDD Programs. (Session 11)

3) Describe four tasks involved in monitoring. (Session 12)

4) Describe the host country's diarrheal disease surveillance system. (Session 12)

IV. WORKING WITH THE COMMUNITY

1) Explain two practices that villagers commonly use when their children have diarrhea. (Session 13)

2) Name two things that villagers believe are the causes of diarrhea. (Session 13)

3) State three techniques used to motivate communities in projects to prevent and control diarrhea. (Session 14)

4) Explain why identifying community leaders is an important step in the planning of your health projects. (Session 14)

V. COMMUNITY HEALTH EDUCATION

1) List five items to include in a health education project plan. (Session 15)

2) Cite three reasons for incorporating evaluation in your project plans. (Session 15)

3) List at least five nonformal education techniques that you can use in health education (Session 16)

4) Describe at least three criteria to use when selecting visual aids (Session 17)

5) Explain why it is important to pretest visual aids before using them with a large group. (Session 18)

6) List three reason for adapting visual aids. (Session 18)

7) List the four steps of the experiential learning cycle and give an example illustrating what you would do for each step. (Session 19)

Handout 1B: Training objectives

At the end of this training course, participants will be able to do the following:

· Describe and work in support of National ORT Programs that deal with the control of diarrheal diseases.

· Teach and motivate community members to prevent diarrhea through sanitation and personal hygiene.

· Teach health workers to assess stages of dehydration and select the appropriate treatment plans using the WHO chart.

· Detect and refer dehydration cases requiring IV Therapy or other medical care to appropriate health facility.

· Teach mothers and health workers to correctly mix and feed their children two kinds of oral rehydration solution during diarrhea.

· Promote breastfeeding and nutritious feeding during and after diarrhea.

· Identify and work with one community to modify local health practices affecting diarrhea which have the highest priority for change.

· Plan, conduct and evaluate health education session on ORT using appropriate nonformal education techniques and visual aids.

· Monitor the preparation and use of ORT in the home following health education and monitor the prevalence of diarrhea in the community.

Trainer Attachment 1A: Pretraining questionnaire for volunteers

Name: .........................................

Program: .........................................

Site: .........................................

Province/Region: .........................................

Counterpart Name: .........................................

Relationship w/Counterpart (check): .........................................

.........................................1. Supervisor

.........................................2. Co-Worker

.........................................3. Other (specify):
......................................... .........................................

Purpose:

The purpose of this questionnaire is to find out the training needs of the PCVs and their familiarity with Oral Rehydration Therapy (ORT) and Health Education. Results will be used in finalizing the design for the Training program.

Instructions:

Please go over the following subject areas by circling the number that best describes your level of understanding or skill now, ranging from Very Insufficient to Very Sufficient

B. Learning Needs

Please write your answers in the space following the question,

1. What are the other skills/knowledge that you have in addition to those listed above:

2. What are your present projects and activities?

3. What problems have you encountered in educating the community about health!

4. What health education skills do you actually use in your work now!

5. What other health education skills do you need to learn and plan to use for the rest of your work in country?

6. What suggestions and comments can you give to make this in-service training most useful for you and your Counterpart?

Thank you for your cooperation. Kindly send this to (Trainer to specify address) together with the questionnaire from your Counterpart (Supervisor and/or co-worker) in this training on or before (Trainer to add date).

Trainer Attachment 1B: Pretraining questionnaire for counterparts

Name: .........................................

Position: .........................................

Site: .........................................

Province/Region: .........................................

Name of your Volunteer: .........................................

Relationship w/Volunteer (check): .........................................

.........................................1. Supervisor

.........................................2. Co-Worker

.........................................3. Other (specify):
......................................... .........................................

Purpose:

The main purpose of this questionnaire is to find out the training needs of the participants and their familiarity with oral rehydration therapy (ORT) and health education. Some information on your community's health conditions and the activities of our Volunteers are requested also. These will help make the training design as realistic and applicable as possible. Results will be used in finalizing the design for the Training program.

Instructions:

Please go over the following subject areas by circling the number that best describes your level of understanding or skill now, ranging from Very Insufficient to Very Sufficient

B. Health Problems and Projects

1. What are the leading causes of infant and children under five sickness in your area? List the top five causes in order of incidence

1. .........................................
2. .........................................
3. .........................................
4. .........................................
5. .........................................

2. What are the five mayor health problems in your areas What are the corresponding causes? (Example; problem is malnutrition; Cause/poverty, lack of health education).

A. Problems

1. .........................................
2. .........................................
3. .........................................
4. .........................................
5. .........................................

B. Corresponding Causes(s)

......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... .........................................

