A Training Program in Community- Directed Intervention to Improve Access to Essential Health Services. Training Guide

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A Training Program in

Community-Directed Intervention to Improve

Access to Essential Health Services

Training Guide

June 2013

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ABBREVIATIONS AND ACRONYMS

ACT

artemisinin-based combination therapy

BCC

behavior change communication

CDD

community-directed distributors

CDI

community-directed intervention

CSO

civil society organization

iCCM

integrated community case management

IEC

information, education, and communication

IPTp

intermittent preventive treatment in pregnancy

ITN

insecticide-treated net

LGA

local government area

LLIN

long-lasting insecticide-treated net

M&E

monitoring and evaluation

ORS

oral rehydration solution

PME

participatory monitoring and evaluation

PMV

patent medicine vendors

RDT

rapid diagnostic test

SP

sulfadoxine-pyrimethamine

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ACKNOWLEDGMENTS

This training program was developed in stages over a period of five years. In 2007 Jhpiego received a grant from the ExxonMobil Foundation to provide community-directed malaria in pregnancy

interventions in several local government areas (districts) in the highly malaria-endemic area of coastal Akwa Ibom, Nigeria. The original modules focused on the provision of intermittent

preventive treatment of pregnant women, acquisition and use of insecticide-treated bed nets, and malaria case management. Later, with additional support from Ellicott Dredges, a Baltimore-based company, the training curriculum was expanded to include integrated community case management of common and febrile illnesses, including malaria, pneumonia, and diarrhea. Based on this

experience, Jhpiego was asked by the World Bank Malaria Booster Program to assist the National Malaria Control Program in Nigeria to train teams in seven focal states on the principles and processes of community-directed intervention as a means of delivering integrated community case management. The basic technical modules were thereby expanded to include more information on the process of establishing and sustaining community-directed interventions. Finally, the Target States High Impact Project, USAID’s MCH/Reproductive Health bilateral project, asked Jhpiego to provide technical assistance and training in rolling out community-directed interventions in the local governments in its focal states.

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INTRODUCTION

Integrated community case management (iCCM) is the provision of basic prevention, diagnosis, treatment, and counseling for common illnesses such as malaria, pneumonia, and diarrhea within and by the community itself. iCCM is implemented by training community health volunteers to provide these basic services within the community. Community-directed intervention (CDI) is an approach that enables communities to organize and direct health service delivery, including the distribution of health commodities, for the community, with the guidance of the government health service. The CDI approach was first used by the African Program for Onchocerciasis Control. When the approach was found to be successful, other programs adopted it for the delivery of other health interventions, including guinea worm control, distribution of insecticide-treated nets (ITNs), vitamin A distribution, immunization programs, and scale-up activities for the control of tuberculosis. The CDI approach gives ownership for planning and decision making about the whole service delivery process in order to achieve sustainability. This training program shows how to use a CDI approach for iCCM interventions that strengthen essential health services.

WORKSHOP OVERVIEW

Competency-Based Training Approach

Competency-based training is learning by doing. It focuses on the specific knowledge, attitudes, and skills needed to carry out a procedure or activity. The emphasis is on the learner’s acquisition of knowledge, attitudes, and skills, rather than just on learning information. Competency in the new skill or activity is assessed objectively through evaluation of the learner’s performance.

For competency-based training to be successful, the clinical skill or activity being taught must be broken down into its essential steps. Each step is then analyzed to determine the most efficient and safe way to perform and learn it. This process is called standardization. Once a procedure such as conducting a focused antenatal care visit has been standardized, competency-based learning guides and evaluation checklists can be developed to make learning the necessary steps or tasks easier and evaluating the learner’s performance more objective.

An essential component of competency-based training is coaching. The classroom or clinical facilitator first explains a skill or activity and then demonstrates it using an anatomic model or other training aid. Once the procedure has been demonstrated and discussed, the facilitator observes and interacts with learners to guide them in learning the skill or activity, monitoring their progress and helping them acquire the necessary skills.

The coaching process ensures that the learner receives feedback at various points in the learning process:

 Before practice—The facilitator and learners meet briefly before each practice session to review

the skill/activity, including the steps/tasks that will be emphasized during the session.

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 During practice—The facilitator observes, coaches, and provides feedback to the learner as s/he

performs the steps/tasks outlined in the learning guide.

 After practice—Immediately after practice, the facilitator uses the learning guide to discuss the

strengths of the learner’s performance and offer specific suggestions for improvement.

The CDI approach stresses building competency not only of individual community volunteers but of the community itself in managing its health programs. Therefore, it is important to envision learning for CDI as something that starts with the first contact health workers have with the community, through the selection and training of volunteers on to follow-up supportive supervision and community problem solving.

WORKSHOP SYLLABUS

This workshop and the related materials are intended to be used in a cascade fashion. Members of national CDI training teams can use the workshop curriculum to train regional and state trainers and facilitators, who in turn can use the materials when they conduct training for district and local government teams. Once the local training teams have learned the CDI approach, they will use the workshop curriculum to train and guide health facility staff and facility-level CDI focal persons, who can then adapt the materials for community-level training activities.

Workshop Goals

The goal of the workshop is to give CDI training teams, CDI focal persons, and community-directed distributors (CDDs) the knowledge, skills, and attitudes they need to effectively provide services at the community level using the CDI approach and to train a critical mass of lower-level implementers.

