IN SERVICE MANAGEMENT COURSE FOR HEALTH ASSISTANTS TRAINING MANUAL
Item
- Title
-
IN SERVICE MANAGEMENT COURSE
FOR
HEALTH ASSISTANTS
TRAINING MANUAL - extracted text
-
a
MANAGEMENT COURSE
FOR
HEALTH ASSISTANTS
RAINING MANUAL
'A’
' Al
I
DEVELOPED BY
THE RURAL HEALTH CENTRE
JAGATSINGHPUR, CUTTACK
IN COLLABORATION WITH
THE LIVERPOOL SCHOOL OF TROPICAL MEDICINE
UNDER THE
AREA DEVELOPMENT PROGRAMME
GOVERNMENT OF ORISSA
In-service Management Course for
Health Assistants
training manual
Rural Health Centre
Jagatsinghpur
Cuttack District
Orissa
India
March 1986
Liverpool School of Tropical Medicine
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Final version edited by Tim Martineau
and designed by Barrie Jones
for The Health Assistants Course Development Group
in Jagatsinghpur
ISBN 0 9508756 5 1
1
Contents
Use of the manual 7
Course overview 8
Module 1
Introduction to the course 11
Module 2
Managing work: introduction 17
Module 3
Managing work: direct supervision 21
Module 4
Managing work: indirect supervision 27
Module 5
Managing work: training 35
Summary of managing work 45
Module 6
Managing staff 47
Module 7
Conducting sector meetings 53
Module 8
Educating and motivating target groups 59
Module 9
Projects 69
Course assessment 74
Appendix
A: Teaching techniques 79
B: Teaching materials required for the course 83
C: Reference materials 89
Foreword
The Area Development Project in Orissa is a part of a country-wide programme undertaken by the
Government of India in 45 selected districts of different states. All area projects are guided by a
model plan developed by Government of India. Following this model Government of Orissa had
identified 5 districts and worked out a five-year project which in turn was implemented in the State
since the year 1980-81. The long-term objectives of the Area Development Programme were to
reduce birth rates and infant and child mortality rates by improving the health status of the people
through extensive provision of health and nutritional care, along with other Family Welfare
services. In order to achieve these objectives, it was necessary to strengthen the available
infrastructure, and develop human resources by provision of management training to the Medical
Officers and job-oriented skills to all categories of health personnel engaged in the delivery of
Primary Health Care in the State.
Though a formal training programme for health workers was continueing in the State long before
implementation of the Area Development Programme, soon after mid-term review in the year 1983
the need of a special input in the area was felt necessary. In order to develop a suitable training
programme for Medical Officers and key health workers through the health training institutions of
the State, Government of India, British Aid Agency (ODA) and the Government of Orissa took a
joint decision for collaboration with an external agency with expertise in the field. Accordingly the
Liverpool School of Tropical Medicine (UK) was identified, and with their consultancy service,
work has been going on in the State to develop and implement training courses for Medical
Officers, Health Assistants (male and female) and Block Extension Educators. The institutions
identified for training programmes are Rural Health Centre, Jagatsinghpur and Health and Family
Welfare Training Centre, Sambalpur. While the former institution is devoted to the training of
Medical Officers and Health Assistants, the latter is solely engaged for course development and
training of Block Extension Educators.
Over the last 18 months, the courses have been implemented, evaluated, revised, modified and
improved and taught to many Medical Officers, Block Extension Educators and Health Assistants.
One of the fruitful achievements of this training programme has been the production of training
manuals for each course. These manuals are primarily intended for use by the staff of the Training
Centres for the training of the Primary Health Care Staff in Orissa. The manual for in-service
training of Health Assistants is a valuable and essential document for the training institutes as a
guide and reference manual. However, much of the material contained in this manual may be of use
to others who may recognise the need for pre-service and continuous training of field staff in
management and communications.
During the process of preparation of this manual willing help and assistance have been extended by
many institutions and individuals to whom the undersigned is grateful. Lastly, I also convey my
gratitude to Government of India, ODA and Professors and Consultants of Liverpool School of
Tropical Medicine for their support and participation in the success of this venture.
Signed
Director, Family Welfare, Orissa
6 September 1986
4
Preface
The process of developing management courses for both Medical Officers and Health Assistants
began at the Rural Health Centre, Jagatsinghpur, in November 1984. This project is part of the
Area Development Project jointly financed by the Government of India, Government of Orissa and
the Government of UK (Overseas Development Administration).
This Management Course, designed for in-service Health Assistants, has gradually been developed
over the last year and a half in which time five courses have been taught at RHC Jagatsinghpur and
one course has recently been taught at RHFWTC Cuttack. Training needs were originally defined
following discussions with State level officers of the Directorate of Health and Family Welfare,
district level programme officers and a series of field visits to PHCs and sub-centres. Subsequently
the course development team has learnt much from teaching the course; the comments, criticisms
and suggestions of early participants, follow-up visits to past trainees in their PHCs and
discussions with Chief District Medical Officers, and latterly conducting the course with the staff
of RHWFTC Cuttack have all led to much revision and improvement ot the course since it was
first conducted in May 1985.
This course covers five broad areas of the management of a primary health care service in a sector
as per MPW pattern of work in India. These are supervision, staff training, staff management, the
sector meeting, and creating awareness amongst the people in the sector about the need for the
health services being offered. These topics are discussed with the help of case studies and videos
from the field and the experiences of the participants. Specific suggestions for improving
management skills are provided in each teaching module, but also much of what the participants
learn is through discussing their own problems (similar to those used for introducing the topic)
with the trainers and their colleagues. Each teaching module has some form of exercise for (he
participants to practise what they have learnt; in some cases this is done in the field. They are
required to choose one problem that they have in their sector and to write a project which uses
methods learnt on the course for solving this problem.
