REVIEW OF CLfNICAL TRAINING

INDONESIA

A Refiort Prepared By PRITECH Consultant: ROBERT S. NORTHRUP, M.:.

During The Period: DECEMBER, 1987

TECHNOLOGIES FCR PRIMARY HEALTH CARE (PRITECH) PROJECT Supported By The:

U.S. Agency For International Development AID/DPE-5927-C-00-3083-00

AUTHORIZATION:

AID/S&T/HEA: 8/10/88ASSGN. NO: DC 386

Indonesia consultation R.S.Northrup December 1987

REVIEW OF CLINICAL TRAINING

TASK: To review the current clinical training

activities, curriculum, and teaching methcds, as part of preparing for extending diarrhea training

activities to a large number of kabupaten in three

provinces in the implementation of the new P2D workplan.

BASIS FOR 1. Discussions with Dr. Sutoto, Dr. Sunoto, Dr.

REVIEW Yati, Dr. Rusdi Ismail

2. Revie o% the curriculum, agenda ot

teaching/learning activities, and book of scientific papers from the courses on diarrheal case management and control at RSUD Dr. Soedono, Madiun, Jawa Timur, Sep 23-24 1987; and the Asean international course held at Jakacta and Yogyakarta 14-28 June 1987 (including the Final Report)

3. Review of the schedule of activities only for the course at Sidohardjo, Jatim, 14-19 Apr

1986

4. Comparison with methods and teaching modules for the WHO Supervisory Skills Course and Program Managers Course

5. Comparison with methods and teaching modules from the WHO-PRITECH Medical Education for Diarrhea Control project (first draft and revisions in progress)

SUMMARY OF RECOMMENDATIONS:

1. Educational and technical details of the courses should be more extensively defined, including course objectives, anoutline of each presentation and practical activity, afacilitator's guide, copies of exercises, instructions andhandouts, and evaluation criteria, methods, and instruments.

2. The national CDD program should define and prepare astandard clinical course with complete materials and methodsdefined. Courses supported by the Program should conform tothe national standard, and use the standard materials.

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3. Course participants should be informed much before the course of the objectives and expectations, and given forms to gather needed information before coming. Supervisors should be prepared by the trainers to support the trainee. Materials needed to apply the lessons of the course should be delivered to the participants home work place before he attends the course.

4. The plans and curriculum for the course should include followup activities by the trainers, to ensure application of the course lessons.

5. Course objectives should specify in detail the skills to be learned, as well as knowledge. Adequate practice with observation and feedback should be given. Evaluation methods should test skills as well as knowledge.

6. Course activities on feeding and diarrhea should be expanded, to include practice in assessing nutritional status and the pre-diarrhea diet, practice in determining appropriate dietary recommendations, and practice in communicating with mothers about diet in diarrhea.

7. Courses should include special activities to build skill in teaching mothers effectively about home management oC diarrhea.

8. Courses should include activities to teach the trainees how to teach others effectively.

9. Courses should include activities to prepare trainees to monitor and assess diarrhea case management being provided by their assistants and by village kader.

10. Courses should add a major component to help trainees prepare to apply the lessons learned in the course at their home workplace, including the establishment of diarrhea training units and oral rehydration units and corners.

11. Courses should strengthen the components dealing with appropriate and inappropriate drug use, to better prepare participants to deal with patient demands for drugs.

12. Trainees should be required to personally manage a minimum number of patients while being observed objectively and provided feedback.

13. Simulated cases and written exercises in case management should be provided to give very structured types of experience and to broaden the types of patients "treated" by the trainees.

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14. Lectures should be replaced where possible with teaching

methods which more actively demand the participation of thetrainee, including the use of readings, written exercises,

and guided discussions.

15. A standard book of readings consistent with nationalpolicies for diarrhea treatment and written in a style to bemaximally useful as a learning tool should be prepared and used in all P2D sponsored clinical courses.

16. P2D courses should be held only in hospitals which meet

criteria which will make effective clinical teaching andlearning possible. The National CDD Program should monitor

these criteria prior to sponsoring courses in a particular

location.

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INTRODUCTION

Under the new CDD plan the National Program will aim to increase substantially the number of MOH physicians and other healthworkers using correct methods for diarrhea case management in three provinces through an intensified and strengthenef' program of clinical training.

Kabupaten doctors will be trained in clinical diarrhea treatment and in a number of kabupatens (approximately half) will develop

diarrhea training units (DTUs) at their kabupaten hospitals.

These doctors and DTUs will be used to train doctors from otherhospitals as well as from the puskesmas level, who will have, in

addition to treating patients directly, the task of supervising

and training other health workers in diarrhea case management,

and establishing Oral Rehydration Units (hospital level) or Oral Rehydration Corners (puskesmas afterlevel) they return from

training. Puskesmas doctors will have in addition the tasks oftraining and/or supervising the diarrhea related activities of

village kader, both during Posyandu activities and outside those times.

Factors which will influence whether this training does lead to the adoption of correct case management techniques, the effective

passing on of the training to other health workers and kaders,

and the establishment of the units as hoped include the following:

- effectiveness of the training - availability of ORS and other appropriate drugs, - availability of equipment and supplies for the DTUs and oral rehydration units and corners - adequate superviision after the training - support and agreement from hospital chiefs

The effectiveness of the training itself, however, is doubtless

the most critical factor in achieving the desired objectives.

It is thus important to review the current training methods,

content, facilities, and materials to determine if they could be made more effective.

WHO has not so far developed a standard clinical course with which one could compare current Indonesian activities. Some suggestions regarding clinical teaching are made in their guide

to the establishment of a DTU, and their technical publications

on management of diarrhea cases establish clinical standards with

which one can compare the printed materials provided to trainees.

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The clinical teaching materials currently being developed by

PRITECH in collaboration with WHO for use by medical faculties

provide numerous examples of teaching methods usable as

alternatives to the customary didactic lecture.

OBSERVATIIONS AND RECOMMENDATIONS

A. GENERAL

1. Clarification and definition of course activities and content:

All the courses reviewed provided an agenda, and most provided handouts or a Of thehook of readings,materials reviewed, however, only the Asean course listed the objectives, and the teaahing methodologies were

only categorized, for example, lecture, discussion, field visit, practical work, case management. Content wasspecified only by topic title generally. Huy doctors who have been trained intraininA courses sponsored andfunded by the P2D program often do not practice correct diarrhea case management. Increased specification and

definition of the training content and methods of each course sponserc. '- the program iscritical to allowing

PZD managers to judge whether their training has been insufficient, incorrect, or poorly done.

Recommendation:

To allow P2D program managers to control the content,

methods, and quality of courses, to provide guidance to course managers and teachers, and to clarify for the trainees what should bethey achieving during the course, educational details' should be more clearly

defined. At a minimum course materials should include the following:

course objectives, both general objectives and specific behavioral and cognitie objectives,

specified for each activity, as well as for the course as a whole. Where possible, the criteria to be used in judging whether the student has attained the desired competency should be made a part of the objective. For example, the objective

would state not only "do correct case management

of diarrhea," but also define critical aspects of how one would judge whether the management was correct. (see evaluation below)

- an outline (or the text and description of slides or other audiovisuals used) for eachpresentation or practical activity, in sufficient detail so that someone reading it will know what happened (or will happen) and what recommendations were made. The outline should include the following:

- the main points or messages to be

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emphasized during lectures and presentations - the questions to be asked by the facilitator during discussions - the activities which both teachers and students will do

For example, during a demonstration of mixing ORS (or sugar-salt solution), it should be noted that each trainee will personally mix and taste the solution, in addition to the teacher demonstrating how to do it. The "Terms of Refedrence" for the Asean course are a good start to achieving the desired level of detail. Even they could be improved; for example, by detailing the types of activities and facilities to be observed, the persons to be interviewed, and the points to be emphasized during a field visit to a community based treatment program.

a facilitator's guide specificying how the teacher introduces and carries out all discussions and practical and field work (any activities other than lectures).

Copies of all trainee exercises, instructions, and handouts

Evaluation instruments and a description of evaluation methods and the criteria to be used in determining whether the trainee's performance is satisfactory.

2. Standardization of courses

The prevailing philosophy at present is that the doctor running the course isallowed to set the agenda and activities, generate the teaching and study materials, and recruit trainers as available from among faculty members and hospital colleagues.