Expected Outcomes

 Action plans illustrating how the learners will strengthen essential health services using the CDI

approach (see Appendix 2: Sample Annual Action Plan)

 A strategy development document

 A cadre of core lower-level CDI implementers with the most up-to-date knowledge, skills, and

attitudes for using CDI

Learning Objectives

The learners in this workshop are CDI training teams at the national, regional/state, district, and health facility levels. Some of the modules will help the learners understand the process of setting up CDI for integrated community case management (iCCM). Other modules are geared to the technical content that they will pass on to CDDs.

By the end of the workshop, the learners will be able to: 1. Define community participation;

2. Explain the value and benefit of community involvement in health programs; 3. Identify and define community structures (e.g., kin groups, hamlets);

4. Identify the various volunteer community health agents and their roles;

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5. Describe the community social and economic factors that affect health;

6. List community resource persons who can be involved in control of malaria, pneumonia, and diarrhea;

7. Describe community-level prevention methods;

8. Demonstrate accurate diagnosing skills, drug prescription, and illness treatment; 9. Demonstrate recording and reporting skills for community data; and

10. Describe storage methods for drugs and commodities at the community level.

General Objectives for Training CDDs

After learning to organize CDI, the CDI training teams will help communities recruit CDDs for training. The trainers will then organize CDD training sessions in which they train CDDs to:

1. Mobilize their communities to use the interventions at their antenatal care clinic and other related services at their health facilities;

2. Provide information about malaria, pneumonia, and diarrhea prevention and control activities to women, men, and caregivers in their communities;

3. Conduct home visits and provide selected services during the visits;

4. Refer clients for treatment of malaria and other illnesses at the health facilities within their communities;

5. Keep records on prevention and control activities in the communities; and 6. Manage commodities supplied for use in their communities.

Training Contents

Session/

Module Topic

Registration and Pre-Test

1 Overview of iCCM Strategy through Community-Directed Intervention 2 The CDI Process

3 The Value of Community Involvement

4 Mapping Community Structure, Networks, and Organization

5 Community-Directed Interventions to Deliver Malaria Plus Packages 6 Applying CDI to Home Management of Malaria

7 CDI in LLIN Distribution and Use

8 Applying CDI to Intermittent Preventive Treatment in Pregnancy 9 Role of the CDI Focal Person

10 A Review of Effective Training Skills

11 Sample Module for CDDs on Community Case Management 12 Introduction to Health Services Supervision

13 Basic M&E Concepts for Integrated Community Case Management of Malaria

14 Supply Chain Management for CDI

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15 Roles of Local Government Area CDI Team Members 16 Rapid Diagnosis Test Training

17 Community Management of Pneumonia 18 Community Management of Diarrhea 19 Behavior Change Communication

Review/Evaluation, Post-Test, Certificates

Sample Course Schedule

Day/Time Monday Tuesday Wednesday Thursday Friday

Morning 1 ~09:00– 10:30 Introduction Modules 1 and 2 Review

Module 6 Review Module 10 Review Module 14 Review Module 18 Break

Morning 2 ~11:00– 1:00

Module 3 Module 7 Module 11 Module 15 Module 19

Lunch Afternoon 1 ~2:00– 3:30

Module 4 Module 8 Module 12 Module 16 Team work & planning meetings Break Afternoon 2 ~4:00– 5:00

Module 5 Module 9 Module 13 Module 17 Closing

Training/Learning Methods and Materials

Learning Methods

The following learning methods are used for this workshop:

 Illustrated lectures

 Large and small group discussions  Case studies

 Role plays  Group activities

Learning Materials

The following workshop learning materials are used along with this guide:

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 National guidelines for integrated community case management, if available

 Modules, in the form of PowerPoint presentations, which should be adapted to the country

setting (available on the Jhpiego website, at http://www.jhpiego.org/en/content/training-program-community-directed-intervention-cdi-improve-access-essential-health-service)

 Handouts the facilitators can make from the PowerPoint slide modules after they have adapted

the slides

 Sample materials for demonstration and practice exercises

 Materials, including long-lasting insecticide-treated nets (LLINs) and insecticide-treated nets (ITNs) and hanging kits; rapid diagnostic tests; bowls, bottles, spoons for oral rehydration solution (ORS); soap for hand washing

 Samples of medicines such as artemisinin-based combination therapies (ACTs) in different age packs, ORS packets, amoxicillin/cotrimoxazole

WORKSHOP LOGISTICS

Learner Selection

Training Teams and Focal Persons

State/regional training teams should be interdisciplinary, involving staff from maternal health, child health, malaria control and other health agencies, pharmacy, monitoring and evaluation, and other relevant sections of ministries of health. The teams can also include representatives of

nongovernmental organizations and donor agencies. Teams may consist of 10–15 people. Later they will divide up the districts in their area and provide training on a rotational basis at that level. District CDI teams also should reflect the multiple disciplines involved in running an iCCM

intervention. District teams are responsible for training staff from the health facilities in their areas. The training team initially trains most or all of the staff on the technical updates needed to manage health issues covered under iCCM. After this general training, the team may ask facilities to

nominate one or two staff members for additional training to serve as CDI focal persons and be responsible for rolling out CDI in their surrounding communities.