3. What are your present programs, projects or activities related to the control and prevention of diarrheal diseases?

4. In which of these activities do you need your Volunteer's support!

Trainer Attachment 1C: Trainer pretest guide

The following 5 categories of topics are the basis for the ORT pretest:

I. Diarrhea, Diarrhea, and rehydration

II. Nutrition and Diarrhea

III. Working With The Health System

IV. Working With The Community

V. Community Health Education

Attached are the answers to the sample pretest (Handout 1A). The sessions in which the answers are addressed are listed on the pretest below in parenthesis for participants" future reference. Use or modify these questions as appropriate for your country. If you develop your own pretest, be sure it is no longer than 35 questions. Distribute it to participants as Handout 1A.

Trainer Attachment 1D: ORT Pretest answer sheet

I. Diarrhea, Dehydration and rehydration

1) These will vary with the county some suggested answers may include, dirty water, contaminated food, food practices, viruses, weaning.

2) Fecal-oral route

3) Use of latrines or proper disposal of excrete

Hand washing before eating and preparing food
Getting and protecting a safe water source
Keeping foods very cold or very hot to prevent growth of bacteria and other organisms

4) More than 10 liquid stools per day

No tears
Very fast and weak pulse
No urine for six hours

5) Give ORS

Continue breastfeeding or providing other liquids such as tea, lemon or orange juice, chicken broth etc.

6) Combine 1 teaspoon of salt and 8 teaspoons of sugar in 1 liter of water.

7) Potassium is usually not used in preparing home-made solution. Potassium is important because the body loses this substance and a minimum level is needed for the body to function. Sodium bicarbonate 'or trisodium citrate) is also found in ORS and helps prevents "acidosis", a condition that decreases the dehydrated child's appetite.

II. Nutrition and Diarrhea

1) Appropriate diet for a one year old child with diarrhea is to continue breastfeeding and give the child 1/4 - 1/2 cup of fluid after each loose stool. Give easily digested foods such as boiled rices, eggs and porridge and foods rich in potassium such as bananas or pineapple.

2) "The vicious circle" of diarrhea means that malnourished children appear to suffer more severe episodes of diarrhea than healthy children and diarrhea causes serious growth faltering.

3) Four signs indicating a child is at high risk for malnutrition and disease are:

- Child of a widow or divorced person
- Repeated bouts of diarrhea and/or illness in early months of life
- One of more than seven siblings
- Weight loss.

4) Three kinds of anthropometric measures are:

- Arm circumference
- Weight to age
- Weight to height or length.

5) Four strategies for preventing malnutrition are:

- Nutrition education
- Promotion of breastfeeding
- Use of nutritional weaning foods as a supplement to breastfeeding
- Monitoring growth and development.

III. Working With the Health System

1) This will vary with the country

2) This will vary with the country

3) The tasks involved in monitoring consist of:

- determining what to monitor
- determining how and when to monitor
- developing checklists for monitoring and
- after monitoring providing feed back

4) This will vary with the country

IV. Working With the Community

1) This will vary with the country

2) This will vary with the country

3) Members of a community can be motivated by:

- building on local self-help traditions
- starting with a project that will produce results quickly before going into more long term efforts.
- using teaching techniques that actively involve community members

4) Community leader contribute to the success of a project by:

- helping people in the community know and gain confidence in you .
- helping identify problems and resources in the community
- giving general information about the program and helping interpret it to the villagers.

V. Community Health Education

1) Items to include in health education project plans are:

- the objective (outcome you expect)
- the target group
- techniques and visual aids to use
- location and duration of the project
- resources needed (expertise, supplies, equipment etc.)
- when and how to evaluate the project

2) Evaluation should be included in your project to:

- measure how well your objectives are befog met
- assess the performance of the health education
- assess what the participants learned

3) Five examples of nonformal education techniques are:

- role play
- story telling
- large group discussion
- demonstration with skills practice field trips

4) Visual aids used should be

- culturally appropriate
- well designed (communicate the message)
- accomplish the objective it was designed for

5) It is important to pretest visual aids to understand whether they attract and hold the interest of the group and whether they communicate the intended message.

6) Visual aids should be adapted because:

- it is often easier to change well-tested educational materials from another country to suit local conditions then to start from scratch.

- technical information requires few changes from one culture to another.

