How to Train Community Health Workers in Home-Based Newborn Care

Transcription

1 How to Train Community Health Workers in Home-Based Newborn Care Training Manual By The SEARCH Team Abhay Bang, MD, MPH Priya Paranjpe, M.Sc., M. Ed. Sanjay Baitule, DHMS In collaboration with Judith Standley, CNM, MPH Volume 4 : Module 8 : Acute Respiratory Infections Module 9 : Interpersonal Communication Module 10 : Injecting Vitamin K

2 Time Day 1 Welcome Song (10 min) Module 8: Acute Respiratory Infections Session 1: Review of field experience after Training Workshop 3 (Module 7) (2 hrs) TEA Session 2: Local beliefs and customs (45 min) Session 3: Why is ARI important? (30 min) Session 4: How to assess and diagnose a cough and cold, pneumonia and wheezing (30 min) LUNCH Session 4 (continued) : How to assess and diagnose a cough and cold, pneumonia and wheezing (1 hr 30 min) TEA Session 4 (continued): How to assess and diagnose a cough and cold, pneumonia and wheezing (45 min) Session 5: Treating ARI (45 min) Evaluation (15 min) TIME TABLE TRAINING WORKSHOP 4 OF CHW TRAINING Day 2 Day 3 Song. Review of previous day (10 min) Session 5 (continued) : Treating ARI (1 hr 55 min) Song. Review of previous day (10 min) Session 2 (continued) : Asking questions (30 min) Session 3: Listening (1 hr 30 min) TEA TEA Session 5 (continued) : Treating ARI (20 min) Session 6: ARI review and assessment (1 hr 25 min) Session 4: Sharing health information and advising on care (1 hr 45 min) LUNCH Session 6 (continued) : ARI review and assessment (20 min) Session 7: Completing the ARI Form (1 hr) TEA Module 9: Interpersonal Communication Session 1: Introduction and components (1 hr) Session 2: Asking questions (30 min) LUNCH Session 5: Interpersonal communication: Assessments (1 hr 30 min) TEA Module 10: Injecting Vitamin K Session 1: Vitamin K (1 hr 30 min) Evaluation (15 min) Evaluation (15 min) Day 4 Song. Review of previous day (10 min) Session 2: The Syringe (1 hr 30 min) Session 3: Giving an injection (30 min) T EA Session 3 (continued) : Giving an injection (30 min ) Session 4: Giving an injection: Practice and assessment (1 hr 15 min) LUNCH Session 4 (continued) : Giving an injection: Practice and assessment (1 hr 30 min) T EA Session 4 (continued) : Giving an injection: Practice and assessment (30 min) Summary and planning for work in the community (1hr) Evening: Evaluation and Closing

3 CONTENTS Module 8 : Acute Respiratory Infections Session 1 : Review of field experience after Training Workshop 3 (Module 7) 241 Session 2 : Local beliefs and customs 243 Session 3 : Why is ARI important? 245 Session 4 : How to assess and diagnose a cough and cold, pneumonia and wheezing 247 Handout 1 : Diagnosis of ARI 253 Session 5 : Treating ARI 254 Handout 1 : ARI management chart 259 Handout 2 : Dosage exercises 261 Training Aid 1 : Answers to HO-2: Dosage exercises 262 Handout 3 : Case exercises : Diagnosing and treating ARI 263 Session 6 : ARI review and assessment 265 Handout 1 : ARI examination paper 268 Session 7 : Completing the ARI Form 271 Handout 1 : The ARI Form 273 Handout 2 : Case presentation : Completing ARI Treatment Form 277 Training Aid 1 : Completed ARI Form Based on HO Module 9 : Interpersonal Communication Session 1 : Introduction and components 284 Handout 1 : Interpersonal communication skills checklist 288 Session 2 : Asking questions 289 Handout 1 : Model role play script : Questions exercise 292 Training Aid 1 : Model role play script : Questions exercise Answers for trainers 293 Session 3 : Listening 294 Training Aid 1 : Model role play script : Listening 297 Session 4 : Sharing health information and advising on care 298 Training Aid 1 : Model role play script: Counseling and sharing care information 301 Handout 1 : Case ideas for role plays 302 Session 5 : Interpersonal communication: Assessment 303 Handout 1 : Case ideas for role plays 304 Module 10 : Injecting Vitamin K Session 1 : Vitamin K 305 Handout 1 : Illustration of injection site (lateral thigh) 307 Session 2 : The syringe 308 Handout 1 : Injection: Possible mistakes and consequent dangers 310 Session 3 : Giving an injection 311 Handout 1 : Injection skills checklist for vitamin K 313 Session 4 : Giving an injection: Practice and assessment 314 : Summary Planning for work in the community 316 Post-Training evaluation of CHWs at the work site: Modules 8, 9, and

4 240 How to Train Community Health Workers in Home-Based Newborn Care

5 Module 8: Acute Respiratory Infections Session 1: Review of field experience after Training Workshop 3 (Module 7) Day : 1 Time Required : 2 hours Purpose To provide an opportunity for trainees to discuss their experiences in the field after the third training workshop, to review their experiences with home visiting the neonate, and how they managed filling the Home Visiting Form. Trainers will note topics/skills where trainees may have had difficulty and need more explanation or practice. Objective At the end of the session the CHW will be able to: 1. Discuss successes and problems with home visiting (using the Home Visit Form, examining the neonate, asking the mother questions, etc.), experienced during the field work. Materials l Home Visit Forms for each CHW (Training Workshop 3 Module 7 Session 2 HO-1) Preparation l l Module 8 Acute Respiratory Infections Session 1 Review of field experience after Training Workshop 3 (Module 7) Instruct the trainees in advance to bring their copies of the Home Visit Form. Write the items listed in #2 below on the blackboard or white paper. Training Methods Presentation/Discussion (55 minutes) Instructions to Trainers : 1. Have trainees sit in a large circle. 2. Ask each trainee to give a 3-5 minute summary of her field practice to include (write the following on the board so the CHWs can remember what to discuss): o Experience with home visit after delivery o Using the Home Visit Form o An experience she learned from and what she learned o How she felt about her own practice o How she felt examining the newborn during the home visits o How she felt while providing eye, cord and skin care? Did she face any difficulty? o Any difficult or negative experiences o Any progress in becoming the Ideal CHW How to Train Community Health Workers in Home-Based Newborn Care 241

6 Module 8 Acute Respiratory Infections Session 1 Review of field experience after Training Workshop 3 (Module 7) o Any topics or skills she needs to review from Module 7 3. As CHWs talk be sure to: o Keep track of time. o Clarify any confusing points. o If relevant, discuss any points brought up in the large group. o Summarise and point out common feelings/findings. o Note areas where trainees may need more practice or information. Drama Games (1 hour) Instructions to Trainers : 1. From the previous presentation, ask trainees to repeat some of the difficult situations that came up in the discussion, and some of the positive experiences, such as: family very happy with help from CHW, CHW insecure doing examination of baby during home visits, CHW explaining to family why she needs to visit often after delivery, etc. 2. Write the difficulties or the positive experiences on the board. (15 minutes) 3. Divide trainees into groups of three. 4. Have each group pick a topic and develop a role play showing, through good communication skills and sharing of feelings, how the difficulty can be dealt with, or how the positive experience can help CHW and others. Have CHWs think about the qualities of the ideal CHW when they are preparing the role play. (15 minutes) 5. Have each group present their skit (5 minutes) followed by a short discussion (5 minutes). Summary (5 minutes) Ask trainees to summarise the discussion of field work including areas needing more attention if any. Make correction if any and add missed information. Give feedback on how trainees performed (in general terms) during the post-training evaluation in the field. Congratulate the CHWs for their good work. The trainer evaluates his/her own session (during session) Objective Discuss relevant events experienced during the field work. Assessment Method Presentations. 242 How to Train Community Health Workers in Home-Based Newborn Care

7 Module 8 Acute Respiratory Infections Session 2 Local beliefs and customs Module 8: Acute Respiratory Infections Session 2: Local beliefs and customs Day : 1 Time Required : 45 minutes Purpose To prepare CHWs to effectively manage acute respiratory infections (ARI) in children upto the age of five years, in the community. The CHWs will review the local terminology, customs and beliefs about respiratory illness in their communities, as well as discuss how children are cared for during illness. This will be useful when managing ARI in the community and talking to parents about care. Objectives At the end of the session the CHW will be able to: 1. List local terms used when referring to pneumonia, cough and cold, and wheeze, and any local beliefs on why children get such illnesses. 2. Describe local customs for treating respiratory illness, including care of the sick child, and reasons why. Materials White paper/flip chart paper or blackboard Markers or chalk Training Methods Group Discussion (35 minutes) Instructions to Trainers : 1. Gather the trainees in a large group. 2. Start the discussion by asking the trainees to tell you what kind of respiratory infections they see in their villages. Have them give the local names as you write them down on white paper. These could be words that are better to use in the community than scientific words. Discuss the descriptions of the conditions expressed by these local terms and their seriousness. 3. Try to involve all the trainees. 4. Ask the trainees to explain any local beliefs on why children get respiratory illnesses. List these causes (and there may be a number of different ones) next to the local name of the disease on the white paper. 5. Ask how mothers know the child is sick. When is the sickness considered serious? 6. Next ask about the usual treatment of these illnesses. Write the treatment on the paper next to the illness and the cause of the illness. When is treatment necessary? Do mothers take children to the PHC? To the local healer? Do they use herbs? Do they buy expensive cold and cough preparations? How to Train Community Health Workers in Home-Based Newborn Care 243

8 Module 8 Acute Respiratory Infections Session 2 Local beliefs and customs Do mothers continue to feed infants (breastfeed) and children who are sick? Why or why not? What do you think should be done? 7. Briefly summarise the discussion and keep the white paper to review in a latter session. Summary (10 minutes) Have a trainee summarise the local terms used for respiratory illnesses. Ask another trainee to explain some of the local beliefs on causes of ARI. Ask a trainee to explain traditional treatments for ARI. Have a trainee discuss local practices for home care of the child with a respiratory illness. The trainer evaluates his/her own session (during session) Objectives List local terms used when referring to pneumonia, cough and cold, and wheeze, and any local beliefs on why children get such illnesses. Explain local customs on how to treat a respiratory illness, including care of the sick Assessment Method Participation in group discussion. Questions and answers. Participation in group discussion. Questions and answers. 244 How to Train Community Health Workers in Home-Based Newborn Care

9 Module 8: Acute Respiratory Infections Session 3: Why is ARI important? Day : 1 Time Required : 30 minutes Purpose To emphasise the importance of ARI as a killer of young children, how treating a cough or cold with tonics and other medicines is costly and ineffective, and how timely treatment of pneumonia with antibiotics is life-saving. Objectives At the end of the session the CHW will be able to: 1. Give two reasons why ARI is important. 2. Explain why pneumonia should be treated. 3. Explain the consequences of buying tonics and medicines for the common cold. Materials l l White paper/flip chart paper or blackboard Markers or chalk Module 8 Acute Respiratory Infections Session 3 Why is ARI important? Training Methods Presentation and Group Discussion (20 minutes) Instructions to Trainers : 1. Ask the trainees if they can remember how many coughs or colds their children had last year? Listen to their answers. 2. Explain that on average in India children have as many as 5 or 6 colds or coughs a year. It is the most common illness in young children. 3. Ask the trainees to mention some of the consequences of a child being sick so often. Listen to their answers, and write them on white paper or the blackboard. Add any of the items below if they were not mentioned: o Child may lose weight while sick and become weak. o Child misses school. o Someone needs to stay home to care for the child (if home from school). o Money is spent on cough tonics and medicine and perhaps a doctor. 4. Explain that the term ARI (acute respiratory illness) includes coughs and colds and pneumonia. While coughs and colds are a nuisance, they do not need treatment and will eventually go away, usually in seven days. Pneumonia however is a serious disease and if not treated could kill the child. 5. Explain that pneumonia is one of the biggest killers of children under five years of age in India. By treating pneumonia in their communities, CHWs will be saving lives. 6. Ask the trainees to remember the discussion in the previous session on how people in their communities treat coughs and colds. Ask the trainees to think back to the last time their child had a How to Train Community Health Workers in Home-Based Newborn Care 245