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CDDs

CDDs are selected by their communities. Communities should be encouraged to develop selection criteria that will ensure that they select people they can rely on and respect. Communities might consider factors such as age, gender mix, duration of residence, ability to read and write in the local language, quality of character (e.g., trustworthiness), and other issues.

Communities should select the number of CDDs that will meet their needs. For example, they may decide that they need a female CDD to deliver malaria in pregnancy interventions or child illness case management, while a male could distribute bed nets or other supplies. If training is held close to the villages where CDDs live, the costs of training will be similar, regardless of the number of CDDs trained.

The workshop curriculum is designed to ensure that CDI focal persons guide CDDs in the implementation of their community tasks.

Workshop Duration

 Five to seven days of training will be needed for the training teams at various levels, including

the CDI focal persons. The training can be divided into a CDI organizational workshop and an iCCM technical update workshop, if this makes the training more convenient for the learners.

 CDD training can be spread out over time for the convenience of both trainers and CDDs (e.g.,

by offering a series of CDD training sessions at weekly markets).

Suggested CDI Team Workshop Composition

 20–25 learners  2–4 facilitators

 Depending on the number of districts in a region or facilities in a district, the training team may

need to hold more than one workshop to accommodate all learners. Larger workshops provide less opportunity for trainee participation.

ROLES OF COMMUNITY PARTNERS AND OTHER STAKEHOLDERS IN SUPPORTING CDDs

The community partners and stakeholders for iCCM using a CDI approach include

community-based organizations, faith-community-based organizations, civil society organizations (CSOs), and other

nongovernmental organizations and agencies operating at the community level. These

organizations and agencies have important roles to play in community prevention and

management of malaria. Their activities may be coordinated by the national association of civil

society organizations, which may have membership on the country’s Country Coordinating

Mechanism (a body that helps prepare proposals for the Global Fund to Fight AIDS,

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Tuberculosis and Malaria). There may also be CSO coordinating bodies at the state/regional and

district levels that could be engaged to help roll out CDI for iCCM.

Roles of Community Partners

• Participating in establishing and facilitating community-based health development committees in support of the CDDs

• Encouraging community ownership of iCCM

• Creating awareness by sensitizing communities to the rationale and implementation process of the iCCM strategy

• Ensuring that CDDs carry out iCCM in accordance with national guidelines

• Ensuring that CDDs prepare good quality data with approved data capture tools and submit it to the health facilities

• Designing behavior change communication (BCC) materials (or adapting existing materials) with the input of the communities

• TrainingCDDs on follow-up and referral services

• Networking with other CSOs in the community or LGA to strengthen the iCCM strategy

• Identifying barriers to the implementation of iCCM and sharing them with the community to proffer solutions

Roles of the Local Government (District)

• Distribute and disseminate to the village health committee and health facilities a strategy document for implementation of iCCM

• Advocate for support and ownership of the program to traditional and religious leaders

• Using the supervisory checklist, conduct on-the-job supportive supervision of CDDs

• Coordinate all activities related to implementation of iCCM, including activities of CSOs in the LGA

• Report to the ministry of health on the implementation of iCCM

• Ensure sustained availability of commodities for communities and health facilities

• Monitor training and supply of commodities for CDDs

• Ensure proper storage of commodities supplied

Roles of the State/Regional Ministry

• Distribute and disseminate to LGAs and health facilities a strategy document for implementation of iCCM

• Adopt for implementation the national strategy document for iCCM

• Advocate for support and ownership of the program by policymakers

• Using the supervisory checklist, conduct on-the-job supportive supervision of CDDs

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• Coordinate all activities related to implementation of iCCM, including activities of CSOs in the state

• Report to district, regional, and national health authorities, including specific programs (e.g., malaria, child health), as appropriate

• Ensure sustained availability of commodities for LGAs and health facilities

• Monitor training and supply of commodities for CDDs

• Ensure quality assurance of commodities supplied

• Write terms of reference for the facilitation team at the LGAs

Role of the National Malaria Control Program

• Advocate for support and ownership of the program by policymakers

• Develop and print strategy document for implementation

• Distribute and disseminate strategy document for implementation

• Coordinate all activities related to implementation of iCCM, including review of policies to support implementation

• Using the supervisory checklist, conduct on-the-job supportive supervision

• Ensure sustained availability of commodities to states and LGAs

• Monitor training of CDDs and health workers

• Monitor supply and distribution of commodities to states and LGAs

• Ensure quality assurance of commodities supplied

HOW TO USE THIS GUIDE

This training guide should be used in conjunction with the 19 training modules that comprise the CDI training curriculum. The modules may be downloaded from the Jhpiego website at:

http://www.jhpiego.org/en/content/training-program-community-directed-intervention-cdi-improve-access-essential-health-service

The curriculum was created for use in a five- to six-day workshop. The 19 sections in this guide give facilitators guidance and instructions for planning and conducting each of the workshop modules. Before facilitating a CDI workshop, we recommend that facilitators read through the PowerPoint presentation for each module. The modules may be adapted to the local/national context, as needed.