This has resulted in courses which vary widely induration, teaching methods, and content. The books of readings contain articies inwhich the recommendations for treatment actually differ from one article to another. Feeding recommendations and recommendations for the use of drugs and antibiotics, for example, differ from the national PZD policy insome of the readings I reviewed.

Course leaders moreover noted that they were often unable to control the content or methods used by other participating faculty. They noted that lectures and reading 2aterials provided by such lecturers were often out of date, or contained different recommendations from the national or international norms.

The amount of time allowed for ward experience varies substantially from course to course. Given that courses are taking place during different seasons and at hospitals of different size and utilization, itseems likely that the actual hands-on experience of trainees in assessing and rehydrating diarrhea patients and teaching their mothers varies also. This may be a major cause of the failure of some courses to change the behavior of the trainees after they return home.

Recommendation:

The national P2D program, in collaboration with experienced pediatricians, should define a standard course in the degree of detail described above, and provide standard materials (objectives, outlines and reading materials, facilitator's guides, exercises, and evaluation methods and instruments) for use in the

standard course. Clinical courses supported by the P2D program should be expected to conform to the standard course as a minimum, both in content including

recommendations regarding clinical care, and in teaching methodology including the minimal level of clinical experience expected.

B. PREPARATION AND FOLLOW-UP

3. Preparation for the course

Trainees are often informed only a few days before a course that they are to attend. They arrive with little idea of what they are to receive, Nore importantly, they have not had an opportunity to analyze the importance

of diarrhea case management intheir own activities, on problems they may have encountered inthat onarea, or

the problems they sight face ifthey were to implement a DTU, OR unit, or OR corner.

Supervisors of the trainees are also generally uninformed about the specific purposes of the course (el to prepare the trainee to establish a DTU), and are not prepared to provide appropriate support and specific

supervision to the trainee as he attempts to implement the training after returning.

Equipment, supplies, and educational materials needed to implement the training are usually absent when the trainee returns. This sakes immediate implementation impossible. Ifdifficulties are encountered inobtaining

such materials later, even delayed implementation may be prevented, Any delays inimplementation result in a decrease inthe knowledge, skills, and motivation of the trainee necessary to male the implementation a success.

Recommendation:

Course participants should be selected well in advance of the course. At that time they should be informed of the purposes and objectives of the course, and of what they will be expected to do to implement the training.

Forms or other guides should be provided also at that time to assist them in gathering any information needed and in thinking through any potential problems they may

face after the course in planning and carrying out the tasks of implementing the expectations of the course after returning home,

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Supervisors should be more fully informed about the expectations of the trainees. Guidelines, checklists, and funding if necessary should be provided to the supervisor so that he can adequatealy support and monitor the implementation tasks to be carried out by the trainee.

Where equipment, supplies, or training materials will be needed by the trainee to carry out the implementation tasks expected, they should be ordered well in advance of the course, and delivered to the trainee's work site prior to his departure for the course.

4. Course Follow-up

At present there isno tollowup component by the trainers for the courses being taught. This makes itvery easy for the trainee to return home and slip back into his routine activities, while ignoring the implementation tasks expected by the course. Those trainees that do attempt to apply what they have learned may face problems which say not have been covered by the course. Without followup interaction or support from the course trainers or uanagers the trainees say have difficulty solving these problems, and be prevented from applying what they have learned, For example, if the course has only taught that antibiotics and antidiarrheals are not needed inthe ordin'ry case of diarrhea, and has not provided experience inanswering and convincing iothers who demand such drugs, the trainee give into such demands.

Recommendation:

Provision for followup contact and support by the trainers to the trainees should be built into the plans and curriculum for each course, in addition to the preparation activities already described. This may take the form of a one-day follow-up seminar of all the trainees to be held 3 months later to review progress and problems in applying the course instructions; a visit by the trainers or their representative to each trainee at his home site, to monitor implementation and provide support; or a report to be submitted after three months by the trainee on his progress.

To stimulate trainees to carry out correct case management procedures, the use of a special clinical form requiring more detailed observations and documentation of treatment recommendations may be required for a period of 6 to 12 months after the training. Analysis of detailed data reported from this form, or inspection of these records by a supervisor, will help in identifying errors or omissions in case management. A sample form is included as Appendix A.

C. COURSE CONTENT

5. Skills as well as knowledge

The Asean course (the only one where obj .-ives were described) list as its objectiver only 'knowledge' ina

series of topic areas. Itisclear from the actual objectives listed and the activities of the course that the trainees are expected to acquire more just knowledge. Nevertheless, the prominence of lecturns inthe other courses reviewed, the use of evaluation techniques emphasizing written post-tests probably consisting primarily

of multiple choice questions and other tests of knowledge, and the lack of activities demanding that the

participants practice certain actions ina structured situation (eg role playing, simulated cases) suggest that infact the courses will result primarily incognitive learning rather than the learning of skills needed to manage diarrhea patients. This may he an important cause of the failure of these courses to change treatment behaviors by the trainees.

Recommendation:

Objectives for the courses should clarify and specify

the skills expected of the trainees as well as knowledge. Course activities should include opportunity for practicing desiredthe skills in a structured situation, in addition to the less structured case management activities on the diarrhea ward or clinic. Evaluation procedures should be strengthened to assess by observation, simulation, or other appropriate technique whether the competency has been acquired by the trainee.

6. Feeding during diarrhea

The results of recent clinical studies on diarrhea treatment have made itchar that the provision of correct feeding during and after diarrhea episodes is of critical importance not only because of its role in

maintaining the nutrition and growth of the child, but also because of the role of the food instimulating

absorption of fluids, thereby reducing stool output and duration. Vhile the schedules of the Indonesian clinical courses have all included a unit, usually a lecture, on nutrition and diarrhea, effective casemanagement requires an active attempt by the doctor or health worker to identify deficiencies inthe prediarrhea weaning diet through appropriate questioning, to identify malnourished diarrhea cases for special

nutritional attention 1,and to provide advice and effective motivation to mothers regarding an appropriate diet.

*. most likely through weighing the patient and then

plotting the patient's weight on a growth card (KMS)

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Recommendation:

A revised clinical diarrhea training course curriculum should include expanded teaching learning activities on feeding and diarrhea, in order to cover the following points:

- the importance of continued feeding for the nutrition and growth of the patient - the importance of continued feeding for stimulating improved fluid absorption and more rapid recovery from diarhea - methods and practice in assessing nutritional status and the pre-diarrhea weaning diet - details of and practice (exercises) in determining appropriate dietary recommendations for patients of different ages - techniques and practice in convincing mothers to adopt those dietary recommendations

7. Communication with the mother

Itis clear that the adoption and correct performance of a series of behaviors by the mother are essential to the effective treatment of current and future diarrhea episodes with ORT, continued feeding, and recognition of signs of worsening dehydration. Yet, with the exception of a demonstration of airing OHS inone course, the topic of effective communication with the mother iscompletely absent from the course activities or objectives available for review.

While health workers do talk to patients routinely inthe course of their work, many studies show clearly that most clinical encounters consist primarily of requests for information, brief and incomplete at that, and rarely include effective teaching of necessary skills. While this may be appropriate for illnesses for which treatment consists of druis, ORT and the provision of appopriate feeding during diarrhea demand both understanding and acceptance by the mother ifthey are to be carried out effectively.

Knowledge of effective communication and teaching techniques isnot enough; skills are needed, This demands practice, carried out ina situation where observation and instructive feedback can be provided.

Physicians may be too bu:y to perform these educational activities on a routine basis with every diarrhea patient. To teach a paramedic assistant these skills, however, and to monitor and assess their performance by the paramedic subsequently, the doctor must himself be skilled.

Recommendation:

The course curriculum should include activities aimed at producing skill by the trainee in obtaining necessary information from the patient's mother, in

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teaching the mother the skills needed to mix and adminster ORT and other necessary tasks of home case management, and in convincing the mother to adopt these techniotues. These activities should include aspects

specific to diarrhea, such as convincing the mother that antidiarrheals or antibiotics are nL: necessary in treatment, as well as generic components (eg use of

checking questions, getting agreement from the mother,

etc). A draft module covering these areas is attached as Appendix B ("Talking To Mothers").

8. Training the Trainers

Kany of the trainees inthese clinical courses are expected tn return home and train others to provide diarrhea case management, or even to train health workers who will inturn train other workers to provide treatment. In some cases the expected secondary training isto be formal: running courses for village kader, for example. In

almost every case, however, the trainee will have to train others: only a portion of the health workers at apuskesmas, for example, will be able to receive formal clinical training at aDTU; the remainder will have to

be trained by the doctor or senior healthworker 'on-the-job.'