This is a training manual in draft form for the Management Course. It is primarily intended to be
used as a guide by trainers, who have already had some orientation, for teaching this course. It may
also provide some ideas to those developing or teaching similar courses elsewhere; it is hoped that
those outside India will not be baffled by the complexities of sectors and sections, MPWs and
TBAs etc.
Acknowledgements
This course and this manual have been produced under the guidance ot Dr BK Shee, Associate
Professor-cum-Training Coordinator and Dr BK Patnayak, Deputy Training Coordinator. The
course development team has been assisted by members ot the Medical Officer course development
team, the staff ot the Rural Health Centre, the staff of RHFWTC Cuttack, and advice has been
received from officers ot the Directorate ot Health and Family Welfare, Dept SPM, SCB Medical
College, Cuttack and many Chief District Medical Officers, PHC Medical Officers and health
workers who were visited in the field.
The manual has been produced by the Training and Health Education Section,
RHC Jagatsinghpur.
Finally thanks go to the Governments of India and Orissa, the Overseas Development
Administration (UK) and the Liverpool School ot Tropical Medicine (UK) for supporting this In
service Training Project.
5
Course Development Team
Mr Umakanta Mohanty
Health Education Extension Officer
RHC Jagasinghpur
Mr Narayan Dash
Health Educator
Health Education Bureau, Bhubaneswar
Miss Sudhanshubala Das
Public Health Nurse
UHC, Medical College, Ankuli, Berahampur
Mr Tim Martineau
Training Consultant,
Liverpool School of Tropical MedicineJJK
RHC Jagatsinghpur March 1986
6
Use of the manual
This manual is a guide for the trainer rather than a procedure book that must strictly be adhered to.
It is likely that the teaching material will be taught a little differently on each course, hopefully
with some improvement. The time-table provided may be adjusted according to the needs of the
particular group of health assistants on the course.
By reading the overview of the course it should be possible to get a general idea of how the
different parts of the course fit together.
The training modules are the main guide for the trainers. They have been written in the following
format:
Learning Objectives
This states what the participants should know or be able to do at the end of the module.
Description of the module
This gives a brief overview of the teaching material and explains the main themes of the module.
Teaching materials
This is a checklist for preparation of the module. The overhead projector (OHP) slides used in the
teaching are indicated in the margins of the main teaching text. The video reference is also given in
the margins; the relevant counter numbers for the VCR being used can be written here. Some of
the OHP slides are included in the main text and some are given in Appendix B. A summary sheet
for all the materials used is also given in Appendix B.
Steps of the module
The module is usually divided into steps with headings. Instructions are provided for the trainer;
much of this is in the form of direct speech to the participants, but this will usually be taught in
Oriya. Trainer's notes are provided to help make the meaning of the module clearer.
Exercises
Some modules have exercises on worksheets that arc distributed to the participants during the
module.
Reference notes
These notes are for distribution to the participants as a summary of the main points of the module.
(There is therefore some repetition of the main text.) They are best re-written (rather than merely
translated) in Oriya.
The appendices contain reference materials on the Multi-purpose Worker scheme, national
programmes, and technical skills that are used as examples in the course. Some notes on
appropriate teaching techniques for the course are also included.
7
Overview of the Management Course for
Health Assistants
Course objectives
The objectives of the course are for the participants:
1
2
3
to review the aims of the Primary Health Care service as provided at sector level under
MPW pattern of work.
to understand and improve managerial skills necessary for the delivery of an effective
Primary Health Care service
to take a more positive attitude towards their role as managers at sector level of a Primary
Health Care service
Details of the course
1 Introduction to the course (1/2 day)
This short module introduces the Health Assistants to the idea of working in a Primary Health
Care service and their responsibilities for all the different workers within the sector and the tasks
that they perform. This prepares the participants for the training course in management by
supervision, training, coordination and planning.
2 Introduction to managing work (1/4 day)
This module introduces the process of managing work in the sector through both direct and indirect
supervision and training.A framework is given for gathering information about work done in the
health assistant's sector, for selecting the important bits of information and acting on them by
solving problems or giving feedback to the workers on their performance. This provides an
introduction for the next three modules covering different aspects of managing work.
3 Managing work: Direct supervision (2 3/4 days)
In this module the Health Assistants are shown how to look analytically at tasks done by MPWs.
Initially this is done by watching videos of MPWs at work. General checklists with headings to
cover planning and preparation, technical skills, attitude towards work and patients, recording of
work, health education etc are then drawn up for use when supervising such work. The Health
Assistants practise using these checklists while observing workers in the field. The importance of
feedback as a part of the process of supervision is stressed and trainees practise pointing out
mistakes and giving suggestions to MPWs in role-play.
4 Managing work: Indirect supervision (1 1/2 days)
The Health Assistant obviously cannot see all the work being done in his/her sector. Methods of
checking out work after it has been done are discussed eg checking that the visit has been made,
interviewing the householders where the visit has been made, or by examining the records to find
out what work has been done and how effectively. Practical work is done on examining real records
to determine work performance. As records can only be useful if they are kept accurately, some
general advice is given on the maintenance of records. (A field visit may be included in this module
if time permits.)