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MODULE 1: OVERVIEW OF iCCM STRATEGY THROUGH

COMMUNITY-DIRECTED INTERVENTION

SESSION/Module TOPIC TIME

1 Overview of iCCM strategy through

community-directed intervention 45 minutes SESSION OBJECTIVES

By the end of this module, learners will:

• Get to know each other

• List the workshop and learning objectives, course schedule, and materials

 List expected outcomes of the workshop

 Identify skills they wish to share with others

 Decide on the workshop norms

METHODS AND ACTIVITIES MATERIALS/RESOURCES

Illustrated presentation/discussions: Course overview Be sure to cover all of the following topics:

• Background and purpose of the workshop

• Introduction of learners

• Learners’ expectations

• Course structure and modules

• Session, workshop, and learning objectives

• Target audience for the course

• Workshop materials

• Workshop norms

• Learner certification

• Workshop outcomes (strategy development document and action plan)

• Workshop outlines

• Reasons for using a CDI approach for iCCM

• High-impact malaria interventions

• Template for action plan (see Appendix 2) Summarizekey points

• Multimedia equipment

• PowerPoint presentation

• Course introduction

• Flip chart board and papers

• Markers

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MODULE 2: THE CDI PROCESS

Module/ SESSION

TOPIC

TIME

2

The CDI process

60 minutes

SESSION OBJECTIVES

 Define the CDI approach

 Describe program coverage benefits of using CDI

 Outline the steps to establish CDI

 List key approaches in gaining community commitment for a CDI program

 Describe the steps in selecting and training community distributors

 Explain how CDI can be adapted for use in controlling malaria

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Community-directed

interventions and key steps

Role play: Divide the class into four or five groups. Each group will

perform a role play about approaching a community to introduce a

CDI program for malaria control:

• The first and second groups will perform a role play about

the first meeting with the community gatekeepers.

• The third and fourth groups will perform a role play about

holding the second community meeting.

Be sure to cover all of the following topics:

• What is community-directed intervention?

• CDI and onchocerciasis

• Benefits of CDI

• Expanding beyond ivermectin

• Lessons learned in a CDI approach

• Start-up components of a CDI approach

• Approaching the health service

• Roles for the health service

• Training health care providers for their roles

• Approaching the community

• Roles for the community

• Discussing and gaining commitment to community roles

• Training community distributors

• Major interventions for malaria in pregnancy

• Delivery of community health education on malaria

Summarize key points

• Multimedia

equipment

• PowerPoint

presentation

• Flip chart board and

papers

• Markers

• Role play instructions

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MODULE 3: THE VALUE OF COMMUNITY INVOLVEMENT

SESSION/ Module

TOPIC

TIME

3 The value of community involvement and

its role in community and home

management of malaria

45 minutes

SESSION OBJECTIVES

 Identify and define community structures

 Define community participation

 Explain the value and benefit of community participation and involvement in health programs

 Identify the various volunteer community health agents and their roles

 Describe the community social and economic factors that affect health

 List community resource people who can be involved in malaria control

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: The value of community

involvement: Roles in home management of malaria

Be sure to cover all of the following topics:

• Module objectives

• Definition of community

• Why community involvement is important (brainstorm)

• What constitutes a participatory approach

• Community role in participation

• Examples of community participation

• Community problem-solving

• Rationale and scientific basis for home management of

malaria

• Community involvement and access gaps

• Community management and agents

• Factors that affect malaria control

• What communities can do

• Local resources to support program implementation

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

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MODULE 4: MAPPING COMMUNITY STRUCTURE, NETWORKS, AND

ORGANIZATION

SESSION/Module

TOPIC

TIME

4 Community structure, networks, and

organization

60 minutes

SESSION OBJECTIVES

 State the definition of community used in “to roll out community-directed interventions”

 Describe the purpose of community mapping in building support and solving problems

 Explain the value of involving community members in mapping their own community

 List the steps and activities needed to map the organizations and resources in a community

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Community structure,

networks, organization, mapping, and headcounts

Be sure to cover all of the following topics:

• Community mapping

• Components of mapping

• Resource and social mapping

• Why social mapping is important

• Using social mapping information

• Factors that influence what community looks like

• Rural and urban communities

• Charting the mapping results

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

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MODULE 5: COMMUNITY-DIRECTED INTERVENTIONS TO DELIVER

MALARIA PLUS PACKAGES

SESSION/Module

TOPIC

TIME

5 Using CDI to deliver Malaria Plus

Packages

90 minutes

SESSION OBJECTIVES

By the end of this module, learners will

:

• Name the components of a Malaria Plus Package

• Describe key household and community practices that affect child growth promotion

and development

• List steps and activities for disease prevention at the home/community to reduce

illnesses and deaths

• Explain home management of malaria-related diseases such as diarrhea, chest infection,

malnutrition, and anemia

• List activities to promote care-seeking and compliance with healthy practices

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Using CDI to deliver

Malaria Plus Packages

Be sure to cover all of the following topics:

• Session objective

• Background and purpose

• Why Malaria Plus Packages?

