CHAPTER 1: TRAINING OBJECTIVES

Exactly what the training includes, how it is done, and how long it takes will differ from one facility to another. These things will depend on the number and type of participants and the resources and capabilities of the facility. However, the training should always accomplish the two basic purposes:

• to train physicians and other health workers to manage cases of diarrhoea properly, and
• to prepare participants to practice improved case management in their own facilities or private practices.

This chapter provides objectives for training at a health centre or small hospital that will accomplish these purposes. What Are Characteristics Of Good Training?

Good training teaches needed skills and knowledge in a positive and supportive way. Specifically, it is: Performance based

• Skills and knowledge that will help participants to perform their jobs better are the focus of the training. The instructor relates what he is teaching to the work the participants will be doing.

Active

• Participants have an active role in the learning, so that they understand and remember more than if they just listened or read. They ask and answer questions, have discussions, write plans, explain something, give a demonstration and do role plays. As much as possible, they practice the new skills in a situation that is similar to their work situation.

Individualized

• Each participant is able to ask questions and get explanations, demonstrations and coaching to the extent needed to learn the skill. The training schedule and methods are flexible to allow for differences in the ways participants learn.

Well organized

• Careful planning and administrative support enable the training to be done smoothly. Participants and instructors know what to do when, and have the space and supplies needed. There are few administrative problems to cause delay and little confusion to distract participants.

Positive

• The instructor demonstrates pride, confidence and commitment to what he is teaching. He shows that he cares if the participants learn.

Training Objectives For Increased Understanding Of Diarrhoea And Case Management

Each participant will receive information to increase his or her understanding of diarrhoea, its management, and related issues through different methods such as written instructions, presentations, first hand experience, talking with staff, and reference articles. On completion of the training, participants will be able to answer basic questions about the following topics:

• Principles of Clinical Management of Acute Diarrhoea
• Diarrhoeal dehydration
• How ORT works
  • Formulation of ORS solution
  • Effectiveness of ORS solution
• Convincing mothers to use ORT
• Advantages of ORT over IV therapy
• Reasons for failure of ORT
• Home fluids to prevent dehydration
• Feeding during and after diarrhoea
• Antimicrobials and other drugs
• Management of Diarrhoea
• Assessment of the patient and degree of dehydration
• Early home treatment of diarrhoea to prevent dehydration (Treatment Plan A)
• Treatment of some dehydration using ORS solution (Treatment Plan B)
• Treatment of severe dehydration using IV therapy (Treatment Plan C)
• Associated conditions
• Other problems
• Treatment of dysentery, cholera, and persistent diarrhoea
• Epidemiology and Etiology of Diarrhoea
• Mode of transmission
• Risk factors for acute diarrhoea
• Relationship of malnutrition and diarrhoea
• Risk factors for persistent diarrhoea
• Seasonality
• Invasive diarrhoea and secretory diarrhoea
• Etiologic agents
• Other causes of diarrhoea
• Prevention of Diarrhoea
• Breast-feeding
• Improved weaning practices
• Use of plenty of clean water
• Handwashing and use of latrines
• Proper disposal of stools of young children
• Measles immunization

Training Objectives For Development Of Skills In Case Management

During the training, each participant will develop the following skills by practicing them under the supervision of the instructor and other staff:

Assessment

1. Assess diarrhoea cases to:
   
   a) determine extent of dehydration,
   b) identify other problems (e.g., dysentery, persistent diarrhoea, severe malnutrition, fever) that require treatment or referral.
   
2. Select an appropriate treatment plan for preventing or treating dehydration.
3. Determine if treatment or referral is needed for other problems.

Treatment of Non-dehydrated Cases (Treatment Plan A)

4. Teach each mother management of diarrhoea at home (fluids, food and signs that indicate a child should be brought to a health worker).

Note: If it is the policy to give ORS packets to mothers of children who do not have signs of dehydration, participants should demonstrate and teach mothers how to mix and administer ORS solution.