Despite these inescapable tasks and expectations, however, the currect course curricula do not include anyobjectives or teaching-learning activities aimed at preparing the trainee to be an effective trainer.'

Recommendation:

Objectives and teaching-learning activities aimed at providing the needed knowledge and skills in how to

teach others about diarrhea treatment should be included in the courses for trainees who will be

expected to carry out such Training of Trainers (TOT)

activities after returning home. Since most trainees will need to do this at least informally, among their co-workers or assistants, such a TOT component should doubtless be a part of most clinical courses.

Where trainees re expected to run formal courses in diarrhea treatment, this TOT component should be more complete, and should include practice in needed teaching techniques in a structured setting with feedback. For those trainees with more informal TOT activities to perform, the component may be briefer,

but should not be eliminated altogether, and should be altered to prepare the trainee for performing "on-thejob" training rather than conducting a course.

2. except those which prepare him to teach mothers. Mothers must be taught the components of diarrhea treatment, butdo not need to be taught how to teach others about diarrhea.

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9. Monitoring and Assessment/Supervision

Monitoring and assessment of diarrhea case management being carried out by paramedics or kader isan important part of the job for many doctors or other health workers being trained inclinical courses. This istrue for a large number of Depkes workers who will never have the opportunity to participate in a formal 3upervisory Skills course. Current curricula do not include any activities related to this task. Practice inobservation and judging the quality of treatment activities can help in sharpeaing appreciation by the trainee of needed clinical skills, as well as providing skill inmonitoring.

Recommendation:

Objectives and teaching-learning activities and materials in the area of monitoring and assessment of diarrhea treatment should be included i,, diarrhea clinical courses for trainees who will have responsibility for supervising diarrhea treatment activities by assistants or kader. A checklist which can be used in such monitoring activities during a course is attached as Appendix C.

10. Applying and Implementing the Training Lessons

As noted ingeneral comments Iand Z above (Preparation and Follow-up), trainees can be expected to face a range of problems in initiating correct diarrhea case management, establishing a DTU, OR Unit or OR Corner. These range from obtaining needed materials to obtaining permission from the hospital supervisor to use needed space, from schjeduling 'on-the-job' training to organizing monitoring activities, from planning kader training to rearranging the furniture for an OR Corner. While adequate preparation and followup of the course will help inovercoming those problems, including specific activities inthe course to prepare participants to plau aL carry out those tasks will be critical to ensuring that they do happen.

Recommendation:

Courses should include as a major component activities designed to prepare the trainee to carry out the lessons of the course after returning home. Problems which can be anticipated should be described and discussed with instructors. Equipment and materials needed should be itemized. A schedule of activities should be prepared, with specific dates for completion. Each trainee should be required to submit prior to departure a plan detailing how he will carry out. the desired activities, overcome problems, obtain supllies, etc. The course materials should include a detailed list of the required components of this implementation plan. This plan should provide the basis for the

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followup activities recommended above (Recommendation

#2). The course schedule should provide an opportunity

if possible for the participants to compare and discuss their individual plans, particular discussin to

anticipated problems and hoi they plan to overcome them.

11. Excessive drug use

While every course includes inits lectures, reading materialg, and otheractivieis the ust and misuse of drugs

indiarrhea treatment, the tendency ismore toward merely justifying the correctness of not using drugs based on their lack of effectiveness.

Recommendation:

Clinical courses should expand their efforts dealing

with drug use to include activities which

- identify and discuss the reasons why doctors use drugs for diarrhea treatment even ,when they know that they are unnecessary

- provide practice in dealing with patients's demands for drugs

Some possible teaching-learning activities with this objective are attached as Appendix D.

D. TEACHING METHODS

12. Clinical experience

Bands-on personal clinical experiance in2anaging dehydrated patients isessential for convincing trainees that

OR? iseffective. This experience iust be adequately supervised inorder for it to be effective inprovidingthe trainee the needed practice and skills. Merely sending the trainee to the ward to serve as 'jaga mala3'

with no objective observation or feedback on his performance will accomplish little.

The present clinical courses all include activities labelled 'Experience in case management' insome fashion,

but the time allotted may be as little as Z hours, the actual activities to be carried out by the trainee or

the trainer are not defined, 3nd the number of patients to be managed as a minimum isunclear.

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Recommendation:

Courses should require trainees co personally manage a minimum number of patients (for example, at least 1 dehydrated patient, a total of 3 diarrhea patients), from initial assessment to teaching of the mother. Specific criteria for determining competence and correctness should be defined formally and provided to both supervisors and trainees in the form of a checklist.

Course materials should define more clearly the activities of both trainees and instructors on the ward. Efforts to avoid merely assigning patients to trainees for care, with no clear expectations of what is to be practiced, should be made.

The trainee's assessment of the patient, history taking, interaction 4ith the mother, diagnosis, and treatment should be observed by a supervisor if possible or another trainee using a formal checklist, and feedback and instruction provided when deficiencies are observed. To monitor the effectiveness of the trainee's communication and teaching of the mother, the mother's understanding of critical points in case management should be checked by the trainee's supervisor (or colleague) interviewing the mother and observing her prepare ORS.

13. Use of simulated cases and written exercises

It is likely that eyon in busy DTUs patients with all the desired clinical characteristics will not be available to each of the students. Inaddition there may be times of the year when even basic cases o.,cute watery diarrhea without complications may be few in number.

Recommendation:

Simulated cases and written exercises with case histories and related questions (see Appendix E for examples) should be provided to - broaden the range of case types "managed" by each trainee - ensure a kind of P.ccive case management by the trainee even when patient numbers are few - provide a structured introduction to use of the Clinical Assessment Chart prior to seeing live patients - serve as an objective tool for evaluation of trainee understanding and skills If possible the P2D program should attempt to make

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available at each s'onsored course cases presented

using video, to ensure that well-defined clinical experiences can be guaranteed to all trainees.

14. More active teaching methods, fewer lectures

Lectures are well-known to be rather ineffective tools to convey knowledge to trainees, and totally ineffective inconveying skills.

Recommendation:

Efforts should be made to reduce the proportion of lectures in the schedulea of the courses, substituting

instead readings, written exercises using the content of the readings, and directed discussions emphasizing key points.

15. Reading materials

As already uuted, the reading materials available for review were often in disagreement between articles, and with national standards.

Inaddition many of the articles were dense and complicated. Key points were hard to find, and not identified by underlining or setting apart from background data.

The articles usually are bursting with scientific facts, but with some notable exceptions do not clearly

translate those into recommendations for action by adoctor or health worker which can be put into operation

directly. For example, various microbiologic causes of dysentery are described and quantified, and treatment

for each noted, but the recommended approach for the health worker facing a patient with dysentery and having

no mians of making a diagnoais other than an anamnesis and observation of stool isnot clarified.

Ideally the reading materials should be a teaching tool during the course, and a useful reference after the

trainee returns home. Unfortunately there was no indication that the trainees were erp,ected to read an! of

thesaterials during the course, and no activities in uhich they were expected to refer to them to seek necessary information. As such, itseems unlikely that they will be used at any time.

Recommendation:

A standard book of readings and references should be prepared and made available for all trainees at P2D sponsored clinical courses. This would ensure that the contents are consistent with national policy, and that the quality and usefullness of the text can be maximized.

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Efforts should be made to enhance the usefullness of the materials as a teaching tool and practical reference for the clinician, by - keeping the style simple and direct (avoiding

"scientific writing") - formatting the material with underlining, boxes, lists, and other techniques so that key points jump out at the reader - always including the use and application of the scientific information provided

Trainees should be led to use the materials during the course by including exercises in the curriculum which require the reader/trainee to read the materials and use information from it. Such exercises can provide an effective alternative to lectures as an active mechanism for giving information to trainees.

16. Facilities where clinical courses will be held

Inview of the importance of the trainee both seeing and having direct experience incorrect case management techuiques, it is important that the locations used fot trining meet certain criteria involving both numbers of cases available ":the trainees for practice and thesethods and quality of case management techniques being used.