• Household and community practices

• Growth promotion and development

• Disease prevention

• Prompt and appropriate home management of

illnesses

• Care seeking and compliance

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

• CDD kits

• Community counseling

card

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MODULE 6: APPLYING CDI TO HOME MANAGEMENT OF MALARIA

SESSION/Module

TOPIC

TIME

6 Applying CDI to home management of

malaria

80 minutes

SESSION OBJECTIVES

 Outline the three components of malaria case management

 Describe the processes of case management with children and with pregnant women

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Home management of

malaria

Small group work: Use of case studies

Practice session: Basic management of cases and referral

Be sure to cover all of the following topics:

• Session objective

• Essential components of malaria case management

• Diagnosis of malaria and benefits

o

Rapid diagnostic test kits

o

Microscopy

• Types of malaria

• Recognizing malaria in pregnant women

o

Uncomplicated malaria

o

Severe malaria

• Treatment of malaria

o

Malaria in pregnancy

o

Malaria in children

• What to do when convulsions occur

• Referral

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

• Rapid diagnostic test kits

• ACTs

• Community counseling

card

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MODULE 7: CDI IN LLIN DISTRIBUTION AND USE

SESSION

TOPIC

TIME

7 Applying CDI to the distribution and use

of LLINs

60 minutes

SESSION OBJECTIVES

• Explain how to obtain and safely maintain stocks of LLINs

• Estimate LLIN needs based on community census

• Discuss the need to educate community members on the importance of sleeping under LLINs every night (especially children and pregnant women)

• Discuss the need to encourage pregnant women to collect and use LLINs as soon as they realize they are pregnant

• Outline the process of teaching community members how to use the nets

• Outline follow-up procedures for facility staff and CDDs to encourage continued LLIN use

• Discuss the importance of making sure that all women of reproductive age have and use an LLIN so that they will be protected at the beginning of their next pregnancy

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussion: Supplies, storage, and

distribution of LLINs/ITNs at the community level

Demonstration: Demonstrate hanging a net over a sleeping

area, and allow learners to practice net hanging

Be sure to cover all of the following topics:

• Obtaining and safely maintaining stocks of ITNs based

on community census estimates

• Educating community members on hanging nets and

use of nets

• Educating community members on the value of nets

• What information on causes of malaria to share

• Benefits of ITNs and net maintenance

• Comparison of treated and untreated nets

• Encouraging net use early in pregnancy

• Making home visits

• Ensuring net use

• Other ways to prevent malaria

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

• A bed and mattress

• An ITN

• Net hangers/ropes

• Nails and hammers

• Nail removers

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MODULE 8: APPLYING CDI TO INTERMITTENT PREVENTIVE TREATMENT

IN PREGNANCY

SESSION/Module

TOPIC

TIME

8 Applying CDI to IPTp

90 minutes

SESSION OBJECTIVES

 State their country’s specific malaria data

 Identify IPTp special target groups

 Describe the basis for IPTp and the use of SP for IPTp

 State the difference between chemoprophylaxis and IPTp

 Decide who should be given IPTp

 Decide who should not be given IPTp

 Describe how to give IPTp

 Describe the benefits of IPTp

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Malaria control during

pregnancy

Role play: Demonstrate the steps in giving IPTp

Practice session: Learners practice administering IPTp in a role play

Be sure to cover all of the following topics:

• Session objective

• Overview of malaria illness in Nigeria

• Why is malaria education important during pregnancy?

• Special target groups for control of malaria in pregnancy

• World Health Organization’s IPTp recommendation

• The use of SP for IPTp

• The difference between chemoprophylaxis and IPTp

• Delivering IPTp through CDI

• Deciding who should receive IPTp

• Deciding who should not receive IPTp

• How to give IPTp

• Benefits of IPTp

• Health education on IPTp

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

• CDD kits

• Doses of SP

• Clean water and cups

• Community counseling

card

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MODULE 9: ROLE OF THE CDI FOCAL PERSON

9 Role of CDI focal person 90 minutes

SESSION OBJECTIVES

• Determine who is a CDI focal person

• Describe the role of the CDI focal person

• Explain how the health facility as a whole supports the CDI focal person and CDI activities

Illustrated presentation/discussions: Role of a CDI focal person

Small group discussion: Why do we need a CDI

focal person?

Practice session: List the duties of a CDI focal person

Be sure to cover all of the following topics:

• Session objective

• Why do we need a CDI focal person?

• Who is a CDI focal person?

• Key duties of a CDI focal person

• Mobilizing the community

• Training the CDDs

• Supervising preparation

• Supervising CDDs

• Coordinating supplies

• Coordinating partners

• Monitoring and evaluation

• Role of health facility

Summarize key points

• PowerPoint presentation/handouts

• Markers

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MODULE 10: A REVIEW OF EFFECTIVE TRAINING SKILLS

10 Review of effective training skills 90 minutes

 List principles and approaches of adult education for training health workers

 Describe a conducive learning environment that enables active skills practice and learning

 Identify locally appropriate learning aids

 Provide examples of training methods and experiences that are interactive

 Explain the need to monitor, evaluate, and revise training

Illustrated presentation/discussions: Effective training skills

Brainstorming session: How can we make the environment conducive to learning and enable active skills practice?

Questions and answers

Practice session: If time permits, allow learners to develop training topics and present/facilitate individually for 5 minutes.