5 Managing work: Training (3 days)
An important method of feeding back findings from supervision to improve the level of
performance of the workers is through training, both formal and informal. Much of what a Health
Assistant would teach is concerned with practical skills. Methods of teaching that will help
workers to do things better than they did before are discussed and practised in the form of micro
teaching. The trainees learn more about training by assessing the effectiveness of each other's
teaching in this exercise.
8
6 Summary of Managing work (1 hour)
A brief summary is given of how the past three modules can help the health assistant to improve
the management of work in his/her sector.
7 Managing staff (1 day)
Poor performance of health workers is often attributed to their attitude - or 'lack of attitude'. It is
not possible to provide standard solutions to this kind of problem. Case studies are therefore
presented and discussed by the participants so that they might work out some solutions based on
their own experience. The case studies cover attitude towards work and patients and the willingness
of the worker to try to solve his/her problems to improve the delivery of health care services. Steps
are suggested for analysing this kind of staff management problem and for finding appropriate
solutions.
8 Sector meetings (1 day)
The sector meeting is an important tool to help the Health Assistant plan and supervise the work
in the sector. It is an opportunity for planning and monitoring work done, coordinating the staff as
a team, problem-solving and informal training. It uses, collectively, many man-hours. To be
worthwhile, therefore, it must be well-planned, there must be an atmosphere which encourages all
staff to contribute to discussions and clear decisions must be made, recorded and acted upon. All
these points are discussed after watching excerpts of a real sector meeting on video.
A simulation of part of a meeting is shown in which a decision made is very unclear; the trainees
are asked to record it and discuss how the decision could be made more obvious to those attending
the meeting. The trainees practise running 'mini-meetings' to ensure that all the techniques of
conducting a meeting, as discussed in the module, are used, and a good atmosphere is created.
Lastly, ways to encourage the workers to attend the meeting are discussed.
9 Educating and motivating target groups (2 days)
Much of the preventive work done by the health staff is concerned with persuading people to accept
new ideas and practices. People are usually resistant to new ideas unless they can see a clear
advantage for themselves. It is therefore necessary for the health worker to understand what their
target group already thinks about a particular health problem and what actions they normally take.
If the health worker fully understands the health message, he/she may then be able to provide the
most appropriate health education to the target group in view of their beliefs and circumstances.
In the second part of the module the reasons why people do not accept programmes are discussed
with particular reference to the family welfare programmes. Some of the difficulties of motivating
couples to accept family planning are discussed and methods of motivation are taught.
10 Projects (1/2 days)
It is hoped that participants will be able to use most of the things taught on the course when they
return to their PHCs. However, as it might be difficult for them to use everything they have learnt
immediately they return, they are asked to consider one particular aspect of their work which they
would like to improve. They prepare a plan during the course for making this improvement using
management ideas that they have learnt on the course. This is presented at the end of the course.
National programmes and technical skills
The course is primarily concerned with the management of the sector. Where necessary both
national programmes and technical skills are discussed and reference materials are provided in the
appendices to this manual.
9
Suggested time-table for the management course
Daily schedule:
Morning session
Afternoon session
Tutorials & staff
discussions
Day
Morning session
1
Joining, registration, pre-course assessment
& inauguration
2
1 Introduction to managing work
3
3 Direct supervision
4
3 Direct supervision
5
3 Direct supervision
6
4 Indirect supervision
7
5 Training
8
5 Training
9
5 Training
10
6 Managing staff
11
7 Conducting sector meetings
12
8 Educating and motivating target groups
13
8 Educating and motivating target groups
14
9 Projects
15
Post-course assessment Closing session
* adjust for morning hours in summer months
10
10am - 1pm*
2 pm - 4pm
4 pm - 5pm
Afternoon session
2 Introduction &
3 Direct supervision
4 Indirect supervision
9 Projects Part 1 (Ihr)
Summary of
Managing work(l hr)
Clarification of doubts
1 Introduction to the course
time 1/2 day
Learning Objectives
On completion of the module the participants will have:
1
a clearer concept of primary health care in relation to work at sector level
2
an introduction to the idea of HA as a manager of workers and volunteers in the sector
3
an introduction to the role and tasks of manager and purpose and plan of the training course
Teaching Materials
i
2
3
Case study A on video
OHP charts 1-5
Reference notes for participants
Description of the module
Before we commence any discussion about the management role of the health assistant, it is
necessary to clarify the type of work he/she is to manage in the sector. Thus the difference between
purely medical care and primary health care is demonstrated through two case studies. This leads on
to a broader discussion of the meaning of primary health care at sector level. This in turn
demonstrates the vast range of jobs that need to be done by the various workers and volunteers. The
tasks of the health assistant as a manager are introduced. It is explained that the remainder of the
course will be devoted to helping the health assistant learn how to improve their management,
skills in order to improve the delivery of primary health care and the course time-table is explained.
Steps of the module
1 Approach to health care
The following two case studies are presented:
Video ref:
Case study A
Three children are brought to the sub-centre one by one; they are all suffering from diarrhoea. The
health worker gives them medicine but does not realise that as the patients all come from the same
village there might be some common cause for the illness. The worker gives no health education.
Do not discuss the case study now. Present case study B.