10 Module 8 Acute Respiratory Infections Session 3 Why is ARI important? cold. Did they buy any cough syrups or medicine? How much did it cost? Ask a few trainees to get an idea of how much was spent. 7. Explain that many people pay a lot of money to buy cough mixtures and other remedies for the common cold and cough, but that these mixtures and remedies do not cure the illness. Instead, a lot of money is spent which causes the families hardship and anxiety. 8. Explain that injections are unnecessary pricks to the child and loss of money to the family. Injections are not necessary or useful for treating coughs and colds. 9. Explain that on the other hand, if a child has pneumonia, this must be treated with antibiotics. You will be learning how to tell the difference between a cough and cold and pneumonia. This is very important information! You will be able to help people in your community by treating pneumonia and giving the family advice on how to care for the child at home. You will help them save money, and save their child. Remember, injections are not needed to treat pneumonia; antibiotic tablets or liquids work as well. Content Box ARI Facts ARI causes the most illness in children; every year each child has on average 5 or 6 episodes of cough and cold. Most children recover, but some develop serious infections called pneumonia. If untreated, pneumonia can kill the child. Pneumonia is the most common cause of death in children, especially those less than one year of age. Pneumonia should be treated with antibiotics. Injections are not needed to treat pneumonia; antibiotic tablets or liquids are effective. Money need not be spent on expensive tonics and medicines for treating coughs and colds; these are not effective. Home remedies like ginger tea/tulsi are better and far less costly. Summary (10 minutes) Review the Content Box. Ask a trainee to explain why ARI is important. (ARI causes the most illness in children; this can lead to less growth, weakness, less ability to fight infections; severe ARI [pneumonia] is the biggest killer of children.) Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session (during session) Objectives Give two reasons why ARI is important. Explain why pneumonia should be treated. Explain the consequences of buying tonics and medicines for the common cold. Assessment Method Questions and answers. Questions and answers. Questions and answers. 246 How to Train Community Health Workers in Home-Based Newborn Care

11 Module 8: Acute Respiratory Infections Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing Session 4: How to assess and diagnose a cough and cold, pneumonia and wheezing Day : 1 Time Required : 2 hours 45 minutes Purpose ARIs cause death of a large number of the children under five years of age in India. This session will prepare CHWs to assess and diagnose ARI in children, so they can begin this work in their communities. Objectives At the end of the session the CHW will be able to: 1. Ask relevant questions to ascertain the age of the ill child and symptoms. 2. Look and Listen to the child to: o count respirations for a full minute o check for chest indrawing o listen for wheezing o listen for stridor 3. Differentiate between a cough and cold, pneumonia and wheezing based on assessment (ask, look and listen) and the classification of the disease. Materials Trainer Resource: WHO Training Video Handout 1 (HO-1): Diagnosis of ARI Case Studies (not a handout, to be written on the board or white paper) Blackboard or white paper/flipchart paper Markers Preparation Obtain a copy of the WHO Training Video and make sure the video equipment is set up and working. Make adequate photocopies of Handout 1 depending on the number of trainees. You may write the case studies on flipchart paper in advance to save time. Keep covered until you are ready to use them. Training Methods Active Presentation: Ask, Look, Listen (45 minutes) Instructions to Trainers : 1. Explain that ARI is one of the main causes of death in children under five. It can be easily diagnosed and treated in the community. For this reason, CHWs are being taught this method for assessing, How to Train Community Health Workers in Home-Based Newborn Care 247

12 Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing diagnosing and treating ARI. 2. Explain that at this time CHWs will only be treating infants one month to five years. By the end of their training, they will also be able to treat newborns in the first 28 days, but that will not be covered at this time. 3. Explain that there are three parts to this methodology: assessment, diagnosis, and treatment, which includes home care advice to the parents and medication if indicated by the severity of the disease. In this session CHWs will learn about assessing and diagnosing. 4. Explain that assess means getting information about the child s illness by asking the mother questions, looking at and listening to the child. 5. On the top of white paper write Ask Look Listen Ask the trainees to tell you what they would ask a mother if she brought an ill infant or child with a respiratory infection. Write the answers under Ask. 6. Do the same for what they would look at and what they would listen for. 7. Praise them when they identified the correct question or action. Add any that were missed and remove incorrect or not necessary items after explaining why. Content Box ARI Management Sheet : Assessment of Child Ask Age of the child Cough? For how long? Fast breathing? For how long? How many times in the past? Fever? For how long? Fit/Dati? For how long? Unconscious/Drowsy? For how long? Diarrhoea/Vomiting? Yes/No Suckling/Drinking? As usual? Less than usual? Does not drink since Child had measles in last 30 days? If yes, since days Look (when child is calm) Unconscious/Very lethargic and drowsy? Count respirations for 1 minute (if child is between 1-2 months and rate is over 60, count again) Chest indrawing? Is malnutrition severe? (the child very thin, or short for his age, or swelling over feet) Dehydrated? (dry mouth, sunken eyes, poor skin turgor) Measles? (fresh-red) (old-black) Temperature (record) Listen Stridor? Wheeze? Grunt? 248 How to Train Community Health Workers in Home-Based Newborn Care

13 Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing 8. Ask for any questions. 9. Review the respiration skills learned in Module Ask a trainee to demonstrate counting respirations for one minute. 11. Ask a trainee to explain what stridor is and to make that sound (a harsh noise when the child breathes in, even when calm, caused by an obstruction in the throat; is life threatening). 12. Ask a trainee to explain what a grunt is and make that sound (a short harsh noise made when the baby breathes out (local kanhavne ). 13. Ask a trainee to explain what a wheeze is and make that sound (a long musical sound when the child breathes out due to narrowing of the breathing tubes in the lungs). Chest indrawing Demonstration: Showing the WHO ARI video (15 minutes) Instructions to Trainers : 1. Show the first part that deals with assessment. 2. Ask for any questions. Presentation: How to decide if the child has a cough or cold, pneumonia or wheezing (45 minutes) Instructions to Trainers : 1. Distribute Handout 1: Diagnosis of ARI 2. Explain that this sheet is a helpful aid in deciding what illness the child has, based on the signs the CHW assessed and the age of the child. The ability to make this decision is called diagnosing the disease. 3. Ask the trainees what happens to the breathing rate when you run around the room. They will answer that it gets faster. Tell them they are correct. In much the same way, when a child is ill with pneumonia, sometimes the respiratory rate goes up. However, sometimes when the child is very ill, he/she may be unconscious or very drowsy and the breathing rate may not be fast. The chart will help you use the symptoms the mother told you and the signs you found to diagnose: o Very severe disease o Old ailment o Pneumonia o Wheeze o Fever (>100 0 F in axilla) (learned in Module 3 Session 3) o Dehydration o Cold and ordinary cough How to Train Community Health Workers in Home-Based Newborn Care 249

14 Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing Content Box Diagnosis of ARI Very Severe Disease: If any one or more of the following signs is present Unconscious/very drowsy Fit/Dati Stridor (while the baby is calm) Not taking feeds Severe chest indrawing Measles with pneumonia Old Ailment: If any one or more of the following signs is present Severe malnutrition Cough for more than 30 days Pneumonia: If any one or more of the following signs is present Fast breathing: Age of child: 1-2 months Breath rate 60 or more per minute (repeat the count) 2-12 months Breath rate 50 or more per minute 1-5 years Breath rate 40 or more per minute Wheeze/Asthma Child has wheeze or Three or more attacks of fast breathing in the past one year May also have chest indrawing and fast breathing but does not look sick Fever More than F measured in axilla Dehydration (Did the child recently have diarrhoea?) Dry mouth, sunken eyes, poor skin tone Cold and Cough No fast breathing No chest indrawing No wheeze, grunt or stridor Demonstration: Showing the WHO ARI video (15 minutes) Instructions to Trainers : 1. Explain that the WHO ARI Video shows a case management chart that is slightly different than the one used in the Ankur project but they are basically similar. 2. Show the section that deals with diagnosis. 3. Ask for any questions. 250 How to Train Community Health Workers in Home-Based Newborn Care

15 Case Study Exercises: Making a diagnosis (35 minutes) Instructions to Trainers : 1. Write the following case on the board and read it out loud. Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing Case 1 Sunita is 2 years old. Her mother brought her to you because she had a cough and runny nose for five days. After doing the assessment (ask, look, listen), you find that Sunita has a slight fever of 100F, but no fast breathing, no chest indrawing, no wheeze or other signs of illness. 2. Have the trainees use the ARI Management sheet as an aid. 3. Ask the trainees what questions they would ask the mother. Listen to the answers. Make sure all the relevant questions are mentioned. 4. Ask what they would look for and listen to. Listen to the answers and make sure all the look and listen actions are mentioned. Case 1: Questions: 1) Does Sunita have any signs of very severe disease? (Answer: no) 2) Does Sunita have pneumonia? If yes, why. If no, why not? (Answer: No. She has no fast breathing or chest indrawing.) 3) What is Sunita s main sign? (Answer: slight fever) 4) What is Sunita s diagnosis? Why? (Answer: cough and cold, slight fever) Case 2 Ram is a 6-month-old child whose mother called you to the house as he had been coughing for two days. During the assessment of the baby you found him breathing 58 times a minute. He had no fever or chest indrawing, and no wheeze or grunt. Case 2: Questions: 1) Does Ram have signs of very severe disease? (Answer: no) 2) What is Ram s main sign? (Answer: fast breathing at 58 times per minute) 3) What is Ram s diagnosis? (Answer: pneumonia) Case 3 Smeeta s mother called you to the house. She said the 2-month-old baby had been sick for a few days. You ask the relevant questions and Smeeta s mother says the baby is very drowsy and has not been feeding as usual. You look and listen. You cannot wake Smeeta up. She doesn t have fast breathing or chest indrawing. She has no wheeze, grunt or stridor. Case 3 Questions 1) What is Smeeta s main sign? (Answer: unconscious, unable to wake up, and not taking feeds) 2) Does Smeeta have any signs of very severe disease? What are they? (Answer: yes. Unconscious and unable to take feeds) How to Train Community Health Workers in Home-Based Newborn Care 251

16 Module 8 Acute Respiratory Infections Session 4 How to assess and diagnose a cough and cold, pneumonia and wheezing 3) What is your diagnosis? (Answer: very severe disease) Summary (10 minutes) Ask the trainees to state each of the questions to ask a mother when she brings a sick child. Involve the whole group. Ask the trainees what they look for. Ask them what they listen for. Ask the trainees to explain how they decide what illness the child has. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session (during session) Objectives Assessment Method Ask relevant questions to ascertain the age Participation in discussion and case of the ill child and symptoms. studies. Questions and answers. Look and Listen to the child to: Each trainee demonstrates counting - count respirations for -a full minute respirations for 1 minute. - check for chest indrawing Questions and answers - listen for wheezing - listen for stridor Differentiate between a cough and cold, Case studies during session. pneumonia, very severe disease and wheezing based on assessment (ask, look and listen) and diagnosis of the disease. 252 How to Train Community Health Workers in Home-Based Newborn Care

17 Module 8 Session 4 HO-1 Diagnosis of ARI Very Severe Disease: If any one or more of the following signs is present Unconscious/very drowsy Fit/Dati Stridor (while the baby is calm) Not taking feeds Severe chest indrawing Measles with pneumonia Old Ailment: If any one or more of the following signs is present Severe malnutrition Cough for more than 30 days Pneumonia: If any one or more of the following signs is present Fast breathing: Age of child: 1-2 months Breath rate 60 or more per minute (repeat the count) 2-12 months Breath rate 50 or more per minute 1-5 years Breath rate 40 or more per minute Wheeze/Asthma Child has wheeze or Three or more attacks of fast breathing in the past one year May also have chest indrawing and fast breathing but does not look sick Fever More than F taken in axilla Dehydration (Did the child recently have diarrhoea?) Dry mouth, sunken eyes, poor skin tone Cold and Cough No fast breathing No chest indrawing No wheeze, grunt or stridor How to Train Community Health Workers in Home-Based Newborn Care 253

18 Module 8 Acute Respiratory Infections Session 5 Treating ARI Module 8: Acute Respiratory Infections Session 5: Treating ARI Day : 1 Time Required : 3 hours Purpose To prepare CHWs to use treatment protocols, including home care advice, for various ARI ailments in managing sick children. Objectives At the end of the session the CHW will be able to: 1. Explain why treating pneumonia is life-saving and treating cough and cold is money and anxiety saving. 2. Explain how to treat cough and cold, pneumonia and wheezing. 3. Decide on and prepare correct doses for children of different ages. 4. Explain the home care advice for children with cold, pneumonia and wheezing. (CHWs will practice counseling in home care the next day in Module 9). Materials HO-1: ARI Management Chart HO-2: Dosage exercises sheet Training Aid 1: Answers to HO-2: Dosage exercises HO-3: Case Exercises: Diagnosing and Treating ARI (answers are given under case examples at the end of this session) Bottles of cotrimoxazole, short form - cotra (50 ml bottle containing Trimethoprim 40 mg + Sulphamethoxazole 200 mg per 5 ml) Teaspoon measure Salbutamol tablets (4 mg tablets) Paracetamol (500 mg tablets) Knife to cut tablets and to divide doses Spoon or glass to crush tablets Paper to wrap doses and pen for labeling doses Bottle of Cotrimoxazole Preparation Make adequate photocopies of Handouts 1, 2, and 3 depending on the number of trainees. Obtain and have ready the materials listed above. 254 How to Train Community Health Workers in Home-Based Newborn Care