• Time to practice

• Components of effective training

• Foundations for educating health providers

• How to develop objectives for learning

• Planning for teaching

• Preparing the learning environment

• Preparing and using teaching aids

• Using locally available materials

• Delivering an interactive session

• How to facilitate group learning

• Monitoring and revising instructions

• How to facilitate the development of health care delivery skills

• Managing clinical practice

• How to prepare and use knowledge assessments

• PowerPoint

presentation/handouts

• Markers

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MODULE 11: SAMPLE CDD MODULE ON COMMUNITY CASE

MANAGEMENT

11 Sample CDD module on community case

management 2 hours

 List the basic local resources needed to carry out CDD training

 Describe the basic malaria content that is appropriate for community-level volunteers

 Outline training methods that are appropriate for community volunteers

 Explain how community volunteer training can be evaluated

Illustrated presentation/discussions: Sample CDD module on community case management

Role play: Counseling on drug adherence and adverse reactions; compose songs to reinforce learning

Practice session: Checking for actual body temperature, pallor of conjunctiva, finger nail beds, sunken fontanel, and other signs of dehydration

• Overview of session on community case management for CDDs

• Objectives for training session on malaria case management for CDDs

• How to recognize malaria

• How to check for fever

• The need for rapid diagnostic test

• Malaria treatment and appropriate antimalarial medicines, including dosage and regimen

• Treatment scenarios (use case studies)

• Counseling for treatment using drug pack and job aids

• Recordkeeping and reporting

• Follow-up activities to ensure drug adherence

• Referral and practical tips to ensure effective referral

• Evaluation of the session

• PowerPoint

• Flip chart board and

papers/chalk and chalkboard

• Markers

• Samples of appropriate antimalarial medicines

• Treatment recording forms

• Job aids

• Information, education, and communication materials (e.g., counseling card)

• Quiet, well-ventilated room near the community

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MODULE 12: INTRODUCTION TO HEALTH SERVICES SUPERVISION

12 Introduction to health services supervision 90 minutes

 Differentiate between traditional and supportive supervision

 Define supervision

 Describe who is a supervisor and the supervisor’s responsibilities

 Describe the skills and personal characteristics expected of a supervisor

 Define desired standard performance

 State the relationship between training and supervision

 Describe the use of checklists during supervision and assessment for quality improvement (see Appendix 1: Sample Performance Checklist)

 Describe the process of root cause analysis and selection of problem-solving interventions

Illustrated presentation/discussions: Introduction to health services supervision

Brainstorm: Discuss who is a traditional and supportive supervisor

Question and answers: In your own words, what do you understand by supervision?

Practice session: Use of supervision checklist (see Appendix 1: Sample Performance Checklist)

• Traditional versus supportive supervision

• Supervision

• The two levels of CDI supervision

• Who is a supervisor?

• Internal versus external supervision

• Responsibilities of a supervisor

• Skills required for supportive supervision

• Supervisors’ personal characteristics

• Role of supervision for quality improvement of performance standards

• Performance improvement framework

• Desired performance (using the framework to discuss)

• Relationship between training and supervision

• How to assess performance

• Supervisory tools (show example of checklist and how to use it)

• PowerPoint

• Markers

• Supervision checklists

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• How to conduct root cause analysis to identify performance gaps

• How to select appropriate intervention(s) to address identified performance gaps

• Monitoring and evaluation

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MODULE 13: BASIC M&E CONCEPTS FOR INTEGRATED COMMUNITY CASE

MANAGEMENT OF MALARIA

SESSION/Module

TOPIC

TIME

13 Basic monitoring and evaluation concepts

for integrated community case management

of malaria

2 hours

SESSION OBJECTIVES

• Describe participatory monitoring and evaluation (PME)

• State the roles of beneficiaries in PME

• Define a community-based information system and state why it is important

• Explain the meaning of recordkeeping and state why it is important

• Describe reporting and state why it is important

•

Define basic monitoring and evaluation (M&E) concepts and state the differences between

monitoring and evaluation

• State why M&E is important in programming

• Differentiate between data and information

• Describe data and identify qualities of good data

• Identify sources of data

• Demonstrate how to fill out the register for home management of malaria and the referral

form

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrative exercises: On feedback mechanism

Illustrated presentation/discussion

Be sure to cover all of the following topics:

• Differences between monitoring and evaluation using the

when

,

what

,

who

, and

how

approach

• Why monitoring and evaluation are important in programming

• Things that can be monitored and things that can be evaluated

• The meaning of key M&E questions

• Requirements for institutionalizing M&E

• The PME approach

• Principles of PME and its role in CDI

• PME methods and tools

• Types and levels of indicators

• Community-based management information systems and

different types of information that can be generated at

community level

• Multimedia

equipment

• PowerPoint

presentation

• Flip chart board and

papers

• Markers

• Home management

of

malaria/community

daily case register

• Summary forms

• Referral forms

• Exercises and

assignment

materials

27

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• Different actors and their differing information needs at the

community level

• Recordkeeping and reporting: why they are important

• Requirements for setting up a user-friendly recordkeeping

system

• What is data?

• The difference between data and information

• Sources of data

Summarize Key Points

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MODULE 14: SUPPLY CHAIN MANAGEMENT FOR CDI

SESSION

TOPIC

TIME

14 Supply chain management for CDI

50 minutes

SESSION OBJECTIVES

 Describe the process of antimalarial drug procurement and storage

 Explain how to estimate their community’s commodity needs

 Outline the stock recording method and reporting format

 Describe the distribution process for antimalarial medicines and other malaria commodities (e.g., long-lasting insecticide-treated nets and rapid diagnostic tests)

 State how to monitor and report adverse drug reactions

 Discuss the role of patent medicine vendors in malaria commodity management

METHODS AND ACTIVITIES

MATERIALS/RESOURCES

Illustrated presentation/discussions: Supply chain

management for CDI

Be sure to cover all of the following topics:

• Session objective

• Forecasting and estimation of antimalarial commodities

• Procurement and supply

• LGA/district supply chain

• Introduction of forms to account for antimalarial drugs

• The distribution process

• Maintaining stocks and storage facility

• Community preparation

• Monitoring of medicine safety

Summarize key points

• Multimedia equipment

• PowerPoint presentation

• Flip chart board and

papers

• Markers

• CDD kits

• Community counseling

card

29

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MODULE 15: ROLES OF LOCAL GOVERNMENT AREA CDI TEAM MEMBERS

15 Roles of local government area CDI team

members 90 minutes

 Describe LGA/district core team members and their roles

 Explain division of labor among various core team members

 Define a program coordinator and a facilitator (who they are and what they do)

 Describe components of an action plan and the process for developing action plans (see Appendix 2)

Illustrated presentation/discussions: Role of local government areas

Small group discussion: Divide into groups and

discuss the following:

• Tasks for program coordinator

• Tasks for BCC and mobilization

• Procurement, logistics, or supplies office

• Facilitator

• M&E

• Identification of people who could constitute state/LGA/municipal core teams

• Training for state/LGA/municipal core teams

• How to involve all trained LGA/district members

• Division of labor among team members

• The coordinator’s tasks

• Tasks for BCC and mobilization

• Tasks for procurement, logistics, and supplies

• The facilitator’s tasks

• Tasks for M&E and documentation

• How to develop action plan using the sample template (see Appendix 2)

• Markers

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MODULE 16: RAPID DIAGNOSTIC TEST TRAINING

16 Use of rapid diagnostic tests (RDTs) as a component of home

management of malaria 2.5 hours

 Explain why the malaria control program has elected to use RDTs in the country/district

 Describe an RDT

 Name appropriate actions for positive, negative, and invalid RDT results

 Describe the steps in performing a malaria RDT



Demonstrate the correct and appropriate skills for drawing blood safely and effectively with

a finger prick



State the universal precautions



Correctly interpret different RDT outcomes



Demonstrate the skills for performing RDT safely and effectively, using the job aid as a

guide



State appropriate treatment based on RDT results

Illustrated presentation/discussions

Practice session: Divide the class into groups and ask each group to perform a rapid diagnostic test. Each member of the group will conduct the test on a colleague. This continues until each group member has practiced use of RDTs.

Demonstration and return demonstration: Trainer

demonstrates malaria diagnosis using RDTs;learners pair up and take turns conducting RDT tests on one another Be sure to cover all of the following topics:

• Background and purpose

• The overall steps for CDDs

• RDT materials and the purpose for each item

• The role of desiccant, how to dispose of it, and why

• The test cassette and functions of its parts

• Proper identification of clients

• Use of hand gloves, and universal precautions

• Blood collection devices and procedure:

 Capillary tube  Straw  Loop • Multimedia equipment • PowerPoint presentation/handouts

• Markers

• RDT job aids

• RDT test kit: one RDT kit for each learner (the RDT kit usually contains a new and unopened alcohol swab, a new and unopened blood lancet, and a buffer)

• A wrist watch or clock

• A new pair of hand gloves

• A pencil

• A sharps disposal container

• A non-sharps disposal bin

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 Pipette

 Other

• Method of disposal of used materials, including sharps and non-sharps

• RDT results and interpretations:

 Positive

 Negative

 Invalid

• Basic issues in the use of RDTs Summarize key points

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MODULE 17: COMMUNITY MANAGEMENT OF PNEUMONIA

17 Community management of pneumonia 90 minutes

 Describe the global burden of pneumonia and reasons it cannot be neglected

 Describe the signs and symptoms of pneumonia and its relationship to other acute respiratory infections

 Define pneumonia

 Describe methods for prevention and treatment of pneumonia

Illustrated presentation/discussions: Community

management of pneumonia

Small group discussion: Why we cannot ignore

pneumonia in efforts to control malaria

Practice session: Steps for examining chest in-drawing, cough, fast breathing, and timing; and referral

 Session objective

 Why we cannot ignore pneumonia in efforts to control malaria

 The relationship between pneumonia and other acute respiratory infections

 Global/annual pneumonia burden

 Classifications of pneumonia

 Recognition of pneumonia

 Signs and symptoms of pneumonia

 Causes and prevention of pneumonia

 Appropriate examination techniques for chest in-drawing, cough, fast breathing, and timing

 Treatment of mild pneumonia (antibiotics)

 Preventing HIV in children

 Identification of danger signs and when to refer

• Markers

• Community counseling cards

• CDD kit

• Antibiotics (Cotri tablets)

• Basin

• Methylated spirits

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MODULE 18: COMMUNITY MANAGEMENT OF DIARRHEA

Session/Module TOPIC TIME

18 Community management of diarrhea 45 minutes

 State the burden of diarrheal illnesses

 Define types of diarrheal diseases

 Describe steps in recognizing and classifying diarrhea

 List causes of diarrhea and ways to prevent diarrhea

 Describe management of diarrhea

Illustrated presentation/discussions: Applying CDI to management of diarrhea

Small group discussion: Why we cannot ignore diarrhea in efforts to control malaria

Practice session 1: Appropriate handwashing and air drying; preparation of oral rehydration solution Practice session 2: Steps in conducting examination for sunken eyes and fontanel, inelastic skin, and other signs of dehydration