- it saves time and money

7) The steps of the experiential learning cycle are:

Experiencing (doing something)
Processing (Discussing reaction and observations)
Generalizing (deciding what that experience tells you about the real world)
Applying (planning more effective behavior)

These examples should be similar to the one in Session 19

Session 2 - Training program evaluation

TOTAL TIME

1-2 hours

OVERVIEW

A constructive evaluation is an important part of any well-designed training program. During this session, participants and trainers will determine how well the training achieved its stated objectives and how the program might be modified to serve the needs of people working on the control of diarrheal diseases, particularly oral rehydration therapy, more appropriately in the future. The group will complete an evaluation instrument and discuss problems and potential improvements.

OBJECTIVES

· To evaluate in writing and in discussion the effectiveness of the training program. (Steps 1, 3, 4)

· To check individual as well as group goal accomplishments during the training. (Step 2)

· To identify specific ways to improve the training design and program implementation. (Steps 3, 4)

RESOURCES

List of expectations from Session 1.

Handouts:

- 2A Training Program Evaluation
- 1A Pre-test (from Session 1)
- 1B Training Objectives (from Session 1)

MATERIALS

Newsprint, markers

PROCEDURE

Trainer Note

In Session 19 participants critiqued and used a session evaluation form Handout 19B (Session Assessment Sheet). You can use this throughout the course to assess the training course as planned and implemented in the field. Handout 2A (Training Evaluation is a final evaluation instrument to be used as described in this session.

Step 1 (20 min)

Written Evaluation of the Program

Post the list of expectations developed by the group during Session 1 (Diarrhea Dialogue). Review the session objectives and distribute copies of the Handout 2A (Training Evaluation to all participants, ask them to take 15 minutes to fill out the form. Explain that they will discuss the program afterwards.

Trainer Note

Ask participants to take out and refer to their copies of the Training Objectives and the Pre-test. These handouts were used in Session 1 to establish their entry level knowledge and expected outcomes at the start of the program, Now these sheets will help participants gauge their learning and skill development. If alternate forms were used during the initial objective-setting exercise, use them here. If participants also did dally or weekly evaluations of the course, refer back to those also.

Step 2 (15 min)

Individual Accomplishments

Have participants review their pre-tests from Session 1. In turn, ask each person to briefly comment on their personal accomplishments during the program.

Trainer Note

The idea in this step is to give each participant an opportunity to share accomplishments in the context of his or her particular Job and community.

Step 3 (15 min)

Identifying Problems in the Training

Have participants form small groups of four and list on newsprint two to three aspects of the program which have been problematic and possible suggestions for improvement. Encourage participants to be as specific as possible. As the groups finish the task, have them post the newsprint on the wall.

Step 4 (15 min)

Summary and Conclusions

Reconvene the group and review the newsprint suggestions with them. Ask someone to summarize the observations and suggestions for improvement which have resulted from the discussions. Have a participant record these on newsprint for use by the staff later. Circle those observations that seem to be generally agreed upon and most feasible for future training activities.

Close the session by asking the group to comment on how useful they found the written evaluation form and ask them to suggest other ways that program evaluations can be handled.

Alternate Step 4 (45 min.)

Fish Bowl Discussion

If more time is available for evaluation purposes the following sequence is offered as an alternative to Step 4. Have the group reconvene and occupy the chairs in the outer circle of the "fishbowl" ( see the Trainer Note for a description of the arrangement). Explain the "fishbowl" activity. (Ask if anyone has had experience with this activity; have them help with the explanation). The explanation should include the following points:

- Only three people at a time will be in the inner circle.

- The role of each of the three people will be to discuss the posted observations and suggestions from Step 3.

- When someone from the outer circle wants to enter the discussion, they should quickly tap on the shoulder of someone in the inner circle and exchange places with that person.

Explain that the reason for using the fish bowl activity is to provide a structure for discussion and to encourage constructive feedback and suggestions.

Before beginning the discussion, have one of the participants scan the lists and point out common themes or parallels among the observations. Ask for three volunteers to move to the inner circle. Initiate the activity by responding to one of the posted problems.

After all major issues have been discussed, return to the original Step 4 (Summary and Conclusions), and modify it so participants have the chance to comment on the appropriateness of a "fishbowl" discussion for evaluation purposes.

Trainer Note

While the small groups are working in Step 3, arrange the chairs in the room for a fishbowl type of discussion as shown by the diagram below. Place three chairs in the middle of the room facing each other. Place all other chairs in a circle around the three inner chairs. Be sure the newsprint is posted where everyone can see it.

It is important that everyone feel free to express their thoughts. People should be encouraged to exchange places with someone and enter the discussion when they have something to soy. It is a good idea to have at least one member of the training staff remain in the discussion group "inside" the fish bowl.

Handout 2A: Training evaluation

We need your candid feedback on the training program so that we can make improvements in the design and provide the next group of participants with a richer experience. Please keep in mind the original Training Objectives.