19 Module 8 Acute Respiratory Infections Session 5 Treating ARI Training Methods Presentation and Case Exercises: How to Treat Pneumonia, Wheezing and Cough/Cold (30 minutes ) Instructions to Trainers : 1. Review that pneumonia is one of the biggest killers of children under five years of age in India. By treating pneumonia in their communities, CHWs will be saving lives. On the other hand, many people pay a lot of money to buy cough mixtures and other remedies for the common cold and cough. These mixtures and remedies do not cure the cough or cold but cost a lot of money and therefore cause the families hardship and more anxiety. In this session you will learn how to save lives by treating pneumonia, and how to help people in your community manage coughs and colds without the anxiety of unnecessary expense. 2. Distribute the ARI Management Sheet (HO-1). Review the diagnosis and the treatment section with the trainees (leave the Home Advice box for later in the session). 3. Ask for any questions; clarify confusion. 4. Mention that if the child is dehydrated and the mother is breastfeeding, she should breastfeed more often and give ORS. Give ORS to the child by spoon after each stool (fluids lost in the stool need to be replaced by drinking more). 5. Tell trainees that if they diagnose pneumonia and give the mother medicine they have to make a follow-up visit the next day to see how the child is doing. 6. Ask the trainees the case questions listed below. Praise correct answers. If an answer is not correct ask the group if they have another answer. Make sure the person not answering correctly is able to answer subsequent questions. o Amril has pneumonia. He is 3 months old. What treatment would he get? (Answer: ½ tsp cotra 2 times a day for 7 days) o Meera has very severe disease. She is 1 year. What will you give and do? (Answer: give 1 tsp cotra and refer immediately) o Geeta is diagnosed with wheezing. She is 3 months old. What treatment will she get? (Answer: Salbutamol, 1/8 tablet 3 times a day for 5 days) o Pradeep is 8 months old. He has a cold and a fever of F. What treatment do you give? (Answer: Paracetamol 1/8 tablet 3 times a day for 3 days) Practice: Determining and preparing doses (45 minutes) Instructions to Trainers : 1. Divide the trainees into groups of three. 2. Make sure each trainee has a dosage exercise sheet (HO-2), and the group should have cotrimoxazole, salbutamol, paracetamol, a teaspoon, knife for cutting the tablet, pieces of paper for wrapping. How to Train Community Health Workers in Home-Based Newborn Care 255

20 Module 8 Acute Respiratory Infections Session 5 Treating ARI 3. Have each trainee answer the dosage questions and then prepare the dosage, and label the packets as necessary. 4. Circulate in the room and give assistance as needed. 5. At the end of the exercise, review the dosage answers in the larger group. (See Training Aid 1 for answers to HO-2.) Presentation and Discussion: ARI: Home care advice (30 minutes) Instructions to Trainers : 1. Ask the trainees to think about what they would say to mothers when caring for an ill child at home. Listen to their answers and write them on white paper. 2. Discuss whether the sick child should eat or not. Listen to the answers. If someone says that children should eat, praise them and ask why? (Children should continue to breastfeed [and eat and drink if they are older] so they don t lose more strength, don t lose weight and don t become dehydrated.) 3. Have trainees look at the Home Care Advice box in HO-1: the ARI Management Chart (see Content Box). Review with the trainees. 4. Compare the Home Care Advice sheet with the white paper from Session 1 (in the morning) where traditional care in local communities is described, and the white sheet from this session listing trainee s opinions on home care. Compare and discuss any differences. 5. If the Home Care Advice sheet differs from what local communities are doing or what the trainees felt should be done, discuss this. Explain any new concepts. Decide the best way to introduce new ideas to the community (such as continued feeding if this is not done). Content Box Home Care Advice Feed the child during illness o Clear the nose if interfering with feeding o Soothe the throat and relieve cough with local remedies (ginger tea/tulsi) o If fever give paracetamol o Increase feeds after illness Increase fluids o Increase breastfeeding o Offer the child extra to drink MOST IMPORTANT: Watch for the following signs; and if they occur call the CHW or go to the PHC o Breathing becomes difficult o Breathing becomes fast o Child is unable to drink o Child may become sicker 256 How to Train Community Health Workers in Home-Based Newborn Care

21 Module 8 Acute Respiratory Infections Session 5 Treating ARI Case Exercises: Diagnosing and treating (1 hour) Instructions to Trainers : 1. Hand out the Case Exercises (HO-3) 2. Have each trainee work individually. (Cases and answers are below.) 3. Review after 20 minutes and answer any questions. Case 1 Neeta is 1 and ½ years old. She has been diagnosed with wheezing. She also has a respiratory rate of 52. What is her treatment? What would you tell her mother about caring for her? Case 1 Questions: 1) What is her diagnosis? (Answer: pneumonia and wheezing) 2) What medicine would you give Neeta? (Answer: Cotra and Salbutamol) 3) How much medicine would you give her? (Answer:1 tsp. Cotra 2 times a day for 7 days and 1/4 tablet of salbutamol 3 times a day for 5 days) 4) What would you tell her mother about giving the medicine? (Answer: Cotra: Give 1 tsp of cotra in the morning and 1 tsp cotra in the night for 7 days. Salbutamol: give1/4 tablet (one packet) in the morning, one packet in the afternoon and one packet at night for 5 days.) 5) What other advice would you give Neeta s mother? (Answer: Continue to feed Neeta; if she develops fast or difficult breathing or is unable to feed, go to the PHC or call me immediately.) Case 2 Jeena is 3 months old. Her mother calls you because she has had a cough for 2 days. You ask, and look and listen Your findings are: breathing at 68 times per minute, no wheeze or grunt, temperature of F. Case 2 Questions: 1) What is the diagnosis? (Answer: pneumonia) 2) What medicine would you give Jeena? (Answer: Cotra and paracetamol) 3) How much medicine would you give her? (Answer: 1/2 teaspoon 2 times a day for 7 days and 1/ 8 tablet paracetamol 3 times a day) 4) What would you tell her mother about giving the medicine? (Answer: Give ½ teaspoon of the cotra in the morning and evening. Make sure to give the cotra for 7 days. Give 1/8 tablet of paracetamol 3 times a day for 3 days.) 5) What else would you tell Jeena s mother? (Answer: Continue to breastfeed Jeena. She needs the energy from the breastmilk. If Jeena gets worse: very drowsy of unconscious, or unable to feed, take her to the PHC immediately.) How to Train Community Health Workers in Home-Based Newborn Care 257

22 Module 8 Acute Respiratory Infections Session 5 Treating ARI Case 3 Pramod is 4 months old. His breathing is 40 times a minute and he has no breathing sounds or chest indrawing. His temperature is 99 0 F. Case 3 Questions: 1) What is his diagnosis? (Answer: cough and cold; no pneumonia) 2) What medicine would you give Pramod? (Answer: none) 3) What advice would you give Pramod s mother? (Answer: Continue to breastfeed Pramod. He needs the energy from the breastmilk. No medicine is needed at this time. If Pramod gets worse very drowsy of unconscious,or unable to feed call me immediately.) Summary (10 minutes) Ask a trainee to explain why treating pneumonia is lifesaving and treating coughs and colds are anxiety and money saving. Discuss. Ask the trainees to explain how they would decide what treatment to give for a particular illness. (Use the ARI diagnosis and treatment chart.) Ask a trainee to explain the home care advice for a child ill with an ARI. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session (5 minutes) Objectives Explain why treating pneumonia is life saving and treating cough and cold is money and anxiety saving. Explain how to treat, cough and cold, pneumonia and wheezing. Decide on and prepare correct doses for children of different ages. Explain the home care advise for children with cough, cold, pneumonia and wheezing. Assessment Method Questions and answers. Case examples during group discussion. Dosage sheets and observation of preparing doses. Each trainee correctly decides and prepares the correct dose for a child. Case exercises. 258 How to Train Community Health Workers in Home-Based Newborn Care

23 Module 8 Session 5 HO-1 ARI Management Chart Diagnosis Treatment Very Severe Disease: If any one or more of the following Give dose of cotra and refer to the hospital signs is present immediately! Unconscious/very drowsy Fit/Dati Stridor (while the baby is calm) Not taking feeds Severe chest indrawing Measles with pneumonia Old Ailment: If any one or more of the following signs Refer to the doctor for examination. is present If the child also has signs of pneumonia, Severe malnutrition start cotra. Cough for more than 30 days Pneumonia: if the child has fast breathing Age of child Rate of breathing 0-6 months *1-2 months Breath rate 60 or more per minute (repeat the count) 1/2 teaspoon (2.5 ml) of cotra 2 times a day 2-12 months Breath rate 50 or more per minute (morning and evening) for 7 days 1-5 years Breath rate 40 or more per minute 6 months 5 years 1 teaspoon (5.0 ml) of cotra 2 times a day (morning and evening) for 7 days Wheeze Less than 1 year: Salbutamol (4 mg tablet) 1/8 tablet (0.5 mg) 3 times a day (upto 5 days if needed) Child has wheeze or (morning, afternoon and evening) fast breathing (more than 3 attacks in a year) 1 to 5 years: Salbutamol ¼ tablet (1 mg) 3 times a day (upto 5 days if needed) May also have chest indrawing and fast breathing but doesn t look sick. (morning, afternoon and evening) Fever More than F measured in axilla Birth to 1 year: Paracetamol (500 mg) 1/8 tablet three times a day 1 to 5 years: Paracetamol 1/4 tablet three times a day *Care of the ill neonates (<28 days) will be covered in Module 16. This ARI management is for children from 1 month to 5 years. How to Train Community Health Workers in Home-Based Newborn Care 259

24 Module 8 Session 5 HO-1 Diagnosis Treatment Dehydration (Did the child recently have diarrhoea?) Breastmilk /ORS/Ambil Dry mouth, sunken eyes, poor skin tone Cold and Cough No fast breathing No injection or medicine. No chest indrawing If fever, give paracetamol. No wheeze, grunt or stridor Continue feeding. Home Care Advice Feed the child during illness Increase fluids o Clear the nose if interfering with feeding. o Soothe the throat and relieve cough with local remedies (ginger tea/tulsi). o If fever give paracetamol. o Increase feeds after illness. o Increase breastfeeding o Offer the child extra to drink MOST IMPORTANT: Watch for the following signs and if they occur call the CHW or go to the PHC o Breathing becomes difficult o Breathing becomes fast o Child is unable to drink o Child becomes sicker 260 How to Train Community Health Workers in Home-Based Newborn Care

25 Module 8 Session 5 HO-2 Dosage Exercises 1. Rani has pneumonia. She is 5 months old. What treatment would she get? 2. Meera has very severe disease. She is 18 months old. What will you give her and do? 3. Geeta is diagnosed with wheezing. She is 4 months old. What treatment will she get? 4. Pradeep is 11 months old. He has a cold and a fever of F. What treatment do you give? 5. Sudhir is 4 years old with pneumonia. What treatment will you give? 6. Gopal is 4 months old with fast breathing (55 times a minute) and has had a cough for a month. What treatment will you give? 7. Amba is 10 months old with dehydration. She has no fever or fast breathing. What treatment should she get? 8. Sonali is 3 months old with very severe disease. What treatment should she get? 9. Sunita is 4 years old with a cough, cold and wheezing. What treatment should she get? 10. Pramod is 3 months with chest indrawing and he is difficult to awake. What treatment should he get? How to Train Community Health Workers in Home-Based Newborn Care 261

26 Module 8 Session 5 Trainer Aid 1 Answers to HO-2: Dosage Exercises 1. Rani has pneumonia. She is 5 months old. What treatment would she get? 1 teaspoon cotra 2 times a day for 7 days. 2. Meera has very severe disease. She is 18 months old. What will you give her and do? Give 1 teaspoon of cotra and refer her to the hospital immediately. 3. Geeta is diagnosed with wheezing. She is 4 months old. What treatment will she get? 1/8 tablet Salbutamol 3 times a day for 5 days. 4. Pradeep is 11 months old. He has a cold and a fever of F. What treatment do you give? Paracetamol 1/8 tablet 3 times a day for no more than 3 days. 5. Sudhir is 4 years old with pneumonia. What treatment will you give? 1 teaspoon cotra 2 times a day for 7 days. 6. Gopal is 4 months old with fast breathing (55 times a minute) and has had a cough for a month. What treatment will you give? 1 teaspoon cotra 2 times a day for 7 days. If Gopal s cough does not improve with this treatment he should be referred to a doctor for an examination. 7. Amba is 10 months old with dehydration. She has no fever or fast breathing. What treatment should she get? She should have ORS (up to 1/2 cup after every loose stool) and mother should breastfeed often. 8. Sonali is 3 months old with very severe disease. What treatment should she get? ½ teaspoon cotra and immediate referral to the hospital. 9. Sunita is 4 years old with a cough, cold and wheezing. What treatment should she get? Salbutamol ¼ tablet 3 times a day for 5 days. 10. Pramod is 3 months with chest indrawing and he is difficult to awake. What treatment should he get? ½ teaspoon cotra and refer to hospital immediately. 262 How to Train Community Health Workers in Home-Based Newborn Care