OHP 1
Case study B
A person is suffering from acute diarrhoea. He goes to the local sub-centre. The health assistant
asks him where he is from. He teaches him the need to take fluids and gives him a packet of
ingredients to make rehydration solution. He says that the patient should buy more of these packets
when he gets home. The patient says that these packets are not available in his village, so the
Health Assistant shows him how to make a similar solution using sugar and salt. Later, a second
and a third patient come with the same complaint They are treated in the same manner. The Health
assistant discovers that they all come from the same village. He decides to go and investigate the
cause of the diarrhoea. On arrival he tries to find other cases and give treatment. He then contacts
the Village Health Guide and asks him to show him the source of water for the village. (Show
picture here) He finds the well and notices that it is not protected by a proper parapet to stop dirty
water draining in. It only has a few bamboos around it The air smells rather strong and the Health
Assistant realises that this is the area where the children go to the latrine; people are also washing
their clothes and their dishes very close by. He suspects that germs from their faeces and washing
of clothes and dishes are being washed into the well which is causing the acute diarrhoea. He
discusses the problem with the VHG and tells him to advise people to defaecate and wash clothes
and dishes further away from the well. He suggests that the VHG inform the Village Health
Committee of the
•n
problem and discuss with them how to get a proper parapet made for the well, or as a longer term
solution possibly to request the government to provide a tube-well. He makes sure that the VHG
understands why and how to teach people to make rehydration solution. He suggests they meet the
head teacher of the primary school to ask him to teach the children about rehydration when children
have diarrhoea and how to keep drinking water clean.
Compare the two approaches to the problem. Examine their main features.
Trainer's notes_______________________________
In case study A simply treatment was given. No advice on how to prevent the diarrhoea was given,
and more importantly nothing was said about the need to take fluids. Because the worker did not
ask where the people came from, she was not able to establish that the source of the problem was
common to them all.
In case study B rehydration solution is prescribed instead of drugs and the need for fluids is
explained. Because the HA asks where the people are from, he quickly realises that there is a
common problem and so decided to find out what it is. To solve the problem, he tries to get the
help of the VHG and the village health committee and uses the primary school for teaching the
children about the problem.
You might say that in case study A it is treated as a medical problem; the solution was treatment
with medicine. In case study B it is treated as a health problem; the solution lies in appropriate
treatment, investigation of the cause of the problem, and prevention of further occurrences of the
illness by improving the sanitation situation and by health education. Much of this work is done
by the people of the village.
'Do you have this kind of problem in your area ? What other health problems do you have ? ’
List out on OHP. Strike out problems like heart disease, cancer etc and explain that they do not
come within the area of health care provided by a primary health care service.
OHP 2
Discuss the components of Primary Health Care as shown in the OHP chart, relating them to the
previous case study where possible.
Summarise the discussion on Primary health care as it is practised at sector level.
'In Primary Health Care health workers try to improve the health of a community not only by
giving medicines, but by tackling the causes of illness. This means providing mother and child
care to prevent them getting sick. It means teaching about good health and hygiene practices. It
means having good water and sanitary facilities etc etc. This is done with the help of members of
the community and cooperating with other departments and organisations dealing with water,
agriculture etc and using indigenous know-how.'
'Many governments throughout the world have decided that they will adopt this approach of
Primary Health Care so that they will be able to provide basic (or primary) health care to all their
citizens by the end of this century. This is in accordance with the slogan of the World Health
Organisation Health for all by the year 2000.'
2 How is the work to be done ?
Start by explaining about the multi-purpose worker (MPW) scheme.
The necessary infrastructure has been provided by the Government of India by introducing the
MPW pattern of work. Under this scheme an attempt has been made to bring about a cohesive and
coordinated approach to provide comprehensive health care - curative, preventive and promotive - at
the doorstep of every individual by a single health worker. The peripheral health care delivery
responsiblity has been entrusted to a pair of workers (male and female) catering to the needs of
about 5,000 population, which comprises a health section.'
'If the work discussed above is what needs to be done at sector level, we need to discuss how this
work is to be done.'
Who are the people doing the work in the block ?'
12
OHP 3
Discuss the staffing patterns using the map of the sector. Show on OHP.
'What are the main responsibilites of all these people ?’
Discuss the chart with the responsiblities in the organisational pattern of PHC staff. Show on
OHP.
OHP 4
z:Responsibilities in the organisational pattern of the PHC
MO in-charge
BEE
Health Assistant
MPW
^VHG/ TBA
Management
Communication
Supervision and delivery of health services
Delivery of services
Liaison between Department and the community
3 Management of the sector
’Both the work to be done and who is to do it has been discussed. How can these two be organised
so that the desired approach to primary health care is achieved ? ’
’It is the job of the health assistant to ensure that an effective primary health care service is
provided in the sector. Therefore the health assistant needs to manage both the workers and the
work. As a manager, some of the tasks of the Health assistant are to:
ensure that work is done effectively and efficiently
ensure that staff and VHG / TBAs are well- motivated to do the work
ensure that HAs, staff and VHG /TBAs are involved as a team in planning implementation,
problem-solving and evaluation of work
increase awareness in the community about health problems, what services are available and
what they, the members of the community, can do about these problems
Trainer’s notes_________________
These are the areas of management that will be covered by this course. There are other
management tasks which are not specifically included eg indenting, control of stock and store,
programme planning. The topics chosen for this course are those that the course developers felt
were the highest priority; teaching modules for other aspects of management could be developed in
future and incorporated in the course.
The management tasks of the health assistant are broadly discussed in this course. Trainers will
provide some advice; you will be able to provide advice to each other from your own experience.
Some things we will be able to practise in the field; some things in the classroom. You will select
one topic of particular interest to you that is covered by this course and make a plan for carrying it
out when you return to your own sector.’
(Show the plan of the course on OHP)
OHP 5
Management course for Health Assistants
Introduction to the course
Managing work: Introduction
Direct supervision
Indirect supervision
Training
Summary
Managing staff
Sector meeting
Educating and motivating target groups
Project presentations
^Course assessment and clarification of doubts
At this point you should distribute the timetables to the participants.