Recommendation:

Training should be conducted only in hospitals which meet criteria which will allow effective clinioal teaching to occur. The National CDD Program should determine and disseminate these criteria. The following criteria are recommended:

- .ufficient diarrhea patients available during- a course so that each trainee can personally treat at least one moderately or severely dehydrated patient, and three patients overall - all &iarrhea patients receive education in home case management (not just dehydrated patients, not just patients admitted for rehydration) - use of intravenous fluids and drugs (antibiotics and antidiarrheals) is consistent with national case management policy - patient diets are provided and controlled by the hospital, and are consistent with recommended national treatment policy

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- the hospital superintendent, course manager, and other trainers agree to teach the course according to

the national standard curriculum, methods, and materials

Other criteria may also be useful. The National ODD

Program should take steps to ensure that hospitals

conducting P2D sponsored courses meet the defined criteria.

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APPENDIX A - pg. I DIARRHEA CLINICAL FORMPatient No. _______________________________Month

Day YearPatient Name ___,,___,,.___o,_AM

raffly FirsOte Parent Name ,___,_,,___,,_______, ADM Address _ .,_ _ _ ___DIS_

EXAMINER/STJ-ENT MED UNIT_ CUNIC CITY.-_ DISTRICT PROVINCE_

CURRENT DIARRHEA EPISODE1-O nset (D ate & Tim e) . Du ration AC I O2- Sools past 24hrs. Description S TAEBO T EAC__SAKN____TE3- Blood? YES NO 4- Mucus? YES NO FLUIDS extra usual5- Vomittlng (Past 24hrs.) less stopTimes BREAST MILK6- Fever? usual less stopYES NO 7- Abc. Pain? YES NO8-Other diarrhea related symptoms

FOOD extra usual less stop OCESE

-

MEDICINE yes no

9- Urination past 2-6hrs? YES NO

10-Other illnesses present now: YES NO ORS yes no

OTHER: 11- Past history.

CURRENT DIET PRIOR TO DIARRHEA:Breastfeedng: YES NO Bottle: YES NO Of Yes Describe Formrfia):

Other Food: YES NO (IfYes Describe Food):

ASSESSMENT: Adequate Inadequate ON ADMISSlON:

Wieght Temperature Pulse (radial) N F F/W A (comments)__Nutrition Status (from wieght chart):

COMMENTS ON HISTORY:

(Describe Details By Ouestion #)

INSTRUCTIONS: Use this chart to summarize your findings and determine treatment.FORDEHYDRATION (circle appropriate answers)FOROTHERPROBLEMSf

A B CASJKABOUT:OiARRP.rE < Fe 'd l oors~(da/y IO 0 Iourd srf+11dy IClqurd macf|tlldy "9Ioo IIF ,tR LATIEffstood W104IG=HAS: ITHEN:Teest 'l n elooroor'allVOMITING None ora smell amount Same Very frequentTHi:ISTU;?1EN Normal( diarrhea for lowe thain 14Norm-a G1eeer, than norm lj ci anlbiotic !to sflngSll8A emI am~ount., darel UriaoldteNo otSdnkunne Mrs.ly. days. dO T*rWdYIt arf s also:LCI( AT: i Wall., men Ureill. iOeoy, ,rtaOle IfODay or Mhinr rdeft rsaedVery sleffoy.un;onscious

.4l9ry undemounsthied.e- I jewy 0n4e uns P-.'sPietism Abse'E'VES AbsentNormalT I 4lROI CHING NWt Sunmen Very Cry and tunken |eeWe n 2-' PMtDrIyfllulM~1LlE-rLl & %10 Very dry eoelnel Severety uriderourlsriece eycyI chl rfrBREATHING Norml Fauter then normal W refer 10treatment W,Very fast and deoo_SKIN Pinch goes FEE,- for o .- mftcDarlmeat..Ck quicey P'ncn goes sec $Is"y long@hen continueI ileaongPULSE GOes back very siOcy anoNormal Fater Mansnormal 14 days -in or mthout rer tooIrTalremlFCNTANELLE can

TAKE TEmPERATURE. Very SunmenNormal Sunken

Very fal, 411. leel blood. r fe M r".nWIEGoIT IF POSSIaLE. Loss of les tlla Los 1,gm le~ Ia.25gm of 25-1oo gin. Loss of v ro gin. 34.5 C Snomemorneo I :c: for each Kg. W ,egm (101F)o greatetforeach Kg. o ,wgr for cr1Ad-[r "l cloin aDO:E: o each Kg. a( ,,imf,gfPatient has no signsato 2 fannigl re af hese Igrs 2 o more of these sgl s L.ooefor and trel Otro,cehycrarron Saro 0"4121rmt01m &,irves,dnrdrson cause (e.g. Oi eumv.a.;

http:OiARRP.rE

APPENDIX A - pg. 2

PATIENT'S CLINICAL PROGRESS SHEET

NAME: __ DATE: -- HOUR:,

CUNICAL STATUS ON ADMISSION HOURS AFTER ADMISSION

At 2 Hours At 4 Hours At 6 Hours At 24 hours

Weight (kg.) Temperature (rectal)

Pulse (min.)

Resp. /min. Hypernia (0/+ + +)

Irritability (0++ +) Lethargic (0/+ - +) Sunken fontanelle (0/+ + +) Sunken eyes (01 + +) Dryness of Oral

Mucosas (0/+ + +) Tears (present or absent)

On Admission HOURS AFTER ADMISSIONFrom 0-2 Hours From 2-4 Hours fFrom 4-6 Hours From 6-24 Hours

Number of stoo!s Episodes of vomiting _

ORS consumed (volume) _

Other fluids drunk (volume) IV fluid given (volume) Food eaten Medicines taken

GUIDELINE GIVEN TO MOTHER

Mother's understanding of ORT: Fpeding advice to mother: Home mix: Quantity to be given: Return referal advice: Feeding during treatment: Breast: Signature:Other:

Name:

CLINICAL SUPERVISOR'S CHECK LIST 1- Dehydration Assessment ENQUIRY OF MOTHER 2- Fluid Administration 3- Feeding Advice To Mother:

4- Mother Understandinr, Home ORT: 5- Mother Understands Indications For

Return:

APPENDIX B

TALKING TO M1OTHerS

MODt7L

PRITZ CH/WHOM:EDICAL DUCATION PROJECT JU7NE 1987

LEADER'S GUIDE

.g --...

/

TALKING WITH MOTHERS

ABOUT DIARRHEA

a workshop for physicians

PRITECH Technologies for Primary Health Care

.7/

LEADER'S GUIDE: TALKING WITH MOTHERS ABOUT DIARRHEA

Contents

Page

Checklist of Supplies Needed at the Workshop

Scheduling the Workshop

Introduction to the Workshop

I. The Need for Better Communications

II. Asking Checking Questions

III. Using Examples

IV. Using a Mother's Pamphlet

V. Giving Support

Summary

Answer Sheets for Exercises A, C, and E

I

2

3

4

6

10

11

12

16

17

/

Leader's Notes

CHECKLIST OF SUPPLIES NEEDED AT THE WORKSHOP

Before the workshop, gather together the supplies you will need. 8e sure that you obtain and make copies of the workshop bocklet and answer sheets for all participants.

Supplies needed for the workshop._lader:

* If a flipchart stand isavailable,

- 2 flipchart pads and black and red felt tip markers

* If a blackboard is available,

- white and colored chalk

* If neither a flipchart stand nor a blackboard are available, obtain masking tape to tape paper on the wall.

Supplies needed for each participant:

* one copy of the booklet, "Talking With Mothers About Diarrhea"

* one copy of the answer sheets to the exercises in the booklet

* paper, pencils, and an eraser

Supplies needed for each small group of 3 - 4 participants for the role p]ay on teaching mothers to mix ORS solution (Exercise F):

* ORS packets (2 - 3)

* a vessel to hold the mixed solution

* locally available containers for measuring the appropriate amount of water

* water (2 litres)

* a spoon or other utensil to stir the ORS solution

* a drinking glass

1

Leader's Notes

SCHEDULING THE WORKSHOP

The times below are for the workshop leader to use in planning a schedule

for the workshop. The working times shown include time needed for reading

text and completing exercises and discussions. Allow additional time for

breaks.

ACTIVITY MINIMUM WORKING TIME TO ALLOW

(IN MINUTES):

Introduction to the Workshop 10

I. The Need for Good Communications 20

II. Asking Checking Questions 90

III. Using Examples 30

IV. Using a Mother's Pamphlet 40

V. Giving Support 90

Workshop Summary 10

1OTAL: 4 hours, 50 minutes

If a full day is available for the workshop, discussions could be allowed

to continue longer. Also, more participants could be given the opportunity

to practice new skills in the ffnal role play (Exercise F).