27 Module 8 Session 5 HO-3 Case Exercises: Diagnosing and Treating ARI Case 1 Neeta is 1 and ½ years old. She has been diagnosed with wheezing. What is her treatment? What would you tell her mother about caring for her? Case 1 Questions: 1. What medicine would you give Neeta? 2. How much medicine would you give her? 3. What would you tell her mother about giving the medicine? 4. What other advice would you give Neeta s mother? Case 2 Jeena is 3 months old. Her mother calls you because she has had a cough for 2 days. You ask, and look and listen. Your findings are: breathing at 68 times per minute, no wheeze or grunt, temperature of F. Case 2 Questions: 1. What is your diagnosis? 2. What medicine would you give Jeena? 3. How much medicine would you give her? 4. What would you tell her mother about giving the medicine? 5. What other advice would you give Neeta s mother? How to Train Community Health Workers in Home-Based Newborn Care 263

28 Module 8 Session 5 HO-3 Case 3 Pramod is 4 months old. His breathing is 40 times a minute and he has no breathing sounds or chest indrawing. His temperature is 99 0 F. Case 3 Questions: 1. What is his diagnosis? 2. What medicine would you give Pramod? 3. What advice would you give Pramod s mother? 264 How to Train Community Health Workers in Home-Based Newborn Care

29 Module 8 Acute Respiratory Infections Session 6 ARI review and assessment Module 8: Acute Respiratory Infections Session 6: ARI review and assessment Day : 2 Time Required : 1 hour and 45 minutes Purpose To assess CHW ability in accurately diagnosing and treating cough and cold, wheezing and pneumonia according to the ARI management criteria. Objective At the end of the session the CHW will be able to: 1. Accurately (75%) diagnose and decide on appropriate treatment for children 1 month to 5 years of age with cough and cold, wheezing and pneumonia. Materials WHO ARI video Handout 1 (HO-1): ARI Examination paper Preparation Obtain a copy of the WHO ARI Video and make sure the video equipment is set up and working. Make adequate photocopies of Handout 1 depending on the number of trainees. Training Methods Audio-Visual Training Aid: WHO ARI video (45 minutes) Instructions to Trainers : 1. Play the ARI Video. Stop when necessary to have CHWs work on the case examples. 2. Discuss the examples and review the criteria. Assessment (45 minutes) Instructions to Trainers : 1. Distribute the Examination Paper (HO-1). (Questions and answers follow.) 2. Allow 20 minutes for individual work. 3. Collect the papers and then discuss each question and answer. 4. Clarify any confusion. 5. CHWs should achieve at least 75% in order to be given the necessary medications to treat pneumonia and wheezing. If a CHW has not achieved this score, she can retake the test either at the end of or at the next training session. 6. CHWs should be told to use the ARI management sheet to answer all questions. This is not an examination of the CHWs memory; in the field, she will have the ARI management chart and should use it. In this examination we are testing her understanding of the management process and ability to How to Train Community Health Workers in Home-Based Newborn Care 265

30 Module 8 Acute Respiratory Infections Session 6 ARI review and assessment use the Chart to accurately diagnose and treat ARI. Passing grade is 75%. Examination Paper: Questions Part I: Assessment: 3 points for each correct answer (total for this section: 12 possible answers x 3 =36 points). 1. Write any 5 of the 9 questions that you would ask a mother when she brings a child with a respiratory illness. (Answer: see ARI Management Chart) 2. Write 4 of the 7 things you would look at when examining a child with a respiratory illness. (See ARI Management chart) 3. Write 3 sounds you would listen for when examining a child with a respiratory illness. (Answer: stridor, wheeze, grunt) Part II:Case Diagnosis: 6 points for correct diagnosis (total points 6 x 6 = 36 points) 4. Anil is 5 months old and has been ill for 3 days. He is breathing 62 times a minute. He is wheezing. He has a fever of F. What is his diagnosis? (Answer: pneumonia with wheezing) (3 points each) 5. Preeti is 3 years old. She has chest indrawing. She has no temperature but is very drowsy. What is her diagnosis? (Answer: very severe disease) 6. Vilas is 2 months old. He has mucus coming from his nose. He is not drowsy and has been feeding. He is breathing at 36 times a minute. He has no chest indrawing or breathing sounds. What is his diagnosis? (Answer: cold) 7. Pradeep is 4 years old. He has had a cough for 40 days. He doesn t have fast breathing or chest indrawing. He looks severely malnourished. What is his diagnosis? (Answer: old ailment) 8. Charu is 7 months old. She has had diarrhoea for 2 days. She has sunken eyes but no fever. She has normal breathing and no chest indrawing. She has no abnormal breath sounds like grunt or stridor. What is her diagnosis? (Answer: dehydration) 9. Ram is 1 year old. He has a musical sound like a flute everytime he breathes out. He does not have fast breathing or chest indrawing. He has no fever. What is his diagnosis? (Answer: wheezing) Part III: Treatment: 4 points for each correct answer. (total points 6 x 4 =24 points). If part of the answer is correct give partial points. 10. Anil is 5 months old and has been ill for 3 days. He is breathing 62 times a minute. He is wheezing. What is the treatment for Anil (case number 4 above)? (Answer: ½ tsp cotra 2 times a day for 7 days for pneumonia, and Salbutamol; 1/8 tablet 3 times a day for 5 days) 11. Preeti is 3 years old. She has chest indrawing. She has no temperature but is very drowsy. What is the treatment for Preeti (case number 5 above)? (Answer: give 1 tsp cotra and refer immediately as she has acute pneumonia. If the parents refuse to take her to the doctor or PHC, continue to treat her with 1 tsp 2 times a day for 5 days.) 12. Vilas is 2 months old. He has mucus coming from his nose. He is not drowsy and has been feeding. He 266 How to Train Community Health Workers in Home-Based Newborn Care

31 Module 8 Acute Respiratory Infections Session 6 ARI review and assessment is breathing at 36 times a minute. He has no chest indrawing or breathing sounds. What is the treatment for Vilas (case number 6 above)? (Answer: no medicine as he only has a cold. You can advise home remedies like ginger or tulsi tea. Continue to breastfeed. Tell mother to watch for signs of difficult or fast breathing or if Vilas stops feeding; if so, immediately see a doctor.) 13. Pradeep is 4 years old. He has had a cough for 40 days. He doesn t have fast breathing or chest indrawing. He looks severely malnourished. What is the treatment for Pradeep (case number 7 above)? (Answer: refer to doctor; give home care, ginger or tulsi tea, continue feeding.) 14. Charu is 7 months old. She has had diarrhoea for 2 days. She has sunken eyes but no fever. She has normal breathing and no chest indrawing. She has no abnormal breath sounds like grunt or stridor. What is the treatment for Charu (case number 8 above)? (Answer: give ORS [up to 1 cup] after each stool, continue feeding [breastfeeding and the feeding soft foods if complementary foods have been started]; refer to doctor.) 15. Ram is 1 year old. He has a musical sound like a flute every time he breathes out. He does not have fast breathing or chest indrawing. He has no fever. What is the treatment for Ram (case number 9 above)? (Answer: Salbutamol ¼ tablet 3 times a day for 5 days) 16. As part of home care advice, name four danger signs parents need to watch out for in their children and immediately seek help: o Breathing becomes difficult o Breathing becomes fast o Child stops eating o Child gets sicker Summary: (15 minutes) Have a CHW explain the questions to ask a mother who brings a child with a respiratory problem. Have another CHW explain what to look for and listen to. Have a CHW explain how she decides if the child has a cough or cold, or has pneumonia or is wheezing. Have a CHW explain what home care would be for a child sick with a cough or cold. Pneumonia? Wheezing? Make corrections if any and add missed information. Congratulate the CHWs for their good work. Evaluation (during session) Objective Assessment Method Accurately (75%) diagnose and decide on Answers to examination paper: at least 75%. appropriate treatment for children 1 month to 5 years of age with cough and cold, wheezing and pneumonia. How to Train Community Health Workers in Home-Based Newborn Care 267

32 Module 8 Session 6 HO-1 Name of CHW ARI Examination Paper Please refer to the ARI Management Chart as you would when working in your community. Part I: Assessment: 3 points for each correct answer (total for this section: 12 possible answers x 3 = 36 points). 1. Write any 5 of the 9 questions that you would ask a mother when she brings a child with a respiratory illness Write 4 of the 7 things you would look at when examining a child with a respiratory illness Write 3 sounds you would listen for when examining a child with a respiratory illness Part II: Case Diagnosis: 6 points for correct diagnosis. (total points 6 x 6 = 36 points) 4. Anil is 5 months old and has been ill for 3 days. He is breathing 62 times a minute. He is wheezing. He has a fever of F. What is his diagnosis? 5. Preeti is 3 years old. She has chest indrawing. She has no temperature but is very drowsy. What is her diagnosis? 6. Vilas is 2 months old. He has mucus coming from his nose. He is not drowsy and has been feeding. He is breathing at 36 times a minute. He has no chest indrawing or breathing sounds. What is his diagnosis? 7. Pradeep is 4 years old. He has had a cough for 40 days. He doesn t have fast breathing or chest indrawing. He looks malnourished. What is his diagnosis? 268 How to Train Community Health Workers in Home-Based Newborn Care

33 Module 8 Session 6 HO-1 8. Charu is 7 months old. She has had diarrhoea for 2 days. She has sunken eyes but no fever. She has normal breathing and no chest indrawing. She has no abnormal breath sounds like grunt or stridor. What is her diagnosis? 9. Ram is 1 year old. He has a musical sound like a flute every time he breathes out. He does not have fast breathing or chest indrawing. He has no fever. What is his diagnosis? Part III: Treatment: 4 points for each correct answer. (total points 7 x 4 =28 points). If part of the answer is correct you will receive partial points. 10. Anil is 5 months old and has been ill for 3 days. He is breathing 62 times a minute. He is wheezing. He has a fever of F. What is the treatment for Anil? 11. Preeti is 3 years old. She has chest indrawing. She has no temperature but is very drowsy. What is the treatment for Preeti? 12. Vilas is 2 months old. He has mucus coming from his nose. He is not drowsy and has been feeding. He is breathing at 36 times a minute. He has no chest indrawing or breathing sounds. What is the treatment for Vilas? 13. Pradeep is 4 years old. He has had a cough for 40 days. He doesn t have fast breathing or chest indrawing. He looks malnourished. What is the treatment for Pradeep? 14. Charu is 7 months old. She has had diarrhoea for 2 days. She has sunken eyes but no fever. She has normal breathing and no chest indrawing. She has no abnormal breath sounds like grunt or stridor. What is the treatment for Charu? 15. Ram is 1 year old. He has a musical sound like a flute every time he breathes out. He does not have fast breathing or chest indrawing. He has no fever. What is the treatment for Ram? How to Train Community Health Workers in Home-Based Newborn Care 269

34 Module 8 Session 6 HO As part of home care advice, name 4 danger signs parents need to watch out for in their children and immediately seek help: Points: Part I (out of 36) Part II (out of 36) Part III (out of 28) Total Points: (out of 100) 270 How to Train Community Health Workers in Home-Based Newborn Care

35 Module 8 Acute Respiratory Infections Session 7 Completing the ARI Form Module 8: Acute Respiratory Infections Session 7: Completing the ARI Form Day : 2 Time Required : 1 hour Purpose To prepare CHWs to complete the ARI form accurately. Objective At the end of the session the CHW will be able to: 1. Complete the ARI treatment form accurately. Materials Handout 1 (HO-1): The ARI Form Handout 2 (HO-2): Case presentation: Completing the ARI Treatment Form Preparation Make adequate photocopies of Handouts 1 and 2 depending on the number of trainees. Training Methods Presentation (15 minutes) Instructions to Trainers : 1. Distribute HO-1: the ARI Treatment forms. 2. Explain that this form must be used for each child examined for a respiratory illness. The first part of the form is completed on the day the child is examined (Day 1). Progress is recorded on Day 2 and Day The first part of the form is similar to the ARI management chart. Briefly review each section by having a trainee read it out loud. Ask for any questions. 4. Review the Day 2 and Day 7 questions. Clarify any confusion. Case Presentation (40 minutes) Instructions to Trainers : 1. Distribute HO-2, the Case Presentation, to each CHW. 2. Have each trainee work individually to complete the ARI Treatment Form based on the Case Presentation. 3. After completion, have the trainees exchange forms with another trainee. 4. Review the answers in session and clarify any problems. 5. Collect the forms for assessment. 6. If there is time, ask the trainees to do the 2 nd Case Presentation for further practice. How to Train Community Health Workers in Home-Based Newborn Care 271