Then distribute and explain the reference notes on the module.
13
for participants
reference notes
1 Introduction to the course
1 Primary Health care in the Sector
In Primary Health Care health workers try to improve the health of a community not only by
giving medicines, but by tackling the causes of illness. This means providing mother and child
care to prevent them getting sick. It means teaching about good health and hygiene practices. It
means having good water and sanitary facilities etc etc. This is done with the help of members of
the community and cooperating with other departments and organisations dealing with water,
agriculture etc and using indigenous know-how.
Many governments throughout the world have decided that they will adopt this approach of
Primary Health Care so that they will be able to provide basic (or primary) health care to all their
citizens by the end of this century. This is in accordance with the slogan of the World Health
Organisation Health for all by the year 2000.
2 Summary of Case studies A & B
In Case study A the illness is only treated with medicine. In Case study B the health assistant
gives rehydration solution which is a more appropriate treatment; he also tries to find out the cause
of the illness, gives health education about simple methods of rehydration and how to keep the
drinking water clean and helps the village people to take action to prevent this illness from
continuing. This is the approach of Primary Health Care.
3 What leads to Primary Health Care
nutrition
child
care
Community
participation
Appropriate
technology
mmunisation
maternal
care
control
of endemic
diseases
family
planning
sanitation
treatment
clean
water
Inter-departmental
co-ordination
14
4 Main tasks of PHC staff
Main tasks of PHC staff
MO in-charge
BEE
Health Assistant
MPW
VHGfFBA
Management
Communication
Supervision and delivery of services
Delivery of services
Liaison between Department and the community
5 List of management tasks of the health assistant
ensure that work is done effectively and efficiently
ensure that staff and VHG/TBAs are well-motivated to do the work
ensure that HAs, staff and VHG/TBAs are involved as a team in planning, implementation,
problem-solving and evaluation of work
increase awareness in the community about health problems, what services are available and
what they, the members of the community, can do about these problems
15
2 Introduction to Managing Work
time 1/4 day
Learning objectives
On completion of the module the participants will have been introduced to the process of managing
work through both direct and indirect supervision and the provision of feedback through training.
Description of the module
To manage the sector the health assistant needs to know what work is going on in his sector.
Ways of getting this information are discussed. If things are not being done well, the manager
needs to find out the reasons. He can then decide what actions he can take, recognising that some
problems will be beyond his scope and will need to be referred to a higher authority. This is shown
as the process of supervision and it introduces the next three modules covering direct and indirect
supervision and the provision of feedback through training.
Teaching materials
i
2
OHP charts 1 & 2
Reference notes for participants
Steps of the module
T In order to manage the work in a sector, it is necessary to know what work is being done and
how effectively it is being done. If work is not being done effectively, the health assistant needs to
find out the reasons. How can you find out about the work that is going on ? '
for example:
-observation
-looking at records
-making follow-up visits
-informal sources of information
-checking stocks etc etc
j
List on OHP.
2 ' If the work is not being done well, what are the possible reasons ? '
for example:
-unclear orders
-poor programming
-improper guidance
-lack of equipment
-ill-motivated and lazy workers
-skill not known or forgotten-problems with villagers not accepting the programme etc etc
OHP 1
List reasons on table on OHP; add second part ie possible solutions for step 3.
reasons for work not
being done well
what can the manager do?
x.
17
3' What then can the supervisor do ? '
-make clearer orders
-clarify work procedures
-teach new or forgotten skills
-solve problems etc etc
List on above table on OHP.
Trainers notes
__________________________
The discussions in sections 2 & 3 are only meant to start off the process of thinking about why
work is not being done effectively and what the health assistant can do about it Do not discuss
this in too much detail at this stage. Make it clear that if work is not being done effectively, it will
not always be the fault of the worker, but may be due to a variety of reasons eg supply of
materials, villagers not accepting the services, skills not known by the worker etc. The way of
solving the problem will be different in each case. However, we must recognise what things Health
assistants can do to solve problems in their sector and what things are beyond their scope. There is
little point in discussing problems that are beyond their scope, apart from acknowledging their
existence, in this training course.
OHP 2
4 ' We can see that supervision is a process of finding out about/checking work and then solving
problems/correcting work (sometimes through training). As the supervisor has limited time, a
stage in between these two is also required to decide which points he should consider and which
points are unimportant or need to be dealt with later. This process can be shown as in the OHP
diagram below: '
- -------------------------------------- ------------------------------------------- ----------------------- Diagram of the process of supervision
collecting
information
about work
done
acting
^^choosing^^^
fon information \
f about work
t
I
done
I
to improve
I
% performance
1
Xmost important \
f information
\
about work
1
I
done
I
\
t
y
5 In the next three modules we will look at ways in which supervision can be used to improve
work performance. The Health Assistant can do some direct observation supervision; but not all
the time, as he cannot be everywhere at the same time. But he can check out work after it has been
done. He needs to decide which are the most important problems to be solved and what the more
serious mistakes in the work are. He cannot always correct work on the spot, but he can find out
the kind of things going wrong and revise topics and skills with the workers as part of the sector
meetings.'
In the next three modules we will examine the following aspects of the supervision process:
ways of carrying out direct supervision
2
ways of carrying out indirect supervision
3
ways of correcting skills through training '
18
Distribute and explain the reference notes for this module.
for participants
reference notes
2 Introduction to Managing work
1 Managing work at sector level
To manage the work in the sector the health assistant needs to know what is going on in his
sector. There are different ways of getting this information. If things are not being done well, the
manager needs to find out the reasons. The health assistant should select the most important
problems and mistakes. He can then decide what actions he can take, recognising that some
problems will be beyond his scope and will need to be referred to a higher authority.
