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Diarrhoea Management Training Course: Guidelines for Conducting Clinical Training Courses at Health Centres and Small Hospitals



Chapter 1: Training Objectives
( http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/dmtc1.htm )

Chapter 2: Handling Administrative Arrangements
( http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/dmtc2.htm )

Note: the introduction and first few chapters of this guide are available here. For more information on organizing a training program, contact CHD.


Diarrhoeal diseases are a leading cause of childhood mortality and morbidity in the developing world. These deaths are caused by dehydration, dysentery, and persistent diarrhoea. Dehydration from acute diarrhoea of all etiologies and in all age groups can be treated safely and effectively by the simple method of oral rehydration therapy (ORT). ORT has made it possible to undertake a global effort to reduce deaths from dehydration and diarrhoea-associated malnutrition. Complete case management can also combat deaths from dysentery and persistent diarrhoea.*

Why Is This Training Needed?

It is essential that every country trains its health staff in proper diarrhoea case management, including the use of ORT. Diarrhoea Training Units (DTU's) have been established in a few large hospitals in many countries to provide this training. However, because DTU's are few in number and can conduct only a limited number of courses, additional training is needed to meet the needs of all health workers.

This course is designed to meet the clinical training needs of health staff who cannot feasibly be trained in DTU's, but are able to be trained in a large health centre or small hospital. Health staff who should attend include physicians, nurses, nurses' assistants, and other staff from health centres and small hospitals where diarrhoea cases of any age are managed, who want to learn about advances in treatment of diarrhoea, including use of ORT. Health staff from the facility conducting the training can attend, as well as health staff from nearby facilities.

The training has two major purposes:

  1. To Train Physicians And Other Health Workers To Manage Cases Of Diarrhoea Properly This purpose is accomplished by having participants observe proper case management and gain first hand experience treating patients. Participants also obtain relevant technical information from written instructions, short presentations, discussions with experienced staff and other participants, and reference articles.
  2. To Prepare Participants To Improve Case Management In Their Own Facilities

    This purpose is just as important as the first, but is easy to overlook. Participants may know how to manage cases properly at the facility where they are trained, but may not be able to use these procedures when they return to their own facility. Unless there is support for the procedures, participants will find it difficult to use them. Support is needed in terms of policies, physical arrangement, supplies, and skilled staff. This training helps participants prepare for this challenge. Using advice from instructors and other participants, changes are identified that will need to be made at each participant's facility so that improved diarrhoea case management can be carried out.

What Activities Will Occur During Training?

This training course will consist of:

  • Written instruction and group exercise to develop skills in case management of diarrhoea, especially oral rehydration therapy
  • Active practice sessions in the facility to gain first-hand experience in the rehydration of paediatric patients
  • Presentations to cover technical material on case management, epidemiology, etiology, and prevention of diarrhoea
  • Exercises and drills (or repeated practice) of key skills in case management
  • Individual and group work to plan how to improve case management in participants' own facilities.

What Type of Facility Can Conduct This Training?

This training can be conducted in a large health centre, district level facility, or small hospital. The facility should:

  • See at least 25 diarrhoea cases under 5 years of age during the week of the training, with at least 5 of those being dehydrated cases, so that each participant will be able to practice case management procedures during the training;
  • Have enough space for 2-8 trainees to meet together as a group, either in the same room as cases are treated or in a room near the ORT area;
  • Be located close to several other facilities with health staff who need training, since the training is suitable for staff from the facility conducting the training and from other nearby facilities;
  • Have staff who are willing and able to serve as course instructors and assistants; and
  • Have one course instructor who is dedicated and committed to improving case management and who successfully completed a DTU course, where he developed the necessary clinical skills, saw how the clinical training should be conducted, and received information on training support available from WHO.

Some facilities that conduct this course may also have 1-2 beds for giving IV therapy to severely dehydrated patients. In contrast to a DTU, the facility conducting this training should be smaller than a DTU, which is usually located in only a few large hospitals in the country and can accommodate up to 20 trainees for a full week course. Each facility that conducts diarrhoea management training will be arranged and will operate somewhat differently from others, but certain characteristics are essential.

  1. The facility may have more than one room, but diarrhoea treatment is usually provided in a one-room multipurpose assessment and treatment area, where mothers and children are seen for all sorts of illness and injury. (See the sample floor plan on page 5.)
  2. Typically, when a sick child comes to the facility, the child is first assessed and a diagnosis is made. If the child has diarrhoea and is dehydrated, he remains at the facility for ORT. Children with most other problems (e.g., acute respiratory infections, minor injuries, malaria) are either treated and sent home, or referred to another facility.
  3. Proper therapy for diarrhoea is practiced on a routine basis, so participants can see the therapy and be a part of it. a) Mothers of diarrhoea cases without signs of dehydration are educated on management of diarrhoea at home. They may practice mixing and administering ORS solution. They learn to recognize the signs that indicate the child should be brought back to the health worker. b) Mothers of dehydrated children are asked to stay with their children to give ORT and continue breast-feeding with the supervision and encouragement of staff. They are taught how to give ORS solution, continue ORT at home, feed during and after diarrhoea, and recognize the signs indicating that a child should be brought back to a health worker. c) ORT is used appropriately; IV therapy is not used when ORT would be effective. If staff are trained and supplies available, IV therapy is given when needed. As soon as the child is able to drink, ORS solution is given in addition to IV therapy.

    d) Simple benches are available for people waiting to be seen. Comfortable benches (or other seats like chairs or mats) with side tables are provided for mothers giving ORS solution. There is space for movement of health staff, patients, and mothers.

    e) Treatment is provided to diarrhoea cases with other problems, such as dysentery, which do not require admission. Antibiotics are used only as needed; antidiarrhoeal drugs are never used.

    f) Before diarrhoea cases leave the facility, staff make sure that they have attended to any other health problems or concerns.

  4. Proper administrative procedures are followed to allow the facility to operate smoothly. a) ORS solution is mixed from packets (or in larger volumes if the number of patients needing ORS solution is sufficient). b) There is adequate ventilation (e.g., fans) and access to toilet and washing facilities. c) Appropriate supplies are available in adequate quantities. The supplies are taken out of the storage area and arranged each morning so that they will be convenient to use.

Why Was This Guide Developed?

WHO realizes that health centres face many problems in trying to provide training. Hands-on training, which requires each participant to treat several patients with guidance and support from the staff, can be very effective. However, hands-on training places considerable demands on the staff and, if not organized well, can be disruptive to the normal operation of a facility.

It is also difficult to select the most important technical knowledge to teach in the limited time available for training. There are many decisions to be made about the skills to be taught, the information to be covered, the activities of the participants, schedules, operational arrangements and supplies. These decisions need to be made in the midst of other important and demanding responsibilities.

This guide was written to simplify the process of delivering this course. It recommends procedures and techniques for both planning and conducting the training. It contains all materials needed for the course, with the exception of any additional references you may wish to provide (see Annex A for list of references). Hopefully, it will reduce the time needed for course planning, and will result in a more effective training experience for all participants.

updated: 7 May, 2015