36 Module 8 Acute Respiratory Infections Session 7 Completing the ARI Form Summary (5 minutes) Have a trainee explain when and how to use the ARI Treatment Form. Make corrections if any and add missed information. Compliment the CHWs for their good work. The trainer evaluates his/her own session (during session) Objective Complete the ARI treatment form accurately. Assessment Method Case Presentation. Each trainee completes the ARI Treatment Form accurately. Module 8 is Completed 272 How to Train Community Health Workers in Home-Based Newborn Care

37 Module 8 Session 7 HO-1 The ARI Form Child suffering from Cough or Breathing Problem: Diagnosis and Treatment Part to be retained with Community Health Worker Name of the Child Sex Age Name of Village Village No House No Family ID No Child ID No Date of birth Date of Treatment Signature of the person receiving the form Date of receipt of the form Part to be handed over to the Supervisor Name of the Child Sex Age Name of Village Village No House No Family ID No Child ID No Date of Treatment Signature of the person receiving the form Date of receipt of the form ) Ask the following questions and fill the appropriate information Cough? Yes/No since days Fast breathing? Yes/No since days Fever? Yes/No since days Fit/Dati Yes/No since days Unconscious/Drowsy Yes/No since days Sucking of Milk/Drinking water? 1) As usual 2) Less than usual 3) Does not drink. Since days hours Did the child suffer from eruption of measles in last 30 days? Yes/No Since days Is the child suffering from Diarrhoea/Vomiting? Yes/No Since days (For the newborn up to 30 days old) What was the gestation period? months 2) Observe while the child is calm and record Unconscious/Very lethargic and drowsy Breath rate (count for 1 minute) Yes/No How to Train Community Health Workers in Home-Based Newborn Care 273

38 Module 8 Session 7 HO-1 (If the child is up to 2 months age and the breath rate is more than 60, then count again.) Is indrawing of chest severe? Yes/No Is the malnutrition severe? Yes/No Dehydrated? (Dry mouth, sunken eyes, skin) Yes/No Measles? (Fresh-red or Old-black) Yes/No Temperature (Record) 3) Listen and record Stridor? Yes/No Wheeze? Yes/No Grunt? Yes/No 4) Other complaints/problems 5) Diagnose and treat Diagnosis Treatment (a) Very Severe Disease For any one or more following symptoms: Give dose of cotra and refer to Suckling/breast feeding stopped hospital immediately Unconscious/ Very drowsy Whether referred to hospital Fit/Dati Yes/No Which hospital Severe indrawing of chest To whom Stridor (while the baby is calm) What was the result? Measles with pneumonia If the child is not taken to hospital continue treatment with cotra (b) Ailment since many days/old ailment For any one or more following symptoms: Refer to a doctor for examination Severe malnutrition (If the child is also suffering from pneumonia start cotra.) Cough for more than 30 days Referred? Yes/No Where? To whom? What was the result? (c) Pneumonia 1) High breath rate Cotra as medicine 274 How to Train Community Health Workers in Home-Based Newborn Care

39 Module 8 Session 7 HO-1 Diagnosis Treatment Age-1 to 2 months 1 to 6 months: 1/2 of the tea spoon (2.5 ml) Breath rate more than 60 Twice in a day (once in morning and On counting twice once in evening) for 7 days Age-2-12 months Breath rate 50 or more + Cough 6 months to 5 years: 1 tea spoon (5 ml) Age- 1 to 5 years Twice a day (once in the morning and Breath rate 40 or more once in the evening) for 7 days (d) Wheeze Salbutamol (4 mg) More than 2 attacks of fast breathing Less than 1 year age: in a year 1/8 tablet (0.5 mg) thrice a day x 5 days (once in the morning, once in the afternoon and once in the evening) 1 to 5 years age: ¼ tablet (1 mg) thrice a day (once in the morning, once in the afternoon and once in the evening) (e) Fever (more than F Paracetamol tablet (500 mg) axial temperature) Age less than 1 year: 1/8 tablet thrice a day (once in the morning, once in the afternoon and once in the evening) (f) Dehydration ORS/Breastmilk/Milk/Ambil Skin? -Dry mouth, sunken eyes (g) Cold and ordinary cough No injection or medicine. Continue feeding. Use home remedies juice of ginger/tulsi If there is fever give paracetamol (h) Other ailments State the Diagnosis State the treatment (6) Progress report after two days - Relief Complete the treatment and enquire on the 7 th day How to Train Community Health Workers in Home-Based Newborn Care 275

40 Module 8 Session 7 HO-1 - No relief/worse Refer to a Doctor/Hospital - Dead - Did the parents give medicine as prescribed Yes/No - Was any other treatment given after starting the present one Yes/No If yes From whom? What was the treatment? Was cotra discontinued after initiation? - Other - New symptoms Vomiting/eruption on skin/jaundice (7) Progress after seven days - Cured? (No cough, no fast breathing ) - Improved (No fast breathing but cough persists) - No change (Fast breathing continues) Refer to doctor - Dead Name of the CHW Signature of CHW Supervisor s report after home visit 1. Condition of the patient 2. Anything special 3. Form filled correctly 4. Disparity in information 5. Mistakes in treatment 6. Ill effects of medicine 7. Conclusion Signature: Date: 276 How to Train Community Health Workers in Home-Based Newborn Care

41 Module 8 Session 7 HO-2 Case Presentation: Completing the ARI Treatment Form Diagnosis and treatment of a baby with cough and acute respiratory infection Case 1 Shankar Diwakar Sonule, a 2-year-old from Dibhana had cough from 1/6/2002. From the second day, and for the first time, the baby had fast breathing. On 3/6/2002 his mother came to the CHW s house. The CHW examined the baby and counted his respiratory rate which was 52 per minute. Baby s temperature was ºF. Baby had grunt. The CHW diagnosed the problem and started treatment. (What is the diagnosis and treatment?) The CHW also advised the mother how to care for the baby. On the second day when the CHW went to Shankar s place, his respiratory rate was 38 per minute and body temperature was 98.2 ºF. Mother said that the baby grunts intermittently. The CHW filled the form, gave advice and went home. On 7 th day CHW again went to the place of Shankar. Shankar was not at home. He was playing outside. Mother called Shankar. CHW checked him. Shankar had no problem. He was normal. Mother thanked CHW. Note: Whatever is not mentioned in the case should be considered to be normal. Case 2 (if time permits) Shevanta Narayan Deshmukh of Porla delivered on 25/04/02 at Hrs. 3 min 12 sec 10. From the baby s birth, suckling and cry was good. On 5/6/02 at 10hrs 20 min in the night, the baby s father reached the CHW s place and requested her to come and see the baby as the baby was not well. The CHW prepared for a home visit, confirmed that the bag had medicines etc. and reached the baby s house. The CHW asked the mother what was wrong with the baby. The CHW examined the baby. Baby s respiratory rate was 65 per minute. So she counted again and it was 64. Mother said that it had been 2 hours since the baby has taken feed. The baby had fast breathing since the evening of previous day. Baby had no grunt. Baby s body temperature was 98.2 ºF. Baby had no cough. How to Train Community Health Workers in Home-Based Newborn Care 277

42 Module 8 Session 7 HO - 2 The CHW checked the baby and diagnosed the problem (What is the diagnosis?) She started the treatment and herself gave first dose to the baby. (What was the treatment?)) She advised the mother on home care of the baby and went home. The next day the CHW again went to see the baby and found that the baby was quite active with a respiratory rate of 58. On the 7 th day the CHW again visited to find that the baby was normal with a respiratory rate of 35. The mother thanked the CHW for treating the baby so well. Note: Whatever is not mentioned in the case should be considered to be normal. 278 How to Train Community Health Workers in Home-Based Newborn Care

43 Module 8 Session 7 Training Aid 1 The ARI Form Child suffering from Cough or Breathing Problem: Diagnosis and Treatment Form filled on the basis of Case 1 of Module 8 Session 7 HO-2 Part to be retained with Community Health Worker Name of the Child Shankar Diwakar Sonule Sex M Age 2 years Name of Village Dibhana Village No House No Family ID No Child ID No Date of birth Date of Treatment 3/6/2002 Signature of the person receiving the form Date of receipt of the form... Part to be handed over to the Supervisor Name of the Child Sex M Age 2 years Name of Village Dibhana Village No House No Family ID No Child ID No Date of birth Date of Treatment 3/6/2002 Signature of the person receiving the form Date of receipt of the form... 1) Ask the following questions and fill the appropriate information Cough? Yes/No since days 2 Fast breathing? Yes/No since days 1 Fever? Yes/No since days 1 Fit/Dati Yes/No since days Unconscious/Drowsy Yes/No since days Sucking of Milk/Drinking water? 1) As usual 2) Less than usual Not mentioned 3) Does not drink. Since days hours Did the child suffer from eruption of measles in last 30 days? Yes/No Since days Is the child suffering from Diarrhoea/Vomiting? Yes/No Since days (For the newborn up to 30 days old) What was the gestation period? months How to Train Community Health Workers in Home-Based Newborn Care 279

44 Module 8 Session 7 Training Aid 1 2) Observe while the child is calm and record Unconscious/Very lethargic and drowsy Yes/No Breath rate (count for 1 minute) 52 (If the child is up to 2 months age and the breath rate is more than 60, then count again.) Is indrawing of chest severe? Yes/No Is the malnutrition severe? Yes/No Dehydrated? (Dry mouth, sunken eyes, skin) Yes/No Measles? (Fresh-red or Old-black) Yes/No Temperature (Record) o F 3) Listen and record Stridor? Wheeze? Grunt? Yes/No Yes/No Yes/No 4) Other complaints/problems NO 5) Diagnose and treat Diagnosis Treatment (a) Very Severe Disease For any one or more following symptoms: Give dose of cotra and refer to Suckling/breast feeding stopped hospital immediately Unconscious/ Very drowsy Whether referred to hospital Fit/Dati Yes/No Which hospital Severe indrawing of chest To whom Stridor (while the baby is calm) What was the result? Measles with pneumonia If the child is not taken to hospital continue treatment with cotra 280 How to Train Community Health Workers in Home-Based Newborn Care

45 Module 8 Session 7 Training Aid 1 Diagnosis Treatment (b) Ailment since many days/old ailment For any one or more following symptoms: Refer to a doctor for examination Severe malnutrition (If the child is also suffering from pneumonia start cotra.) Cough for more than 30 days Referred? Yes/No Where? To whom? What was the result? (c) Pneumonia 1) High breath rate Cotra as medicine Age-1 to 2 months 1 to 6 months /2 of the tea spoon (2.5 ml) Breath rate more than 60 Twice in a day (once in morning and On counting twice once in evening) for 7 days Age-2-12 months Breath rate 50 or more + Cough 6 months to 5 years--- 1 tea spoon (5 ml) Age- 1 to 5 years Twice a day (once in the morning and Breath rate 40 or more once in the evening) for 7 days (d) Wheeze Salbutamol (4 mg) More than 2 attacks of fast breathing Less than 1 year age: in a year 1/8 tablet (0.5 mg) thrice a day x 5 days (once in the morning, once in the afternoon and once at the bedtime) 1 to 5 years age: ¼ tablet (1 mg) thrice a day (once in the morning, once in the afternoon and once at the bedtime) (e) Fever (more than F Paracetamol tablet (500 mg) axial temperature) Age less than 1 year: 1/8 tablet thrice a day Pneumonia and fever (once in the morning, once in the afternoon and once at the bedtime) (f) Dehydration ORS/Breastmilk/Milk/Ambil Skin? -----Dry mouth, sunken eyes How to Train Community Health Workers in Home-Based Newborn Care 281

46 Module 8 Session 7 Training Aid 1 (g) Cold and ordinary cough No injection or medicine Continue feeding. Use home remedies juice of ginger/tulsi If there is fever give paracetamol (h) Other ailments State the Diagnosis State the treatment Pneumonia and fever Cotra_and Paracetamol (6) Progress report after two days - Relief YES- Complete the treatment and enquire on the 7 th day - No relief/worse Refer to a Doctor/Hospital - Dead - Did the parents give medicine as prescribed Yes/No - Was any other treatment given after starting the present one Yes/No If yes From whom? What was the treatment? Was cotra discontinued after initiation? - Other - New symptoms Vomiting/eruption on skin/jaundice (7) Progress after seven days - Cured? (No cough, no fast breathing) Cured - Improved (No fast breathing but cough persists) - No change (Fast breathing continues) Refer to doctor - Dead Name of the CHW Signature of CHW 282 How to Train Community Health Workers in Home-Based Newborn Care