In the next three modules we will examine the following aspects of the supervision process:
ways of carrying out direct supervision
1
2
ways of carrying out indirect supervision
ways of correcting skills through training
3
2 Diagram of the process of supervision
collecting
information
about work
done
acting .
Xon information X
! about work
1
I
done
1 to improve
I
% performance J
choosing
Xmost important \
/ information
\
about work
1
I
done
f
\
/
19
3 Improving work through direct supervision
time 2 3/4 days
Learning objectives
On completion of the module the participants will be able to :
observe work being done using a checklist
1
decide what action needs to be taken to improve work
2
know how to carry out some actions to improve work
3
Description of the module
The module begins by focussing attention on observation of work by using a video of
immunisation being done, and the selection of points to feed back to the worker. Next, the idea of
using a guide to help with the observation of work (ie the checklist) is introduced. Participants
practise using the checklist by watching a second video of work being done; they later use the
checklist to observe real work being done in the field. Having found out how the work is being
done, and having decided what the most important points from the observations are, the supervisor
needs to be able to feed back this information to the worker and/or solve any problems. This is
discussed first through example and then the participants decide and present the kind of feedback
they would give to the workers they observed on the field visit. Lastly, the practicalities of using
checklists for observation of work, or at least a 'checklist-way-of-thinking' are discussed.
Teaching materials
i
2
3
4
5
6
Video of immunisation work
Video of blood-slide collection
OHP charts 1-4
Standard supervision checklist for participants
Supervision checklist prepared for immunisation for participants
Reference notes for participants
Steps of the module
OHP 1
Start by referring to the introduction to managing work OHP 1 and the OHP chart on information
collection. Ask the participants how they carry out their supervision of the workers. Ask if they
make any record of their observations while they are carrying out supervision. If they do, ask how
they then use the information in their notebooks.
Video ref:
1 Watch video of immunisation work; list of comments about the work on OHP.
OHP 1
2 Discuss comments that should be fed back to workers on their perfomiance and problems to be
solved by the health assistant. List on OHP. Suggest that people only take in a few suggestions
about their work at one time. Show OHP slide from Introduction to Managing
Work. Reconsider the list and choose the most important FOUR, points. (NB it does not have to be
exactly four points but the participants should get into the habit of selecting only the most
important comments for feedback to the worker.)
OHP 2
3 ' What are the main elements in the task of immunisation as seen in the video ? '
Guide the discussion so as to bring out the points below:
Show list on OHP______________________________________________
^planning/preparation
-technical skills
-problem identifying/solving
-attitude to job/patient
-recording of work done
^-health education
-z
21
4 Categorise the four comments selected in no.2 into headings in no.3. Discuss how other
comments listed should be categorised.
5 Issue copies of the standard checklist and explain the purpose and method of using.
6. Tell the participants that they will be observing another video - this time of blood slide
collection being done. In GROUPS they should decide what things they will especially look out
for under each heading while observing the video.
Trainer's notes___________________________ __
This is the first time that group work is used in the training course, so the trainer should explain
how the group work should be conducted. See notes in Appendix A
Video ref:
7 Show the video of blood slide collection;
participants watch and record comments on the checklists.
8 Report back and list comments on the OHP. Discuss and select the most important FOUR
points to feed back to the worker.
These might be :
1
only taking thin slide
2
not explaining how to take the medicine
3
etc etc
9 Tell the participants that they will be going to the field the next day to observe work using the
checklist. Divide them into groups and tell each group which tasks they will be observing. They
should then prepare their checklists for the particular task they will be required to observe.
10 Field visit to observe work using checklists in the field,
examples of tasks:
1
ante-natal check-up
2
chlorination of well
3
blood-slide collection
11 Report back: discussion and four most useful comments on work observed.
12 Discussion on the usefulness of the checklist:
-leads to better (keener) observation of problems and mistakes
-provides a record of what happened
-this record may be used for follow-up visits
-this record may be used for planning training sessions-etc etc (add other points here)
OHP 1
13 One of the main purposes of looking at work is to be able to help the worker to improve his
performance. (Show OHP slide from Introduction to Managing Work.)
This necessarily requires the cooperation of the worker. Thus this kind of supervision should have
the following qualities: (show on OHP and explain the points using examples of comments made
about work in the video on immunisation)
OHP 3
aim to help the worker
to improve the quality
of his work himself
therefore the supervisor should enable the worker to
understand the consequences of his mistakes and
therefore help him to feel responsible for the quality of
his work
aim at gradual
improvement through
giving advice and
training
therefore the supervisor should only give feedback on
consolidate improvement
as it occurs
therefore the supervisor should make follow-up visits
after giving suggestions to the worker
teach the worker how
to solve problems, where
^possible by himself
therefore the supervisor should encourage the worker
to think out solutions to some of the problems himself
22
the most important points he observes
14 Taking the comments made about the blood slide collection in section 8 discuss action to be
taken, bearing in mind 'qualities of good supervision as discussed above. Use the OHP chart below:
OHP 4
problems and mistakes
action to be taken
15 The participants prepare action plans in GROUPS for giving feedback to workers on the basis
of findings from the field visit; these will be reported back to the main group and may be
illustrated by role-play.