2

Leader's Notes =

INTRODUCTION TO THE WORKSHOP

This section of the booklet introduces the workshop -- its purpose, for

whom it is designed, the skills taught, and use of the'workshop booklet.

1. Ask participants to read "Introduction to the Workshop."

2. Ask if there are any questions about the workshop design, materials,

or about your role as workshop leader.

3. Review the workshop schedule that you have planned.

3

Leader's Notes

I. THE NEED FOR BETTER COMMUNICATIONS

This section stimulates participants to think about the value of good

communications and the impact of poor communications.

1. Ask participants to read uThe Need for Good Communications."

2. When participants have finished the reading, lead a brief discussion of

idea's for improving communication between the doctor and Maria. List

participants' suggestions on a flipchart. (Note: Whenever you write

a list of participants' suggestions, write the same response only

once.) When participants have mentioned several suggestions, review the

list and relate their ideas to the skills that will be covered in the

training, such as using demonstrations, asking better questions, and

giving the mother some written instructions to take with her. Mention

any additional techniques that are in the workshop which participants

did not mention.

3. Continue the discussion by asking the impact of NOT communicating

effectively with Maria. On the flipchart, list participant's

suggestions of the results.of Maria's visit to the doctor. For

example:

She won't come to the doctor for help next time.

4

http:results.of

She may tell her neighbors that ORS doesn't work.

She will continue her practice of not feeding a child with diarrhea and not giving additional fluids.

4. Conclude the discussion by making the'following points:

Because the doctor is hurried, we can understand why he did not spend

more time talking with Maria. However, you want a child like Maria's

to get the treatment he needs.

If, for example, you recommend oral rehydration therapy to be done at

home, or if you prescribe antibiotics, you rely on the mother to

carry out the treatment. The eff :tiveness of the treatment you

prescribe and your effectiveness a. a physician depend in large part on

your ability to communicate with mo, lers.

Leader's Notes

II. ASKING CHECKING QUESTIONS

1. Ask participants to read "Asking Checking Questions."

2. Ask participants to work individually to complete Exercise A.

[Alternatively, you may lead the group in a discussion of each

question so the group completes the exercise together. Ask different

participants to suggest'checking questions. As good ones are

suggested, the participants write them down in the workbook.

If you use this alternate method, you must quickly assess each question

suggested. If the question is not good (for examiple, it only asks the

mother to agree with something the doctor has said), tell why and then

ask for another suggestion.]

3. After everyone has finished, lead a brief group discussion. Going

question by question, ask one or two participants to tell the group a

checking question that they wrote. Continue through the list of

questions, giving all participants a chance to talk.

4. Distribute copies of the Answer Sheet for Exercise A to all par

ticipants.

5. Ask participants to read the instructions for Exercise B.

6

6. Before the Role Play (Exercise 8)

Explain that the purpose of this role play i to give everyone a chance

to practice asking checking questions.

Divide the group into small groups of 3 to 5 participants. Designate

one participant in each small group tG be the doctor first and one to

be the mother. The other participants will observe and will help the

doctor think of good checking questions.

Review the instructions for all three roles. Call attention to the

two tasks of the observers--they will give the doctor suggestions while

the role play is going on and will write down good checking questions

in their workbooks. The mother should not give the same answers as

written in Exercise A.

Explain that after the "doctor" in each group has covered several of the

"doctor's main questions", another participant will take a turn as the

doctor. (Ask the group to divide up the questions so that each person

will ask about the same number. For example, if there are 3 par

ticipants in a group, each will cover 4 or 5 questions. If there are 5

in a group, each will cover only 2 or 3 questions.) All participants

should take a turn being the doctor.

Explain that you will be roaming from group to group and will give

assistance if needed, but will make overall comments during the large

group discussion afterward.

Seat each small group together (such as in a small circle) with the

doctor and mother next to each other. 'Tell participants that when they

7

change roles, they should also change chairs. If the "doctor" always

sits in the "doctor's chair," itwill be easier to keep the roles

straight.

The small groups will do their role plays simultaneously, so you should

separate the groups as mu-h as possible so they won't distract each

other. For example, put them in different corners of the room, or let

one group take chairs into the hallway.

7. Durina the Role Play

At first go quickly'to each group to check for confusion or difficulty

getting started. Give any additional explanation needed to clarify

what the participants should do and get the role play underway.

When it is time for another person to play the role of the doctor, be

sure he moves into the "doctor's chair." About halfway through the

list of questions, have a different participant take the role of the

mother.

L.isten during the role plays. If a participant is not asking good

checking questions, interrupt him, remind him of some examples, and

let him start again.

8. After the Role Play

When all participants have played the role of the doctor, reassemble

the large group. Tell the group some of your observations of things

done well and some difficulties.

8

Ask the group to think about what they learned from the role play.

Ask:

a) "What were some good checking questions that were asked inyour group?

b) "What is difficult about asking checking questions?"

Ask someone from each small group to tell the others about at least one

checking question that worked well.

Ask the group for answers to question 2. List their answers on the

flipchart.

9. Conclude the discussion by mentioning or asking a Darticlpant to list

some benefits of asking checking questions.

9

Leader's Notes

III. USING EXAMPLES

1. Ask participants to read "Using Examples."

2. Ask participants to work individually to complete Exercise C.

3. After everyone is finished, lead a brief group discussion. Going by

category, ask participants to tell an example they wrote. List these

examples on a flipchart.

During the discussion of the practice category, reinforce the impor

tance of having mothers practice doing a task when the task involves a

manual procedure.

4. Conclude the discussion by asking a participant to state some of the

benefits of using examples when giving instructions to mothers.

5. Distribute copies of the Answer Sheet for Exercise C to all

participants.

10

Leader's Notes ;

IM. USING A MOTHER'S PAMPHLET

1. Ask participants to read "Using A Mother's Pamphlet" and to review the

sample pamphlets provided in their booklets. Ifyou have a pamphlet

that was produced by the national COD program in the country,

distribute it to the participants as well.

2. Ask participants to take a few minutes to think about the questions

listed for Exercise D.

3. When everyone is ready, lead a group discussion of Exercise 0. Ask

participants for their answers to each question. To the extent

possible, give all participants a chance to talk. Record participants'

answers to la, 1b, and 2 on a flipchart.

When participants mention difficulties that they face using or

developing a pamphlet, ask the 'iroup for suggestions of ways to overcome

them. For example, if a participant says that he has little funding

for educational materials, another participant may know a very low-cost

way to print the pamphlets.

4. To conclude the discussion, emphasize that participants can use the

sample pamphlets as needed to develop one for use in their own

facility.

11

Leader's Notes.

V. GIVING SUPPORT

1. Ask participants to read "Giving Support."

2. Ask participants to work individually to complete Exercise E.

3. After everyone has finished, lead a brief group discussion. For each

doctor/mother interaction, ask one or two participants to tell the

group a way of giving support. List participants' suggestions on a

flipchart.

4. Conclude the discussion by making the point that providing positive

consequences following behavior is essential for mothers to continue

the behavior over time.

5. Distribute copies of the Answer Sheet for Exercise E to all

participants.

6. Ask the participants to read the instructions for Exercise F.

7. Before the Role Play (Exercise F)

Gather the supplies for the'role play -- ORS packets, water, a vessel

for holding the solution, a"container for measuring water, a spoon, and

a drinking glass for each small group of 3 participants.

Explain that this role play is comprehensive -- designed to give'

12

practice in all the skills the workshop has covered including asking

checking questions, using examples, using a pamphlet, and giving

support.

Divide participants into groups of 3. Tell each small group to decide

who will play each of the roles.

Review the instructions for all three roles.

Emphasize the importance of the observer role. The observer will pro

vide feedback to the doctor after the role play. In addition, since

the doctor may forget to do something (e.g., give support), the

observer should watch the role play carefully and while the role play

is still going on, remind the doctor of what he has not done so that he

can do it.

In this way, we will be following the teaching methods/philosophy that

we plan to use when teaching mothers. The doctor will practice the

task correctly and the others will learn by watching a demonstration of

the task done well.

Explain that you will be roaming from group to group and will give

assistance if needed, but will make overall comments during the large

group discussion afterward.

Have the small groups move to different areas of the room, decide who

will play each of the roles, and begin the role plays.

13

8. During the Role Play

At first go quickly to each group to check for confusion or difficulty

getting started. Give any additional explanation needed to clarify

what the participants should do and get the role play underway.

During the role play, interrupt only if participants are having dif

ficulty.