47 Module 8 Session 7 Training Aid 1 Supervisor s report after home visit 1. Condition of the patient 2. Anything special 3. Form filled correctly 4. Disparity in information 5. Mistakes in treatment 6. Ill effects of medicine 7. Conclusion Signature: Date: How to Train Community Health Workers in Home-Based Newborn Care 283

48 Module 9 Interpersonal Communication Session 1 Introduction and components Module 9: Interpersonal Communication Session 1: Introduction and components Day : 2 Time Required : 1 hour Purpose To orient the CHW to the importance of effective communication skills when working with people in the community. Objectives At the end of the session the CHW will be able to: 1. Give two examples of how a health worker s communication skill can affect a person s health. 2. Name the three main components of the interpersonal communication process that should be used when working with people in the community. 3. Review the contents of the first component: rapport building (covered in Module 2). Materials Handout 1 (HO-1): Interpersonal Communication Skills Checklist Preparation Make adequate photocopies of Handout 1 depending on the number of trainees. Training Methods Story Telling and Discussion (20 minutes) Instructions to Trainers : 1. Start the session by telling the following story. Read the story to your self and become familiar with it. Try not to read the story to the trainees, but tell it as if you were telling them a story about someone you know. Ashok was 2 months old. He had a cold and cough. His mother, Neeta, took him to the doctor. The doctor was in a hurry; he didn t say hello or greet Neeta. He asked what the problem was and immediately started to examine Ashok. He did not ask any other questions about Ashok and his illness. The doctor examined the baby very quickly and said he wasn t ill and didn t need medicine. Then the doctor rushed out. Two days later, Ashok had fast and difficult breathing. He had stopped breastfeeding. Neeta was worried but she didn t want to go back to that doctor. By the next morning Ashok was much worse and then stopped breathing. He had died. 2. Start a discussion by asking the class what happened. How could the death of Ashok have been prevented? How did the doctor s attitude and his communication affect Neeta s actions? 3. Listen to their answers. If needed, prompt them with the following questions: o How did the doctor act? (He was in a hurry; no greeting. He did not make Neeta feel welcome or that 284 How to Train Community Health Workers in Home-Based Newborn Care

49 Module 9 Interpersonal Communication Session 1 Introduction and components he was interested.) o What did the doctor do? What didn t he do? (He examined Ashok but didn t ask any questions about Ashok s symptoms [remember the ASK questions when managing ARI]. He didn t explain how Neeta should care for Ashok at home, what danger signs to look for and what to do if he got worse.) o Why do you think Neeta didn t go back to the doctor when Ashok got sicker? (She probably didn t like how the doctor treated her. Maybe she thought he would be mad at her for bothering him again. She didn t know that fast breathing and not eating were danger signs and that she should go to the doctor immediately.) 4. Summarise by making the following points: o Because the doctor had a bad attitude and poor communication skills, Neeta did not feel comfortable going back to him. (This is one reason why people sometimes do not use health services.) o She also did not know because the doctor did not tell her that Ashok s new symptoms were very dangerous and that she needed to seek care immediately. (No information on home care and danger signs were given.) o Along with medical knowledge and skills, a health worker needs a positive attitude and effective communication skills to help people in the community take care of themselves and their children. It is essential that people in the community feel comfortable using health services and know when it is necessary to do so. Presentation Main components of the interpersonal communication process (30 minutes) Instructions to Trainers : 1. Explain that the following are the three main components of the interpersonal communication (IPComm) process that should be used when working with people in the community and write them on the board: 1) Building rapport and creating a caring environment. 2) Gathering information for a care plan: questioning and listening. 3) Counseling and sharing information: What parents need to do to care for the child. 2. Explain that these three parts are related to each other. Similar skills are used in all three parts, and each part builds on the previous one. 3. Discuss Part I of the IPComm process: Building rapport and creating a caring environment. 4. Remind trainees that in the very first day of training they have learned some of the skills needed to build rapport with mothers and create a caring environment (Communication Guide HO-1 Module 2 Session 1). 5. Ask the trainees to explain what they learned, both in the session and by working with mothers. 6. Listen to their answers. Make a list which should include: o Start with a greeting, be friendly o Speak clearly, use local language, avoid medical words o Explain why you are visiting or ask why the person came to see you How to Train Community Health Workers in Home-Based Newborn Care 285

50 Module 9 Interpersonal Communication Session 1 Introduction and components o Be patient o Ask for any questions o Listen to the women 7. In addition, explain that body language, how someone uses their body, can also communicate a message. If you are talking to someone and they continue to read a magazine and not look at you, what would you feel? What would his actions communicate to you? 8. Refer back to the discussion of Ashok s story. Ask the trainees to explain how the doctor s actions could have made Neeta feel in terms of building rapport and creating a comfortable environment: o Doctor was rushed. (By rushing the doctor was giving a message to Neeta: he was using his body in a way which could have made Neeta feel that he was more interested in whatever else he had to do than with caring for Ashok.) o No greeting. (Explain that by not greeting Neeta, the doctor did not make her feel comfortable; she therefore did not want to return when Askok got sicker.) o No questions. (By not asking questions, the doctor led Neeta to believe that he didn t care and that he didn t want to care for them.) 9. Explain that showing empathy is another skill that can be used when building rapport. Showing empathy is the ability to put yourself in someone else s place and feel how they feel in a situation. It fosters trust. An example of showing empathy would be: I m sorry this has happened to you. Or I m sorry you re not feeling well. 10. Refer to Part II of the IPComm Process: Gathering information for a care plan: questioning and listening. By listening and asking questions, information is gathered that, along with physical examination, helps the care provider decide what the problem is (diagnosis). Remember the ASK questions when managing ARI. 11. Tell the trainees that the next two sessions will focus on questioning and listening skills. 12. Refer to Part III of the IPComm process: Counseling and sharing information: What parents need to do to care for the child. Making sure parents know how to care for the child at home is a very important part of providing good health care. Tell the trainees that later in this module they will learn skills to help explain home care clearly. 13. Distribute HO-1: Interpersonal Communication Checklist. The first part of this checklist is similar to the one used in Training Workshop 1, although it doesn t list all the points. This doesn t mean they are not important but that not everything could be written on the checklist. The checklist will be used in the following sessions as we learn about Questioning and Listening, and Sharing Care Information. 14. Explain that in this training, many of the examples and role plays will concern management of ARI or treating with aspirin and paracetamol because these are topics the trainees have already learned. As the CHWs continue with their training, they can apply these communication skills to other situations: when helping mothers to breastfeed, helping mothers stay healthy and eat well during 286 How to Train Community Health Workers in Home-Based Newborn Care

51 Module 9 Interpersonal Communication Session 1 Introduction and components pregnancy, when caring for low weight babies and babies with sepsis, etc. Summary (10 minutes) Ask a trainee to give an example of how a health care worker s communication skill (or lack of skill) can affect someone s health. Ask a trainee to state the three components of the interpersonal communication process. Ask two trainees to briefly demonstrate through a role play, how to build rapport and create a caring environment when first meeting a mother who has brought a child suffering from a cold. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session Objectives Give two examples of how a health worker s communication skill can affect a person s health. Name the three main components of the interpersonal communication process. Review the contents of the first components: creating a caring environment. Assessment Method Experience sharing/summary. Question/answers/summary. Questions/answers/summary. How to Train Community Health Workers in Home-Based Newborn Care 287

52 Module 9 Session 1 HO-1 Interpersonal Communication Skills Checklist Creating a Caring Environment Skill: Building Rapport Yes No Comment Greeting Make woman relaxed by smiling, eye contact, body language Soft tone, explains visit, asks how mother and baby are, shows empathy Gathering Information for Care Plan Skill: Questioning and Listening Use appropriate questions and listen actively Encourage dialogue: open-ended questions Show that you are listening (head nodding, eye contact, acknowledging sounds, yes hmm) Do not interrupt Seek more information: probing questions Avoid jumping in with preterm diagnosis Reflect feelings Acknowledging (make client feel noticed and normal) Paraphrase what mother says Counseling Effectively Skill: Counseling and Sharing Information Ask client s understanding of illness or situation Discuss and try to correct any misconception or rumor Use simple and understandable language Ask for any questions or concerns Present the care plan (what the client needs to do) in short sentences and in clear blocks of information Use visual aids when appropriate Ask the client to repeat what she needs to do Ask if she agrees and will try to do what is being discussed Summarize and repeat key information Arrange follow-up if indicated 288 How to Train Community Health Workers in Home-Based Newborn Care

53 Module 9 Interpersonal Communication Session 2 Asking questions Module 9: Interpersonal Communication Session 2: Asking questions Day : 2 Time Required : 1 hour Purpose To help the CHW develop questioning skills and to know how and when to use them appropriately. Objectives At the end of the session the CHW will be able to: 1. Define a closed, open-ended, and leading-and-probing question and give an example of each. 2. Demonstrate the use of closed, open-ended and probing questions when talking to mothers. Materials Question Grid on white paper or blackboard. Handout 1 (HO-1): Model Role Play Script: Questions exercise Training Aid 1: Model Role Play Script: Questions exercise -Answers for Trainers Preparation Copy the Question Grid from the Content Box below onto white flipchart paper or a blackboard. Make adequate photocopies of Handout 1 depending on the number of trainees. Make photocopies of Training Aid 1 for the use of trainers when they perform the scripted role play. Training Methods Presentation (20 minutes) Instructions to Trainers : 1. Ask the trainees to listen to the following two questions: o How much does your son weigh? o Can you tell me what and how much your son eats in a day? What can the trainees say about the differences between the questions? 2. Listen to their answers. Praise and encourage correct answers or observations. Fill in any gaps with the following: o The first question (How much does your son weigh?) is answered with the actual weight (for example 12 kg) or I don t know. This is called a closed question. The question does not require a long answer and may result in a yes or no answer. Many questions on the forms used in this project are closed questions because we are looking for specific information or facts (what is your age, are you married, is the baby feeding normally, etc.). o The answer to the second question is much longer (for example: he breastfed three times and had a chapatti and a small portion of dal in the morning, and vegetable and rice in the late afternoon.) How to Train Community Health Workers in Home-Based Newborn Care 289

54 Module 9 Interpersonal Communication Session 2 Asking questions This type of question is called an open-ended question. The question requires a longer answer based on the woman s actual experience, and provides more information. 3. Display the Question grid (Content Box) on the board or white paper. Question Grid Closed Questions Open-ended Questions Probing Questions Leading Questions When to use: When specific response is required. Some questions in history-taking or in emergency situations Requires: When detailed information is needed, about symptoms, feelings, etc. Greeting, history-taking and during counseling When more information is needed. History-taking and Counseling Avoid using. Little is learned from them. Brief and exact response. Often yes or no answer. Longer reply; allows for expression of feelings and concerns Explanation of an earlier response or statement Respondent is influenced by the question Examples: How many children do you have? Are you bleeding? Can you describe the pain to me? How do you feel about that? Can you tell me more about the pain? Why do you believe that colostrum is harmful? Don t you think you should deliver in the hospital? Fill in sample sentences: Source: Adapted from PATH s (Program for Appropriate Technology in Health) Interpersonal Communication and Counseling Four- Day Curriculum. 290 How to Train Community Health Workers in Home-Based Newborn Care

55 Module 9 Interpersonal Communication Session 2 Asking questions 4. Go through each column; explain each type of question. Remember that probing questions are openended questions that are focused on getting more information (i.e., Can you tell me more about what he eats?). Leading questions should never be used because they influence the answer. Example : You do think breastfeeding is better than bottle feeding, don t you? 5. Ask the trainees to give examples from their own work of each type of question. Fill in the examples at the bottom of the grid. Scripted Role Play (25 minutes) Instructions to Trainers : 1. Perform the scripted role-play. 2. After the role play, discuss what the trainees observed. 3. Ask the trainees why it is important to use different kinds of questions? (Closed questions often give facts or yes/no answers. To get more information on someone s condition, how they feel, or what they do, an open-ended question is needed. To get even more information, a probing question can be used.) 4. Make sure to mention that in some situations, if open-ended questions are not used, key information may not be learned. In the role play, if Preeti had not asked an open-ended question about the feeding she wouldn t have known about this problem; the baby would have lost weight, been very weak, and been less able to fight the infection. Practice Differentiating various kinds of questions (20 minutes) Instructions to Trainers : 1. Distribute scripted role play to trainees. Have them go question by question and write in the space provided if the question is closed, open-ended, probing, or leading. (10 minutes) 2. Review the answers in session. Discuss and clarify. (10 minutes) 3. Collect the papers for assessment. Summary (10 minutes) Have a trainee explain the difference between a closed and open-ended question. Ask another trainee to explain what a probing question is and when to use it. Ask another trainee to give an example of an open-ended question. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session Objectives Define a closed, open-ended, leading and probing question, and give an example of each. Demonstrate the use of closed, open-ended and probing questions when talking to mothers. Assessment Method Model role play script: question exercise. Role play practice and assessment on following day. How to Train Community Health Workers in Home-Based Newborn Care 291