16 Discuss the practical use of checklists for supervision. Ask how many people use personal
diaries or notebooks for their work. Suggest that they could write the headings of the checklist at
the front of their notebooks, or on a piece of card to kept in the notebook. In this way, the
supervisor does not need to have the checklist written out for each piece of work he observes.
Suggest that the checklist can be used as a guide to observing the work. As the supervisor becomes
more familiar with using the checklist, he/she will memorise it, but it will still be useful to keep
it written down somewhere.
' Other supervisors may not have their own notebooks and there may be a shortage of paper.
However, the checklist can still be used for supervision. The supervisor may need to remind
himself of the headings at first, so it would be useful to carry one copy of it while going to the
field. You may not write down any notes. The important thing is that while you are observing
work you should use a 'checklist-way-of-thinking'. This will help you to decide what points you
need to discuss with the worker about the way he has done the job. You may remember to check
the points the next time you observe this particular worker, or to discuss the problem at the next
sector meeting. Of course, it would help if you had a notebook for writing these things down.'
17 Summary of module
Distribute and explain the reference notes for the module.
23
for participants
Standard checklist for observing work.
1
planning/preparation
2
technical skills
3
problem identifying/solving
4
attitude to job/patient
5
recording of work done
6
health education
Note: this is only a suggestion for a checklist The best checklist is one which you find easy to
use and helps you to observe work better.
24
for participants
Some points of a checklist for organising
DPT/polio immunisation camp
1 Planning/preparation
-Decision/and order/date
-Where it is to be done ?
-The actual place of the camp
-The target group and their number (detailed list)
-Procurement of vaccines (the quantity of DPT, polio vaccines needed)
-Physical arrangements
-Publicity
-Other staff required for the work
-Their specific duty (reception, registration, recording etc)
-Procurement of required materials
-Preserving the vaccines/cold chain etc
-Follow-up
2 Technical skills
-Sterilization of syringes, needles etc at the camp site
-Selection of right cases
-Selection of right place in the body for pricking
-Method of pricking
-Drawing vaccine
-Injecting correctly
3 Problem identifying/solving
-Identifying problems
-Trying to solve as and when they occur
4 Attitude to job/patient
-Arriving at the camp site at right time
-Accuracy
-Thoroughly prepared for the job
-Helpful/gentle with patients
-Avoiding waste
-Carefulness
-Friendliness
-Impartiality
-Problem-facing
5 Recording of work done
-All the regisiters ready
-Recording then and there
-Recording correctly and legibly
6 Health education
-Must be clear about what is to be told (Why immunization, what happens when the child is sick,
where to come if any problems etc)
-To ensure that they understand what is said
25
for participants
reference notes
3 Direct supervision
1 Points on the usefulness of the checklist
-leads to better (keener) observation of problems and mistakes
-provides a record of what happened
-this record may be used for follow-up visits
-this record may be used for planning training sessions
2 Good supervision will have the following qualities
-aim to help the the worker to improve the quality of his work himself
Therefore the supervisor should enable the worker to understand the consequences of his mistakes
and therefore help him to feel responsible for the quality of his work.
-aim at gradual improvement through giving advice and training
Therefore the supervisor should only give feedback on the most important points he observes.
-consolidate improvement as it occurs
Therefore the supervisor should make follow-up visits after giving suggestions to the worker.
-give the worker a sense of achievement
Therefore the supervisor should encourage the workers when they make improvements in their
work.
-teach the worker how to solve problems, where possible by himself
Therefore the supervisor should encourage the worker to think out solutions to some of the
problems himself.
3 Practical use of the checklist for direct supervision.
The main points of the checklist can be written at the front of your notebook, or on a piece of card
that you keep in your notebook. This will guide you in your observation of work.
If you do not have a notebook, you may keep the points of the checklist on a card to remind you
when you are observing work. Even if you do not write notes, it will guide you to use a 'checklistway-of-thinking', which will improve the quality of your supervision.
26
4 Improving work through indirect supervision
time 1 1/2 days
Learning objectives
On completion of the module the participants will be able to :
1
know how to use the following methods of indirect supervision: observation, interviewing
house-holders, using records
2
ensure that records are kept accurately and correctly by the workers
3
take action based on the findings of indirect supervision
Description of the module
By using the example of the chlorination of a well, methods of finding out after the event if and
how work was carried out are discussed. This leads on to discussions of the following methods of
indirect supervision: observation, interviewing householders and using records. As records will
only be useful if they are maintained well, some hints are given on record-keeping. Ways of
following up findings from indirect supervision are discussed and the module finishes with group
exercises on case studies for indirect supervision.
Teaching materials
i
2
3
Selection of sub-centre records including tour diary
OHP charts 1-5
Reference notes for participants
Steps of the module
OHP 1
1 Introduction
Start by referring to the introduction to managing work and the OHP chart on information
collection.
' We have seen how the Health Assistant can supervise workers on the spot. However, as they
cannot be everywhere at once. Health Assistants also need other methods of supervising their
workforce. In this module we will discuss some ways the Health Assistant can indirectly supervise
the work in his/her sector. '
' Show either a tour diary or the relevant register which indicates that chlorination of a well has
been done. Ask, If the supervisor were not present at the time, how could he find out if and how
the work was done 1'
List on OHP
A guideline is given below :
-visit the site: taste water, see if well clean
-check bleaching powder stocks
-talk to nearby householders and VHGs: ask if anyone came, ask what he did and said
-check the MPW's records; tour diary recording visit, register
-ask for verbal report at sector meeting (see module on sector meetings)
' Let us discuss in more detail how we would use these methods
1
2
3
visiting the site
asking householders
interpreting records
for supervising other kinds of work, too. (Using the Sector meeting for indirect supervision will be
discussed in a later module.)'