When each role play is over, be sure that the observer and the mother

gi e the doctor feedback on what the doctor did well and what could be

improved.

NOTE: If there is sufficient time, ask a second participant in each

group to take the role of the doctor. Triis will allow another person

to practice what he or she has learned.

9. After the Role Play

Call all the participants back together for a group discussion. Tell

the group some of your observations of things done well and some dif

ficulties.

Ask the group-to think about what they learned from the role play.

Ask:

"What do you warnt to remember about counselling mothers? What

tips would you give someone who wanted to make their counselling

more effective?"

14

Ask someone from each small group to suggest one thing to remember

about counselling mothers or specifically about teaching mothers to mix

ORS. List their suggestions on the flipchart. Ask the group for addi

tional suggestions and continue adding to the list until participants

have no more new suggestions.

15

Leader's Notes -

SUMMARY

1. Ask participants to read the workshop summary card, Talking With

Mothers About Diarrhea.

2. Suggest that participants keep the card ina handy place and refer to

it periodically. Explain to them that when they use these skills

often, the skills will become a habit. However, at first, participants

will need to think about the skills specifically, try them and then

continue to practice them. The card can remind participants of

techniques to try.

3. Ask participants to comment on which skill(s) they plan to try out

first, which skills will be most effective, etc. Durir:g this closing

discussion, encourage participants to obtain or develop a mother's

pamphlet and to use it in their facilities.

16

1P

ANSWER SHEETS

FOR

EXERCISES A, C, and E

17

9i

-----------------------------------------------

Possible Answers To

Exercise A

DOCTOR'S MAIN MOTHER'S DOCTOR'S CHECKING QUESTIONS RESPONSE QUESTIONS

1. What was your concern He seems very Do you have any idea why that made you brina tired and weak. he is tired and weak? the child for help?

What other problems does the child have?

He has diarrhea. For how long has he had diarrhea?

Are his stools soft, o

watery?

How many liquid stools has he had each day?

2. (For child who has When did you first notice diarrhea) the blood? Is there blood in the stool? Yes How much blood is there in

the stool?

3. Has the child been How often has the child vomiting? Yes vomited?

How much vomit has there been each time?

4. Has the child passed Did the amount seem normal urine in the last 6 or small? hours? Yes

Did the color seem normal or darker than usual?

DOCTOR'S MAIN MOTHER'S DOCTOR'S CHECKING QUESTIONS RESPONSE QUESTIONS

I don't know. When is the last time you remember the child passirg urine?

5. What has the child had to drink since the diarrhea began? The usual drinks.

What-are the usual drinks?

How often does he drink?

How much does he drink at a time?

Is this more or less than usual?

Breastmilk Does he want more or less than usual?

Have you.given him anything else to drink? (If so) what?

6. What has the child eaten since the diarrhea began?

He has not been hungry.

What ha'te ynu offered him to eat?

How often have you offered food?

Special soup. What is in this soup?

How often has the child eaten the soup? How much has he eaten each time?

------------------------------------------------

------------------------------------------------

DOCTOR'S MAIN

QUESTIONS

8. What do you usually

do when your child

has diarrhea?

9. (Ifthe recommended home fluid for early treatment of diarrhea is rice water) Do you ever prepare

rice water in your home?

MOTHER'S DOCTOR'S CHECKING RESPONSE QUESTIONS

I try to let How do you do that? his stomach rest. Are there certain foods

you avoid? Which ones?

Do you give him anything

to drink?

I give What kind of medicine? medicine from (What does it look the pharmacy. like? How is it

packaged?)

Do you have some of this medicine with you that you can show me?

How does the medicine affect your child's diarrhea?

Yes How do you prepare it?

How often do you prepare it? How much do you prepare?

What do you normally use it for?

Could you give some to your child when he has diarrhea?

DOCTOR'S MAIN .QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECKING QUESTIONS

No Do you know how to prepare it? (Ifso) Describe to me how you would make it.

Why don't you prepare it? (Do you lack ingredients? Does it take too much time?).

What fluids are usually available in-yur home?

10. (After an explanation of how to feed a child with diarrhea)What are some good foods you can give your child when he has diarrhea?

Mashed foods. What foods will you mah?

What do you have at your home that you can give?

How often will you offer the child food?

11. (After an explanation of how to make ORS solution)How will you make this solution when you get home?

I will mix the packet in water.

How much water will you use? How will you measure it?

How much of the packet will you use?

DOCTOR'S MAIN QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECKING QUESTIONS

12. (After an explanation of how to administer ORS solution)How much of this solution will you give the child?

One half cup Show me how much that is.

What kind of cups do you have at home?

How often will you give this amount?

13. How will you know ifyour child needs to come back for more help?

If he's not getting better.

What signs will you look for?

How long did it take you to get here today? Will it be difficult for you to come back?

Possible Answers To

Exercise C

Showing pictures

Naming a specific

(instead of giving just

a general rule)

Doing a demonstration

Showing an object

Telling a story

Having the mother

practice it herself

* Drawing of a mother breastfeeding

* Photograph of a child with sunken eyes

* Telling a mother to give banana or pineapple, instead of telling her to give foods containing potassium

* Telling a mother to give soup, gruel, or rice water instead of telling her to give food-based fluids

* Showing a mother how to feed ORS to her baby with a spoon

* Showing a mother how to check for the

signs of dehydration

* Packet of ORS

* Container holding a litre of water

* A story of a baby who became dehydrated and died can highlight the danger of diarrhea in a mother's mind. The story might also tell how the baby looked as he was getting worse.

* A story of a baby who got better after

treatment with ORS can highlight the benefits of ORS in a mother's mind.

* The mother measures the correct amount of water to mix with contents of an ORS packet.

* She gives ORS solution to her child with a

spoon.

* She recalls the signs that mean she should

bring her child back and tells them to you.

Possible Answers To

Exercise E

Doctor/Mother Interaction

A mother has brought her

child to the health faci-

lity because the child has

had 5 loose stools since

last night. The mother tells you that since the

diarrhoea started, She

gave her child water and

tea to drink and rice to

tat.

You have asked a mother to

tell you how she will know

if her child needs to come

back for more help. The

child Is not dehydrated

now. The mother says s'ie will bring him back If ae does not want to eat or gets very thirsty.

You have just asked a

mother if she has a vessel

at home that she can use

tc measure a litre of water

to mix with an ORS packet,

The mother says she does not

have a vessel of that size.

A mother is sitting in the

clinic, giving her child

spooifuls of ORS solution oas

the nurse has shown her.

The child suddenly vomits

the solution. The mother

looks very worried.

Ways the Doctor Might Give Support

Complement the mother on recognizing that diarrhea is serious and for knowing to bring her child for treatment.

Complement the mother on continuing to give her child food and liquids at home after the diarrhea started. Confirm that water, tea, and rice are good to give a child with diarrhea. Then suggest some additional fooes and liquids to give when her child has diarrhea and discuss how she will prepare them.

Confirm that these are two very important signs that mean she should bring the child back. Then discuss additional signs that she can look for.

Ask checking questions to determine what types and sizes of vessels the mother has at home. Then show her how she would measure a litre of water using a vessel that she has, such as a glass or soft drink bottle. Have her demonstrate (if not possible, describe) how to measure 1 litre and praise her when she does It correctly.

Encourage the mother to continue giving the solution, but more slowly. Explain the good effect that the solution is having on the child: he is becoming rehydrated, he is regaining his strength, he will soon be hungry again. The vomniting does not mean he is getting worse. The solution is helping him.

Al

/ ,

,,"-.- -..

TALKING WITH MOTHERS

ABOUT DIARRHEA

a workshop for physicians

PRITECH Technologies for Primary Health Care

TALKING WITH MOTHERS

ABOUT DIARRHEA

Contents

Page INTRODUCTION TO THE WORKSHOP 1

I. THE NEED FOR GOOD COMMUNICATIONS 3

II. ASKING CHECKING QUESTIONS 7

Exercise A 12

Exercise B 18

III. USING EXAMPLES 21

Exercise C 25

IV. USING A MOTHER'S PAMPHLET 27

Exercise 0 32

V. GIVING SUPPORT 33

Exercise E 38

Exercise F 39

SUMMARY CARD 41

Reading

INTRODUCTION TO THE WORKSHOP

The effectiveness of an ORT program is ultimately determined by whether

mothers use oral rehydration therapy effectively or not. For a mother to

use oral rehydration therapy effectively, a physician must know how to talk

with her about diarrhea and teach her to care for her child at home. This

requires that the physician have good communication skills. An ability to

communicate we'll with a mother can make the difference between an effective

physician and an ineffective one.