• Why we cannot ignore diarrhea in efforts to control malaria

• Global/annual diarrhea burden

• The classifications of diarrhea

• Recognition of diarrhea

• Signs and symptoms of diarrhea

• Causes and prevention of diarrhea

• Appropriate handwashing and drying process

• Breastfeeding and proper nutrition for infants

• Treatment of diarrhea (ORS preparation and zinc requirement)

• Danger signs of dehydration and when to refer Summarize key points

• Markers

• CDD kit

• ORS sachets

• Soap for handwashing

• Provision for running water (container with tap)

• Basin

• Methylated spirits

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MODULE 19: BEHAVIOR CHANGE COMMUNICATION

Session/Module TOPIC TIME

19 Behavior change communication 45 minutes

At the end of this session, learners will be able to:

 Define behavior change communication

 Differentiate between BCC and information, communication, and education (IEC)

 Identify reasons why people change or do not change behavior easily

 Discuss basic issues and concepts in BCC

 State key BCC-centered messages to promote acceptance of iCCM by policymakers, frontline health care providers, and community members

 Identify basic methods of communicating BCC-centered messages to target audience

Illustrated presentation/discussions: Behavior change communication

Small group discussion: How people can avoid getting malaria and why they are not behaving in those ways Practice session 1: Songs to promote the use of malaria commodities

Practice session 2: Telling stories to facilitate understanding of dangers of malaria

• Basic BCC concepts, messages, and methods

• Reasons people do not change behaviors

• Definition of IEC

• Definition of BCC

• The difference between IEC and BCC

• The role of BCC in malaria prevention and control

• How to differentiate between common fever causes

• The role of RDTs and acceptability among providers and community members

• Why RDT is elected for malaria treatment

• The use of visual aids, community counseling cards, songs, and storytelling in BCC

• Markers

• CDD kits

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EVALUATION

Several evaluation mechanisms can be used with this training program. Here we review evaluation activities and offer a sample pre-/post-test of simple knowledge items. We also identify some tools that can be used to assess satisfaction and learning during the workshop.

Overview of Evaluation

Community-directed intervention includes a coaching process to ensure that learners receive feedback regarding their performance. Coaching can be provided at the following times and in the following ways:

 Before training/practice: The facilitator administers questions to learners before the

training/practice session to review the knowledge and skill/activity, including the steps/tasks that will be emphasized during the session.

 During training/practice: The facilitator observes, asks questions included in the slides or developed ahead of the session, and provides feedback to the learner as s/he performs the steps/tasks outlined in the learning guide.

 After training: Immediately after training/practice, the facilitator uses the learning guide/ set of questions to discuss the strengths of the learner’s performance and offer specific suggestions for improvement.

 Follow-up: Facilitators follow up learners with a checklist to measure their performance as they move out to the field to practice. Follow-up visits can be made every two to three months or as learners come to the facility to replenish stocks. A sample checklist is included in Appendix 1.

 Learners assess facilitators: At the end of the training, learners use questionnaires to provide feedback to the facilitators on their performance.

EVALUATION METHODS AND ACTIVITIES EVALUATION MATERIALS/RESOURCES To accomplish the set objectives, the following

methods of evaluation are suggested:

• Use of pre- and post-test questions to assess knowledge, skills, and competence before and after training/practice

• Use of questions and answers during training and practice sessions to provide feedback

• Use of questionnaires to assess facilitators’ performance and organization and to provide feedback

• Use of checklists to assess performance standard such as retention of knowledge and skills. Each level of assessment is used to provide feedback to ensure that learners improve at the next level.

• Pre- and post-test questionnaires

• Checklists

• Questionnaire to assess

facilitators/organization of the training

• Sample questionnaires and checklists are included in the module(s)

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Post-Training Follow-up and Action

Post-Training Tasks for CDI Team Members

1. Establish an iCCM commodity stocking system in the district/facility. 2. Map the villages in the facility catchment areas.

3. Conduct outreach to villages to explain CDI and facilitate selection of CDDs. 4. Help villages/communities conduct a census for commodity estimation. 5. Organize CDD training that is accessible and convenient for all.

6. Set up a monitoring and evaluation system to guarantee smooth and accurate data flow and reporting from village to facility to district.

7. Organize regular CDD meetings at the health facility for continuing education, reporting, and restocking.

8. Conduct village supportive supervision meetings.

Post-Training Jobs/Tasks for CDDs

1. Conduct home visits and referrals

a. Identify and visit pregnant women and encourage them to register for and attend antenatal care and to deliver at the facility.

b. Encourage women who have delivered outside of the health facility to go to the postnatal clinic so that they and their babies can receive proper care (ask their reasons for delivering outside the facility and report the reasons to the focal person).

c. Check to see if child immunization records are up-to-date and encourage families to receive immunizations.

2. Provide home-based services

a. Distribute ITNs/LLINs, assist household members with hanging bed nets and/or ensure that they have hung the nets correctly, and ensure that they know to sleep under the nets every night.

b. Provide intermittent preventive treatment (IPTp) doses to pregnant women starting at 16 weeks.

c. Ask family members about current illnesses.

d. Administer rapid diagnostic tests (RDTs) for people who complain of fever.

e. Treat people with positive RDTs with artemisinin-based combination therapy (ACT).

A Training Program in Community- Directed Intervention to Improve Access to Essential Health Services. Training Guide