56 Module 9 Session 2 HO-1 Name of CHW Model Role Play Script: Questions Exercise Preeti is a CHW in Gadchiroli district. A mother brought her little boy of 3 months to see Preeti because he had a cough. Type of question Preeti : Hello. How are you both today? Mother : Hello Preeti. I am fine but my baby has a cough. Preeti : I m glad you came to see me. How old is the baby? Mother : He s three months old. Preeti : I m going to ask you some questions about his illness. How long has he had the cough? Does he have fast breathing? Does he have a fever? Mother : He s had the cough for two days. I think he has fast breathing. He doesn t have a fever. Preeti : Has he had fits? Has he been unconscious? Mother : He doesn t have fits and he hasn t been unconscious. Preeti : Does he have diarrhoea? Is he suckling normally? Mother : He doesn t have diarrhoea but he hasn t been feeding. Preeti : Can you tell me about his feeding? Mother : I breastfeed him but I stopped yesterday when he got sick. Preeti : Why did you stop? Mother : I stopped because my mother-in-law said sick children shouldn t eat. Preeti : Can you tell me more about why she thinks that? Mother : She said that he may vomit from the coughing. Preeti : Okay, let me examine the baby. Then we can discuss what you need to do to help him get better. After the examination, Preeti said the boy had pneumonia. She prescribed cotramoxizole and gave the mother home care advice. Preeti especially mentioned that it is important to continue breastfeeding the baby because the baby needs the nutrition and fluid to fight the infection. Even if the baby spits up a little from the coughing, it is better to give him the breast milk because it gives him energy. Preeti offered to go to the home and explain this to the mother-in-law. If Preeti had not asked an open-ended question about the feeding she wouldn t have known about this problem; the baby would have lost weight, been very weak, and been less able to fight the infection. 292 How to Train Community Health Workers in Home-Based Newborn Care

57 Module 9 Session 2 Training Aid 1 Model Role Play Script: Questions Exercise: ANSWERS FOR TRAINERS Preeti is a CHW in Gadchiroli district. A mother brought her little boy of 3 months to see Preeti because he had a cough. Type of question Preeti : Hello. How are you both today? closed Mother : Hello Preeti. I am fine, but my baby has a cough. Preeti : I m glad you came to see me. How old is the baby? closed Mother : He s three months old. Preeti : I m going to ask you some questions about his illness. How long has he had the cough? closed Does he have fast breathing? closed Does he have a fever? closed Mother : He s had the cough for two days. I think he has fast breathing. He doesn t have a fever. Preeti : Has he had fits? closed Has he been unconscious? closed Mother : He doesn t have fits and he hasn t been unconscious. Preeti : Does he have diarrhoea? closed Is he suckling normally? closed Mother : He doesn t have diarrhoea but he hasn t been feeding. Preeti : Can you tell me about his feeding? open Mother : I breastfeed him, but I stopped yesterday when he got sick. Preeti : Why did you stop? open Mother : I stopped because my mother-in-law said sick children shouldn t eat. Preeti : Can you tell me more about why she thinks that? probing Mother : She said that he may vomit from the coughing. Preeti : Okay, let me examine the baby. Then we can discuss what you need to do to help him get better. Read the following to the group: After the examination, Preeti said the boy had pneumonia. She prescribed cotra and gave the mother home care advice. Preeti especially mentioned that it is important to continue breastfeeding the baby because the baby needs the nutrition and fluid to fight the infection. Even if the baby spits up a little from the coughing, it is better to give him the breast milk because it gives him energy. Preeti offered to go to the home and explain this to the mother-in-law. How to Train Community Health Workers in Home-Based Newborn Care 293

58 Module 9 Interpersonal Communication Session 3 Listening Module 9: Interpersonal Communication Session 3: Listening Day : 3 Time Required: 1 hour 30 minutes Purpose To introduce CHWs to listening skills (along with asking the right questions) when working in the community. Objectives At the end of the session the CHW will be able to: 1. Explain why listening is important in effective interpersonal communication. 2. Demonstrate effective listening skills. Materials Training Aid 1: Model role play script: Listening Interpersonal communication skills checklist (Module 9 Session 1 HO-1) Preparation Make adequate photocopies of Training Aid 1 for the use of trainers when they perform the scripted role play. Instruct the trainees in advance to bring their copies of the Interpersonal Communication Skills Checklist. Training Methods Presentation (25 minutes) Instructions to Trainers : 1. Explain that listening is an important communication tool that goes hand-in- hand with asking appropriate questions. Listening is important for all three components of Interpersonal communication (IPComm): o It helps in Creating a caring environment as it makes the person feel the CHW is interested in what he/she has to say. o It helps in Gathering information because by listening, the CHW encourages the mother or father to express feelings and beliefs, describe symptoms, etc. This information (along with physical information, weight, temperature, etc.) enables the CHW to decide if there is a problem, and if so what it is, and what needs to be done to provide care. o It helps in Sharing information about care (will be covered in the next session), as the CHW needs to listen to the parent to make sure they understand how to care for the child. 2. Explain active listening. See Content Box. 3. Ask the trainees to think about their interactions with people. Ask them to describe common signs of 294 How to Train Community Health Workers in Home-Based Newborn Care

59 Module 9 Interpersonal Communication Session 3 Listening a poor listener. Write these on the board. (See Content Box.) 4. Ask the trainees to describe what a good listener does. A good listener uses body language. List the answers; fill in the gaps from the list below. 5. Explain the following listening skills: giving praise, reflecting feelings, legitimizing feelings and paraphrasing. All of these are important in making the person feel comfortable and able to talk. Paraphrasing is also helpful to make sure you understand what the person believes, or to check that the person understands how much medicine to take, etc. Ask for other examples. Content Box Listening Active listening is paying attention to the speaker (person), showing interest, and hearing what is being said. What are some common signs of a poor listener? o Not making eye contact o Interrupting o Jumping to conclusions o Not asking for more information o Tapping feet, shuffling papers, looking outside o Finishing sentences for the speaker How to be a good listener: o Be attentive, concentrate on the client (eye contact, lean toward them, nod your head). o Don t interrupt. o Use silence (gives an opening for the person to express feelings). o Don t jump to conclusions or diagnosis without hearing what the person has to say. Specific listening skills: o Giving praise: If a mother has done something good (given good care, came immediately if danger sign appeared, etc.), praise her. This helps raise her self confidence. o Reflect feelings: When the person states how they are feeling (afraid, worried, happy, etc.) let them know that you hear them by repeating it, for example I hear you say that you are worried. o Acknowledging feelings: Letting the person know that it s normal to feel a certain way. For example: I would be worried too; it s understandable. o Paraphrase: Every now and then repeat what you have heard to make sure you understand and to assure the person that you are listening. Scripted Role Play (15 minutes) Instructions to Trainers : 1. Have trainees review the IPComm checklist (Part II: Gathering Information; questioning and listening). Discuss each point and clarify if needed. How to Train Community Health Workers in Home-Based Newborn Care 295

60 Module 9 Interpersonal Communication Session 3 Listening 2. Perform the scripted role play. 3. Afterwards, ask the trainees to describe what they saw and heard; how did the trainers show active listening with their bodies? With their voices (use of questions, use of reflecting feelings, acknowledging, paraphrasing)? Role Play: Practice (45 minutes) Instructions to Trainers : 1. Divide trainees into groups of Each group performs two role plays: one showing effective listening and questioning skills, the other poor listening and questioning skills. 3. Discuss each role play after it has been performed; have observers point out the active listening and effective questioning skills used. Give praise and feedback as indicated. Summary (5 minutes) Ask 2-3 trainees to review good listening skills. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session Objectives Explain why listening is important in effective interpersonal communication. Demonstrate effective listening skills. Assessment Method Discussion and role plays. Role plays. 296 How to Train Community Health Workers in Home-Based Newborn Care

61 Module 9 Session 3 Training Aid 1 Model Role Play Script: Listening Total time: 15 minutes Introduce the characters and scene to the trainees. The characters are the CHW and mother, Verma. Verma has brought her sick daughter for care to the CHW. The CHW practices active listening. CHW : Hello Vermabai. Verma : Hello. I ve come with Moni my two month-old-baby. She feels very hot and is crying all the time. CHW : (Makes eye contact, nods her head.) I m glad that you ve come. How long has she been hot? Does she have fast breathing? Has she had fits (eye contact, nodding)? Verma : She s been sick since early this morning. She doesn t seem to be breathing fast but she may have had a fit. CHW : Can you describe why you think she may have had a fit? Verma : After a couple of hours, she got very stiff for a few minutes and then she relaxed and started crying. I got scared. CHW : Hmmm (showing she has been listening). It s understandable to be scared when your little one isn t well, I would be too (reflecting and acknowledging her feelings) but don t worry. It s good you ve come so early to see me (praise). From what you said, the baby had a fever for a couple of hours and then got stiff one time for a few minutes (paraphrasing). Verma : (nods) CHW : Let me ask a few more questions, then I ll take her temperature and examine her. How to Train Community Health Workers in Home-Based Newborn Care 297

62 Module 9 Interpersonal Communication Session 4 Sharing health information and advising on care Module 9: Interpersonal Communication Session 4: Sharing health information and advising on care Day : 3 Time Required: 1 hour 45 minutes Purpose To prepare CHWs to share health information and advise parents about providing care. Objective At the end of the session the CHW will be able to: 1. Demonstrate various communication skills (as per checklist) in sharing health and care information with parents. Materials Training Aid 1: Model role play script: Counseling and sharing care information IPComm skills checklist (Module 9 Session 1 HO-1) Handout 1 (HO-1): Case ideas for role plays Preparation Make adequate photocopies of Training Aid 1 for the use of trainers when they perform the scripted role play. Instruct the trainees in advance to bring their copies of the IPComm Skills Checklist. Make adequate photocopies of Handout 1 depending on the number of trainees. Training Methods Presentation and Discussion (1 hour) Instructions to Trainers : 1. Explain that Part III of the Interpersonal communication process is counseling and sharing (or giving) health and care information. 2. Explain that giving or sharing care information (also referred to as counseling) is a two-way process (between health workers and parents) to help parents understand what is going on, and what treatment or care is needed so they can make a decision about what to do in order to stay healthy or get better. 3. Explain that the care plan is what the mother (or father) has to do to care for the child at home (or for themselves if the adult is ill, or pregnant, etc.). This may include giving medicine but it doesn t always have to. It includes advice about feeding, danger signs, and when to come back to the CHW or seek the care of a doctor, etc. 4. Go through each step in the process (see Content Box); explain why that step is important and discuss. 298 How to Train Community Health Workers in Home-Based Newborn Care

63 Module 9 Interpersonal Communication Session 4 Sharing health information and advising on care Content Box Sharing Health Information and Advising about Care Practices Explore parent s understanding of illness or situation to see what they already know: This is important so that you can build on what they already know instead of talking at them as if they didn t know anything. It can also identify any beliefs that may be harmful. Correct, misconception of facts: Sometimes people believe things that can be harmful. An example: some people believe that children should not be fed when they are sick; this is not true and can be harmful to the child. Another example is when people think illness is caused by an evil eye. Be sensitive when you correct misconceptions; do not make the person feel stupid. Only correct misconceptions that may have a harmful effect. Explain the situation clearly; use simple, non-medical language: Always use simple, everyday words. Present the care plan what the mother (or father) needs to do in short sentences and clear blocks of information: Present the information clearly (think before you speak). An example of a block of information would be: Take 1 pill in the morning and 1 in the evening. Take the pills for 5 days or Eat more when you are pregnant. Try eating an extra chappati and more vegetables every day. Ask the mother to repeat what she needs to do in her own words: This is very important to ensure that she understands what needs to be done including medicine if needed, feeding advice, danger signs to look for, and when to seek help. Discuss the care plan (treatment) to encourage compliance: Ask for any questions. Summarize and repeat key information: Repeat the main points Follow up if indicated: Mention when you will visit them or when they should come to see you again. Review danger signs and when immediate care is needed. Modeling Behaviour: Scripted Role Play (15 minutes) Instructions to Trainers : 1. Have trainees review Part III of the IPComm skills checklist - Sharing care information. 2. Perform the scripted role play. Explain that this role play covers all three parts of the IPComm process. How to Train Community Health Workers in Home-Based Newborn Care 299