This workshop is designed to provide physicians who treat children with

diarrhea with the necessary skills and knowledge to improve communications

with the patients' mothers. The specific communication skills taught

in the workshop include:

* How to ask checking questions

- to do a better assessment of the patient,

- to be sure a mother understands what to do at home, and

- to monitor your staff's communications with mothers.

* How to use examples to make instructions to mothers more interesting

and effective

* How to use a mother's pamphlet

* How to give support so a mother will feel positive about what she can

do to care for her child.

1A

In this workshop you will read and do some exercises designed to teach

these communication skills. This booklet provides all the written material

you will need. Your workshop leader will tell you when to read and will

guide your group's work on exercises. You will do several different types

of exercises during the workshop, including individual written work, role

play, and group discussion. When written answers to an exercise are

requested, write your answers in the spaces provided in the booklet. You

can keep the booklet to use as a reference on the job.

I THE NEED FOR GOOD COMMUNICATIONS

Reading

I. THE NEED FOR GOOD COMMUNICATIONS

Maria's one-year-old daughter has diarrhea. She became concerned and

brought the child to the doctor.

DOCTOR: Next patient please.

MARIA: (Enters and sits down.)

DOCTOR: Your card please.

MARIA: (Hands card to doctor without saying anything. Child is quietly

resting in mother's arm.)

DOCTOR: Put your child on the table for me, please.

MARIA: (Places child on table and opens the blanket in which the baby is

wrapped.)

DOCTOR: (Examines the child and discovers that the child has diarrhea.

The child looks a little weak, but there are no dramatic signs of dehydration. Pulse is 110. Skin turgor is normal. But the child

appears to be underweight.)

How long has the child had diarrhea?

MARIA: Just this morning she became sick.

DOCTOR: What have you given her, any medicine?

MARIA: No, doctor.

DOCTOR: Well, I want you to give this packet of medicine. Have you seen

this before? (Shows mother an ORS packet)

MARIA: Yes, doctor.

4

DOCTOR: Then you know how to prepare it?

MARIA: Yes, doctor.

DOCTOR: Good, come back and see me if the child does not get better.

MARIA: Thank you, doctor.

Now answer the following questions about the case above.

1. How long did Maria's child have diarrhea?

2. Was Maria's child dehydr'ted?

3. What had Maria given her child before coming to the doctor?

4. Did Maria know how to prepare the ORS?

5. What will Maria do when she returns home with her child?

Let's look at what was going on in Maria's mind. Actually, it is hard to

know what was in her mind. Did she tell the truth to the doctor? If not,

why might she have lied, or b;en confused, or misunderstood? Imagine for a

moment that you are Maria and listen to her thoughts as she answers several

of the doctor's key questions. Her thoughts are written in ( ) below.

DOCTOR: How long has the child had diarrhea?

MARIA: Just this morning she became sick. (He wants to know when she got

sick. The baby had diarrhea for three days already, but

that is not unusual.., no I am sure he only wants to know when

she became weak from the diarrhea.)

5

DOCTOR: What have you given her, any medicine?

MARIA: No, doctor. (What have I given her...? Well, I gave her that

strong tea to clean out her stomach. My grandmother always used

that with us children. And I have been feeding her less so her

stomach can rest. Oh, but he wants to know what medicine I gave

her. No, I didn't give her any medicine.)

DOCTOR: Have you seen this packet before?

MARIA: Yes, doctor. (I have seen that once, but I don't know what it is.

I better tell him I do know what it is, so that he won't get angry

at me.)

DOCTOR: Then you know how to prepare it?

MARIA: Yes doctor. (I better not tell him I don't know how or he will

think I am stupid. I can always as'( my oeighbor, she always knows

these things.)

DOCTOR: Good, come back and see me if the child does not get better.

MARIA: Yes, doctor. (How am I going-to come back? I live almost four

hours from here, and my husband didn't want me to come today.

What does he mean, "if my baby doesn't get any better"...won't

this medicine work?)

We now have a much different picture of what really happened. If we were

to follow Maria home, we would find that she went to the neighbor, but she

didn't know a..y more about the ORS packet than Maria did. Maria prepared

the nedicine and gave two teaspoons, but the diarrhea continued. Maria felt

the medicine was no good. She did not like the fact that it is a clear

liquid with a salty taste. She decided she would not use the medicine

again. By the next day the diarrhea disappeared, and Maria was not

sure whether the medicine worked or not.

6

0

II. ASKING CHECKING QUESTIONS

Reading

II. ASKING CHECKING QUESTIONS

Asking simple checking questions can dramatically improve your com

munications with mothers. What is a checking question?

It is a question you ask to confirm what a mother knows or to

find out more complete or specific information about something a mother

has said. For example, if a mother told you she had given tea to her

child with diarrhea, a checking question might be:

"How much did she drink today?" or "What else did you give her to drink or eat?"

It also can be a question that gets her to tell you what she has learned,

so that you can check whether she remembers and understands what you have

taught her. For example, after you have explained to a mother how to

treat her child's diarrhea at home, you might ask this checking question:

"Tell me the signs that mean you need to bring Ana back to me."

When you ask a mother checking questions, it is helpful to phrase the

questions so that she iust say more than just "yes" or "no". For example,

you would not ask:

"Do you understand the signs that mean you should bring Ana back to me?"

8

The mother would answer "yes" whether she did or nct. She would be reluc

tant to say she does not remember and possibly seem stupid.

Asking checking questions requires patience. When you ask a mother a

question, you must be quiet and give her a chance to think and then answer.

If the mother Is silent, your impulse may be to answer the question your

self or to quickly ask a different question.

Realize that the mother may know the answer but be slow to respond for

several reasons. She may be surprised that you really expect her to

answer. She may fear her answer may be wrong. She may hesitate to speak

to an authority figure. Wait for her to answer and give her encouragement.

If the mother answers Incorrectly or says she does not remember, you must

be careful not to make her feel uncomfortable. Give her another explana

tion (or demonstration) to teach her. Then check again whether she remem

bers.

Think about the doctor's conversation with Maria. He could have learned a

lot more about what Maria thought and knew if he had asked some checking

questions. For example:

"Is this the first morning she had diarrhea? Did she have any loose

stools before this morning?"

"What foods and .drinks has she had today?"

"Have you ever used a packet like this with your child? How did you prepare it?"

If she makes a mistake in explaining how to mix the ORS, he could say, "Let me show you a better way to make it--a way that is simpler

and makes it work even better." Then, "Maria, now tell me how you will prepare the solution at home."

9

The objective is to make Maria feel comfortable, to get al' the information

needed to understand the child's condition and what Maria needs to be

taught, and to make sure she knows how to care for her child. The doctor

cannot know that Maria understands what to do until he hears her describe

it.

There is another valuable use of checking questions. If you have delegated

the responsibility of teaching mothers tc a nurse or other staff members,

checking questions can help you monitor the effectiveness of their

teaching. For example:

Three-year-old Mo was treated for dehydration and is now ready to

go home. The nurse has talked to his mother about what she

should do at home to care for the child. You, the doctor, did

not see or hear this instruction tiking place. You have only a

couple of minutes to spend with the mother before she leaves.

You can ask 3 or 4 checking questions to find out whether the

mother has been taught the most critical things about caring for

the child at home.

You would not ask the mother, "Did the nurse explain to ,,.4uhow

to mix the ORS?" or, "Do you know how to mix that ORS?" since the

mother would be afraid to answer no.

instead, you would ask, "How much water will you mix with that

ORS packet?"

You could also ask, "How much of the solution will you give to

Mo? How long did the nurse tell you to continue giving the ORS?

10

What else will you give him to eat and drink? When will you

bring Mo back to see the nurse again?"

I the mother can answer these questions correctly, you can be satisfied

that your nurse communicates with mothers very effectively.

11

Exercise A

The table on the next few pages lists some of the main questions that a

doctor needs to know during an interaction with a mother whose child has

diarrhea. Questions I - 6 are some questions a doctor might ask when

assessing the child's condition. Questions 8 - i3 are some questions a

doctor might ask when explaining to a mother how to treat diarrhea and when

ensuring she understands and can follow his instructions.

Some checking questions are already provided on the table for numbers 1, 2,

8, and 9. For numbers 3-6 and 10-13, read the main question and the

mother's response. Then write in one or two checking questions that you

might ask the mother.