Treatment of Cases with Some Dehydration (Treatment Plan B)

5. 5. Treat cases:
   
   a) Examine patient, determine amount of ORS solution to be given in first 4 hours.

   b) Discuss findings and recommendations for treatment with the instructor.

   c) Begin administering ORS solution and teach mother to administer the ORS solution.

   d) Encourage the mother to continue breast-feeding.

   e) Monitor patient's progress regularly and record findings (every 1-2 hours until patient is rehydrated; reassess after 4 hours; select Plan A, B or C to continue treatment).

   f) When there are no signs of dehydration determine amount of ORS solution to be given at home (if it is national policy to give ORS to take home) and advise the mother.
   

6. Mix oral solution by packet or in bulk volume.
7. Deal with difficulties administering ORS solution (such as vomiting).
8. Supervise mothers, nurses, and other staff giving ORS solution.
9. Encourage the mother to continue breast-feeding and to offer food to the child after 4 hours. (If possible, the facility or other family members present at the facility should be encouraged to provide food to children who remain at the facility for 4 hours or more.)
10. Before a mother leaves, teach her how to continue caring for her child at home and the signs that indicate she should bring her child back. Also explain how she can treat diarrhoea the next time it occurs.

Treatment of Severely Dehydrated Cases with IV (Optional)^*

1. 1. Assess patients with severe dehydration: a) Take history and read any medical records or notes.

   b) Examine case.

   c) Determine amount of fluid required.

   d) If there will be a delay in putting in the IV, and if the patient can drink, begin ORS solution while waiting for IV.

   e) Discuss findings and recommendations for treatment with staff.

2. Administer intravenous therapy.
3. Assess patient's progress periodically and record findings (every 1-2 hours until patient is rehydrated). When the patient can drink, also give ORS.
4. After 6 hours (infants) or 3 hours (older patients), reassess the patient and choose Plan A, B or C to continue treatment.
5. Before the child is discharged from the facility, be sure that the mother is taught how to continue caring for her child at home and the signs that indicate she should bring her child back. Also explain how she can treat diarrhoea the next time.

Treatment of Other Problems

1. If blood is present in the stool, treat with an antibiotic. Teach the mother how to feed the child and when to bring the child back. If needed after 2 days, change to another antibiotic.
2. If diarrhoea has lasted at least 14 days, refer dehydrated child or child less than 6 months to a hospital. For other children, teach the mother how to feed the child and when to bring the child back.
3. If the child has severe malnutrition, refer the child to hospital.
4. If the child is under 2 months of age: * Rehydrate as necessary. If there is fever, (38° C or above) after rehydration, refer to hospital. Do not give paracetamol or an antimalarial. If the child is 2 months of age or older: * If temperature is 39° C or above, give paracetamol.

   * If there is falciparum malaria in the area, and the child has any fever (38° C or above) or history of fever in the past 5 days, give an antimalarial (or manage according to your malaria programme recommendation).

Training Objectives For Improving Case Management During the training, participants will prepare to make improvements needed so that cases will be managed properly at their own facilities. Participants may be planning for case management at a small hospital, or a large or small health centre, depending on where they work. To prepare these plans, participants should take the following steps:^*

1. Observe how the facility where training is being done is set up to manage diarrhoea cases. Notice the activities of staff and mothers, the supplies and records.
2. Think of your own facility's operating policies, treatment procedures, equipment, staff and arrangement. Consider different possible arrangements of space and staff for assessment and treatment of diarrhoea patients. List changes needed at your own facility for improved case management. List training, additional resources (such as equipment, space, staff), changes in operating procedures, changes in attitude, etc., that will enable the needed improvements to be made.
   
   Questions that might be asked include:
   
   - Are there other staff at the facility who need to be trained?

   - Are there enough staff at the facility for the expected number of patients, or do some staff need to be reassigned?

   - Are enough supplies and equipment available?

   - Is ORT provided in a suitable area?

   - Do facility operating procedures (such as hours of operation) interfere with proper treatment?

   - Can children who stay for several hours, and their caretakers, be fed?
   

3. Sketch a floor plan for the area where diarrhoea cases will be treated.
4. List the steps that must be done to make any needed improvements, and how you will do those things, such as how you will:
   
   - Obtain the necessary supplies,

   - Train other staff in ORT techniques,

   - Rearrange the facility,

   - Inform and convince staff to follow the current recommendations for use of antibiotics for diarrhoea (i.e., only for dysentery and for suspected cholera cases with severe dehydration),

   - Overcome pressure from staff and patients to use IV therapy and unnecessary drugs.