64 Module 9 Interpersonal Communication Session 4 Sharing health information and advising on care 3. Lead a discussion about what was observed compared to the items on the checklist. Start with reviewing Part I Building rapport and then Part II, Part III. 4. Ask for questions; clarify any confusion. Practice: Role Plays (30 minutes) Instructions to Trainers : 1. Divide into groups of Distribute case examples. 3. Have each group work on a role play focusing on Sharing care information (10 minutes). Have them decide on and write the care information down so they won t forget it. Have each group perform in front of the large group (5 minutes). 4. Discuss each role play after it has been performed. Give praise and feedback as indicated. Summary (5 minutes) Ask a trainee to list the main points in Sharing care information. Add any points missed and discuss. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session Objective Demonstrate ability to use various communication skills (as per checklist) in sharing health and care information with parents. Assessment Method Role plays with checklist. Each trainee demonstrates the ability to use various communication skills (as per checklist) in sharing health and care information with parents. 300 How to Train Community Health Workers in Home-Based Newborn Care

65 Module 9 Session 4 Training Aid 1 Model Role Play Script: Counseling and Sharing Care Information Part I Building rapport and creating a caring environment Meera : Hello. CHW : Hello Meera. (Smiles and makes eye contact) I m glad to see you. How are you and the family? Meera : I m not so well. I have a headache and can t work. CHW : I m sorry you re not feeling well. (empathy) It s good you came to see me (praise) Please sit down. Part II Gathering information questioning and listening CHW : Can you tell me more about your headache? (open-ended question) Meera : I had it when I woke up, it hurts above my eyes. I m afraid I won t be able to get my chores done and make food for the family. CHW : (Nodding, saying hmmm) You re worried the food won t be ready in time. (reflecting feelings) Don t worry, we ll try to make you feel better so you can get the work done. Can you tell me more about this headache? (probing question) Does anything you do make it better or worse? (probing) Meera : It gets a little better if I lie down. It is much worse when I m working. CHW : So you ve had this headache since you woke up and it hurts above your eyes. It s better if you lie down and worse when working? (paraphrasing) Meera : Yes that s correct. CHW : Meera, when was your last period, could you be pregnant? Meera : I m having my period now. CHW : Oh, no wonder you feel badly; many women have headaches at the time of their period. (acknowledging) Part III Sharing Information about care plan CHW : Do you have trouble with stomach acid? Meera : No. CHW : In that case, I can give you aspirin for the headache. Please take 2 tablets 3 times a day when you have headache pain. I will give you enough for 3 days (hands her the medicine), but stop taking the medicine when the headache is gone. If the headache continues for more that 2-3 days, please go see a doctor. Please keep the aspirin out of reach of the children. I d suggest you lie down for the next hour or two. Is this treatment ok with you? Can you repeat the instructions? (asking for information back) Meera : Yes, I will try it. I should lie down for the next hour or two. I should take 2 tablets 3 times a day. If the headache continues for more than 3 days, I should go to a doctor, and I should keep the aspirin away from the children. CHW : Excellent. Do you have any questions? (giving more chance to listen to Meera) Meera : No. I better get home. See you later. CHW: Call me if you need anything. Feel better. How to Train Community Health Workers in Home-Based Newborn Care 301

66 Module 9 Session 4 HO-1 Case Ideas for Role Plays Fill in the details. If using in Session 4, focus on Sharing Information about Care. If using in Session 5, spend time to develop the full three-part interaction. 1. Baby of 3 months is brought by mother with fast breathing (60 per minute) and fever. Diagnosis is pneumonia with fever. 2. Fifteen-year-old girl is brought by her mother. She has twisted her ankle. Diagnosis is swelling and pain. 3. Child of 2 years is brought by her mother. She has a stuffed nose but no fast breathing. Diagnosis is a cold. 4. Man of 45 years old with stomach upset comes with back pain. The diagnosis is back pain. 5. Child of 1 year is brought with a cough. Diagnosis is wheezing; no pneumonia. 6. Baby of 4 months has diarrhoea. 7. Woman of 30, five months pregnant, has a swollen knee after banging into a door. 8. Child of 2 months is breathing rapidly and unconscious. Baby has acute pneumonia. 9. Mother brings her boy of 8 years old. His leg got bruised and scraped when he tripped in the road. 10. Baby of 8 months comes with difficulty breathing. Diagnosis is pneumonia. 11. Five-year-old girl comes with a cold. She is breathing 25 times a minute and has a fever. Diagnosis is cold with fever. 12. Girl of 3 years comes with severe chest indrawing. Diagnosis is acute pneumonia. 302 How to Train Community Health Workers in Home-Based Newborn Care

67 Module 9: Interpersonal Communication Session 5: Module 9 Interpersonal Communication Session 5 Interpersonal communication: Assessments Interpersonal communication: Assessment Day : 3 Time Required : 1 hour 30 minutes Purpose To give CHWs the opportunity to practice interpersonal communication skills through role plays. Objective At the end of the session the CHW will be able to: 1. Demonstrate effective use of interpersonal communication skills when talking to parents. Materials IPComm skills checklist (Module 9 Session 1 HO-1) Handout 1 (HO-1): Case ideas for role plays Preparation Instruct the trainees in advance to bring their copies of the IPComm Skills Checklist. Make adequate photocopies of Handout 1 depending on the number of trainees. Training Methods Role Plays: IPComm skill assessment (1 hour 30 minutes) Instructions to Trainers : 1. Divide the group into pairs. 2. Distribute a number of case ideas (HO-1) to choose from. Have each group prepare two role plays, where a trainee gets to play a CHW in one play and a mother in the other. 3. Have trainees practice the role plays to demonstrate effective skills in the three steps: building rapport, questioning and listening, and giving information. (20 minutes) 4. Circulate in the room observing and helping as needed. 5. Have each pair present two role plays to the whole group (8-10 minutes for each group). 6. Use IPComm skills checklist to assess each role play. 7. Give immediate feedback and praise when indicated. Summary Review the three main components of the interpersonal communication process. Make corrections if any and add missed information. The trainer evaluates his/her own session Objective Assessment Method Demonstrate effective use of interpersonal Role plays using IPComm skills checklist. communication skills when talking to parents. Module 9 is Completed How to Train Community Health Workers in Home-Based Newborn Care 303

68 Module 9 Session 5 HO-1 Case Ideas for Role Plays Fill in the details. Ages can be changed if case used in previous session. 1. Baby of 3 months is brought by mother with fast breathing (60 per minute) and fever. Diagnosis is pneumonia with fever. 2. Fifteen-year-old girl is brought by her mother. She has twisted her ankle. Diagnosis is swelling and pain. 3. Child of 2 years is brought by her mother. She has a stuffed nose but no fast breathing. Diagnosis is a cold. 4. Man of 45 years old with stomach upset comes with back pain. The diagnosis is back pain. 5. Child of 1 year is brought with a cough. Diagnosis is wheezing; no pneumonia. 6. Baby of 4 months has diarrhoea. 7. Woman of 30, 5 months pregnant, has a swollen knee after banging into a door. 8. Child of 2 months is breathing rapidly and unconscious. Baby has acute pneumonia. 9. Mother brings her boy of 8 years old. His leg got bruised and scraped when he tripped in the road. 10. Baby of 8 months comes with difficulty breathing. Diagnosis is pneumonia. 11. Five-year-old girl comes with a cold. She is breathing 25 times a minute and has a fever. Diagnosis is cold with fever. 12. Girl of 3 years comes with severe chest indrawing. Diagnosis is acute pneumonia. 304 How to Train Community Health Workers in Home-Based Newborn Care

69 Module 10 : Injecting Vitamin K Session 1 : Vitamin K Day : 3 Time Required : 1 hour 30 minutes Purpose To orient CHWs to the use of vitamin K in newborns. Objectives At the end of the session the CHW will be able to: 1. Explain why vitamin K is given to newborns and how much is given. 2. Demonstrate where on the baby the injection should be given. 3. Explain what information should be given to the family. 4. Explain why the CHW does not inject any other medicine or give vitamin K to anyone else. Materials Ampoule of vitamin K Handout 1 (HO-1): Illustration of Injection Site (lateral thigh) Infant-like dolls or live infants Preparation Make adequate photocopies of Handout 1 depending on the number of trainees. Obtain and have ready an ampoule of vitamin K and infant-like dolls. If using live infants, make the necessary arrangements to have them present at this session. Training Methods Presentation and Demonstration (45 minutes) Instructions to Trainers : Module 10 Injecting Vitamin K Session 1 Vitamin K Injection Vit K Ampoule 1. Explain that vitamin K is given to babies in the first 24 hours after birth to prevent life-threatening bleeding. 2. Show the ampoule of vitamin K. Explain that vitamin K is a liquid that is delivered by injection. 3. Explain that 1 mg of vitamin K is given to the baby. In the next session you will learn how to measure the amount needed in the syringe. 4. Explain that CHWs should give vitamin K during the first exam of the baby, ideally at one hour after delivery. 5. Explain that the injection is given in the side of the baby s one thigh (right or left), half way from the knee to the top of the thigh. (Put a picture HO-1 of the baby s leg showing the front view of the thigh region along with lower part of leg. The CHWs should be able to make out the thigh.). 6. The injection is given in the muscle in the thigh. It is the mass between the baby s skin and bone. How to Train Community Health Workers in Home-Based Newborn Care 305

70 Module 10 Injecting Vitamin K Session 1 Vitamin K (Put the picture of transverse section of baby s thigh HO-1). 7. Distribute the illustration of injection sites. 8. Demonstrate where to give the injection on either a life-size doll or a young infant. 9. Explain that the time of the injection, and which thigh it was given in, should be noted on Form C. 10. Explain that vitamin K is only given to newborns; it should NOT be given to anyone else as it could cause harm. 11. Explain that CHWs should ONLY inject 1 injection of vitamin K into the newborn. Only one dose is needed. Nothing else should be injected into the baby as it can harm them. 12. Ask the trainees what information should be given to the family. Write the answers on the blackboard. If not mentioned, make sure the following are listed: o Vitamin K is important to prevent life-threatening bleeding in the baby. o Vitamin K is only given by injection, so signed consent is needed (get signed consent before giving the injection). o Every day check the thigh where the injection was given. Look for redness. If injection site is red or hot or swollen, call the CHW immediately. Practice: Identifying the injection site (30 minutes) Instructions to Trainers : 1. Distribute the dolls. 2. Using the illustration as a guide, have trainees practice locating a proper injection site. 3. Circulate in the room and make sure each trainee can find a correct injection site. Summary (10 minutes) Ask a trainee to explain why vitamin K is given. Have a trainee tell the group where the injection should be given. Ask another trainee to explain when vitamin K is given. Ask a trainee to explain what information should be given to parents. Make corrections if any and add missed information. Congratulate the CHWs for their good work. The trainer evaluates his/her own session (5 minutes) Objectives Assessment Method Explain why vitamin K is given to newborns and how much is given. Demonstrate where on the baby the injection should be given. Explain what information should be given to the family. Explain why CHW does not inject any other medicine or give vitamin K to anyone else. Questions and answers. Locating injection site on doll or infant. Questions and answers Questions and answers. 306 How to Train Community Health Workers in Home-Based Newborn Care

71 Module 10 Session 1 HO-1 Illustration of Injection Site (lateral thigh) Injection site for injecting newborn Avoid this: nerves are located here Proper site for injecting Central line Knee Inner side Front Outer side Muscle Bone Skin and fat Transverse section How to Train Community Health Workers in Home-Based Newborn Care 307

72 Module 10 Injecting Vitamin K Session 2 The syringe Module 10 : Injecting Vitamin K Session 2 : The syringe Day : 3 Time Required : 1 hour 30 minutes Purpose To prepare CHWs to give vitamin K injections correctly. Objectives At the end of the session the CHW will be able to: 1. Identify the parts of the syringe. 2. Explain sterilization and why the syringe is presterilised, prepackaged, and disposable. 3. Demonstrate how to draw up the correct amount of vitamin K in the syringe. Materials Handout 1 (HO-1) : Injection : Possible Mistakes and Consequent Dangers Insulin Syringes Ampoules of vitamin K (1 ml=10mg) Water in small cups File to cut top of ampoule Plastic syringe box with secure closure (for used syringes and broken ampoule tops) Cap Needle Barrel Preparation Make adequate photocopies of Handout 1 depending on the number of trainees. Obtain and have ready three sets of the materials listed above for use in the small break-out groups. Training Methods Presentation and Demonstration of the Syringe (30 minutes) Instructions to Trainers : 1. Show an insulin syringe and explain the parts. 2. Explain that sterilization means something is cleaned by special means (either boiling water, steam or chemicals) so that no germs are on it. This syringe has been presterilized (sterilized beforehand) and prepackaged (put in a package and sealed) so it is sterile. The sterile needle is protected by a cap. The needle should not be touched with fingers or any other object. If that is done the needle will get infected with germs. The syringe should not be used if the package is open or the seal is broken. Only sterilized syringes (and needles) may be used as it prevents infection. 3. Draw the scale of the insulin syringe barrel on the board and explain. 4. Show the vitamin K ampoule. 1 mg of vitamin K is given to the baby. This means that the liquid 308 How to Train Community Health Workers in Home-Based Newborn Care Cap Plunger