Numbers 7 and 14 are blank. Write in inother question you would want to

ask, a mother's response, and a checking question.

12

----------------------------------------------

------------------------------------------------

-DOCTOR'S MAIN

QUESTIONS

1. What was your concern

that made you bring

the child for help?

2. (For child who has

diarrhea)

Is there blood in the stool?

3. Has the child been vomiting?

4. Has the child passed urine in the last 6 hours?

MOTHER'S DOCTOR'S CHECKING RESPONSE QUESTIONS

He seems very Do ycu have any idea why tired and weak. he is tired and weak?

What other problems does the child have?

He has diarrhea. For how long has he had diarrhea?

Are his stools soft, or watery?

How many liquid stools has he had each day?

When did you first notice the blood?

Yes How much blood is there in the stool?

Yes

Yes

I don't know.

13

DOCTOR'S MAIN QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECKING QUESTIONS

5. What has the child had to drink since the diarrhea began? The usual drinks.

------------------------------------------------

Breastmilk

6. What has the child eaten since the diarrhea began?

Ue has not been hungry.

------------------------------------------------

Special soup.

7.

14

-----------------------------------------------

DOCTOR'S MAIN -QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECXING QUESTIONS

8. What do you usually do when your child has diarrhea?

I try to let his stomach rest.

How do you do that?

Are there certain foods you avoid? Which ones?

Do you give him anything

to drink?

- -------------------------- :--------------------

I give medicine from the pharmacy.

What kind of medicine? (What does it look like? How is it packaged?)

Do you have some of this medicine with you that you can show me?

How does the medicine affect your child's diarrhea?

9. (If the recommended home fluid for early treatment of diarrhea is rice water)Do you ever prepare rice water in your home?

Yes How do you prepare it?

How often do you prepare it? How much do you prepare?

What do you normally use it for?

Could you give some 'to your child when he has diarrhea?

No Do you know how to prepare it? (If so) Describe to me how you would make it.

15

DOCTOR'S MAIN QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECKING QUESTIONS

Why don't you prepare it? (Do you lack ingredients? Does it take too much time?)

What fluids are usually available in Your home?

10. (After an explanation of how to feed a child with diarrhea)'What are some good foods you can give your child when he has diarrhea?

Mashed foods.

11. (After an explanation of how to make ORS solution)How will you make this solution when you get home?

I will mix the packet in water.

12. (After an explanation of how to administer ORS solution)How much of this solution will you give the child?

One half cup

16 k

DOCTOR'S MAIN QUESTIONS

MOTHER'S RESPONSE

DOCTOR'S CHECKING QUESTIONS

13. How will you know if your child needs to come back for more help?

If he's not getting better.

14.

17

__ Exercise B

This exercise will be a role play. You will work in small groups of 3 - 5

participants. One participant will be the doctor and another will be the

mother. The doctor will ask the questions listed in Exercise A, listen to

the mother's response, and then follow up with a checking question. The

other participants will be observers until they take a turn as the doctor.

They can also help the doctcr think of good checking questions.

Turn to Exercise A. Refer to it during the role pla, and, as you hear

good checking questions, add them to the ones you have already written.

Instructions for

the Doctor: Begin by asking the first question-listed in Exercise A

under "Doctor's Main Question." You may ask it in your

own words. When the mother responds, follow up with a

checking question or two until you are satisfied that

you have complete information. Continue until you have

covered 2 or 3 of the main questions.

Instructions for

the Mother: Answer the doctor's questions as you wish, but be brief

and somewhat reluctant to talk. As the role play,con

tinues, answer questions the doctor asks as you think a

mother might, but hold back some information until the

doctor's questions bring it out.

18

Instructions for

the Observers: Listen carefully and help the doctor as the role

play progresses. If he pauses to think of a checking

question and you have thought of a good one, suggest it

to him. Let the doctor know if hi isasking too many

"yes" or "no" questions, if he is leading the mother to

answer a certain way, or if he isassuming what the

mother means rather than asking.

After the doctor has covered the first 2 or 3 main questions, one of the

observers should take a turn as the doctor. That participant should move

to the "doctor's" chair and continue asking the mother questions and

checking questions (with coaching from the observers, as needed).

Continue until each participant has practiced asking checking questions.

i9

I. USING EXAMPLES

21

Reading

111. USING EXAMPLES

Giving clear instructions to the mother is an essential step in giving good

care to a patient.

Your interaction with a mother includes getting complete and accurate

information from her so that you can asse!,s the child's current condition

and the treatment given so far. Your task is also to give all the infor

mation that the mother needs to care fc, her child and to communicate it

clearly. Using examples will make your instructions more interesting and

effective.

Many different types of examples are described in the chart on page 24.

Examples can make the instruction more real and more pertinent to the

mother, if the examples are relevant to ner experience and knowledge. An

example may be an object or a situation that the mother can see in her

mind. Or, an example may be an object or an action that the mother can

look at while you are talking.

For example, you can show the mother a half cup of solution as you tell her

to give a half cup of solution after each stool. You can let her watch

another mother who is giving her baby ORS solution with a spoon--She can

see how to hold the baby and the pace to give spoonfuls. The visual

image will remain in the mother's memory longer than you- words.

22

Demonstration is particularly powerful in teaching a mother how to do a

task. Showing her how to do the task is much quicker and more effective

than just telling her how to do it. The most effective way to teach a

mother a manual procedure such as mixing ORS is to have her watch someone

else do it and then practice it herself with your guidance. As she tries

it,you can observe what is difficult for her and explain or demonstrate as

needed. When you have seen her do the task correctly, you can be confident

that she has learned it.

23

WAYS TO USE EXAMPLES

Showing pictures * Drawing of a mother breastfeeding

Naming a specific * Telling a mnther to give banana or (instead of giving only pineapple, instead of telling her to give a general rule) foods containing potassium

Doing a demonstration * Showing a mother how to feed ORS to her baby with a spoon

Showing an object * Packet of ORS

Telling a story * A story of a baby who became dehydrated and died can highlight the danger of diarrhea in a mother s mind. The story might also tell how the baby looked as he was getting worse..

Having the mother * The mother measures the correct amount of practice it herself water to mix with contents of an ORS

packet.

24

Exercise C

Below and on the next page we have repeated the list of possible ways to

use examples to make your instructions to mothers more effective. For

each category in the left column, list at least one additional example in

the right column. Try to think of exanples that would apply inyour own

work setting. When everyone has finished the exercise, there will be a

group discussion.

WAYS TO USE EXAMPLES

Showing pictures * Drawing of a mother breastreeolng

Naming a specific * Telling a motler to give banana or (instead of giving only pineapple, instead of telling her to give a general rule) foods containing potassium

Doing a demonstration Showing a mother how to feed ORS to her baby with a spoon

25

Showing an object * Packet of ORS

Telling a story * A story of a baby who became dehydrated and died can highlight the danger of diarrhea in a mother's mind. The story might also tell how the baby looked as he was getting worse.

Havii the mother * The mother measures the correct amount of practice it herself water to mix with contents of an ORS

packet.

26

IV. USING A MOTHER'S PAMPHLET

27

Reading

IV. USING A MOTHER'S PAMPHLET

A mother's pamphlet can greatly improve your communications with mothers.

This is a pamphlet that you and your staff can give to each mother. It

should summarize the most important elements of caring for a child with

diarrhea at home. A mother's pamphlet should have words and pictures that

illustrate the main points. When a pamphlet is being developed, it should

be shown to some mothers to test whetic they understand its messages. Two

examples of a mother's pamphlet are provided on pages 30 and 31. If your

country does not currently have a mother's pamphlet, you should develop one

for your facility that mothers in your area will understand.

There are many reasons a mother's pamphlet can be a useful communications

tool.

* Referring to the pamphlet will remind you or your staff of the

main points you need to cover during counselling sessions.

* The pamphlet will remind the mother of what you explained when she

is at home.

If you or your staff are in a hurry and mistakenly leave out

important messages while with the mother, she will still get those

messages when she refers to the pamphlet at home.

* Because the mother kaeps the pamphlet, the next time her child has

diarrhea she can refer to it and refresh her memory about what to

do.

28

The mother may show the pamphlet to other family members or neigh

bors, so more people will learn the messages it contains.

The mother will appreciate bein5.,given something during her visit.

The pamphlet will simplify the task of training your staff in the

messages