27
2 Visiting the site (observation)
' How would you find out, for example, about:
1
2
3
4
5
malaria
antenatal checkups
treatment of minor ailments
FW motivation
registration of vital events'
Write on OHP.
Trainer’s notes
The following are guidelines:
task
what to look for when visiting the site
malaria
-stencils
-ask to see (presumptive/RT) medicines
-look for mosquito areas
-signs of spraying
antenatal check-up
-may not be possible to see any evidence
treatment of minor ailment
-look at dressing, if done
-prescription, unused medicines
NB it may not always be possible to SEE evidence of work having been done, as shown by the
example of ante-natal check-up.
3 Asking householders (interviewing)
' Visiting the site to observe what work has been done and interviewing householders will often be
done together. For example if you go to check on follow-up care of a sterilisation case, you will
want to look at how the scar is healing but also to ask the person how often the worker is coming
and what he/she is doing. While visiting the site the health assistant might also enquire from the
VHG, members of the village health committee, local teachers, the owner of the tea-shop etc about
what work has been done. 'Discuss with the participants what experiences they have of
interviewing householders as a means of carrying out indirect supervision. Ask what problems they
have. Bring into the discussion some of the points given below, giving examples, about the
approach and techniques of interviewing :
Approach:
-if you appear too 'official' householders might think that you are checking up on them; they will
probably only say what they think you want to hear, so you will be misinformed.
-be careful not to undermine people's respect for the MPW by criticising his work
-take the opportunity to be helpful in giving advice; people see you not only as a supervisor, but
also as a member ofthe health staff - that way you will gain their trust
Interviewing:
-you will find out more by listening than by talking
-talk around the subject first before asking direct questions; you may get extra information and you
will know which direct questions to ask
-ask open questions; don't put words into their mouths
-base questions on your observations (see above)
Trainer's notes______________________________
These points could be introduced through short role-plays by members of the training team to
illustrate the correct or incorrect approaches and techniques of interviewing listed above. This will
help to make the points clearer for the participants.
28
Ask some of the participants to act out in role-play the health assistant interviewing 2 or 3
householders about the chlorination of the well (as discussed at the beginning of the module). The
health assistant should try to find out if the worker came or not, what he did, if he gave any health
education, and if so what did he say etc etc. After the role-play the rest of the participants should
discuss the skill of the 'health assistant' in finding out about the work of the worker.
Mention that it will not always be necessary to go to the village to find out about work done.
Some of the more active villagers may come and complain to the health assistant if work is not
being done properly. This is another way of finding out about work done.
4 Interpreting records
' From the records at sector level, we should be able to answer the following three questions:
I
n
m
is the worker working at all ? (yes/no)
how much work is he/she doing ?(quantity)
how effective is his/her work ? are there any problems ? (quality)
Let us look at these three questions separately.'
I is the worker working ?
' This question might be answered by looking at the tour diary or the records relevant to the work
we are examining.'
OHP 2
Show an example on the OHP of a tour diary that shows work being done.
' This is some evidence that work has been done.'
OHP 3
Show an example on the OHP of Vital Statistics records from Maligaon Section :
Population 1984
Village
A
B
C
age(yrs)
m f
m f
m
0-1
1-5
6-10
21 15
26 38
37 41
17 19
19 21
29 26
D
E
f
m f
m
17 19
17 21
21 26
17 14
19 21
21 17
17 19
21 27
26 29
f
7
'Show the chart and ask the participants if they notice anything strange about the figures. If they
find it difficult, then read out the numbers aloud. They should notice that there is a great similarity
between many of the figures in sections B, C, D and E. The figures for section I look possible.
This is the headquarter village. It is possible that the figures for the other villages were not
collected, but were made up by the worker while sitting in the sub-centre. This means that these
records have no value at all. With the knowledge that a health assistant has of his/her workers and
by looking at the records carefully, it should sometimes be possible to find out if the worker is
'cheating'. In this case the records show you that the work is probably not being done.'
II how much work is he/she doing ?
' Last year in one sector the Tubectomy Operation target achievement is found to be as
follows: (show on OHP; cover the part of the slide showing the no. eligible couples and %
operated on)
OHP 4
Section:
1
2
3
4
total
Cases operated:
60
68
60
67
255
’ Which worker did best ? ' Mark the best village selected.
Say that at the sector meeting when these achievements were discussed, the workers from section 1
and 3 complained that they had worked very hard and spent more time on motivation than their
colleagues.
Are they telling the truth? How could we find out ? What other information do we need ?
The answer is that we need to know the number of eligible unprotected couples in each section.'
(Show on OHP)
29
Section:
1
2
3
4
total
No. eligible
unprotected
couples :
600
850
500
1000
2950
% operated on 10.0
8.0
12.0
6.7
8.6
' So, now who appears to have done the best work ? ’
' To be able to compare the performance we need to know how many eligible couples there are in
each section. Otherwise we cannot use this information accurately for indirectly supervising the
workers. '
OHP 5
III how effective is the work? are there any problems ?
' Let us look a little more closely at the tour diary. Work is being done. Is there anything that you
notice about the way in which the work is being done ? '
Point out that although according to the tour diary shown earlier post-operational follow-up
injections have been given, only two out of a course of five have been given. There are no more
penicillin injections recorded in the tour diary. What can we leam about the effectiveness of the
work ? What problems might this indicate ? There is a need for the Health Assistant to examine
the situation more closely.
' In this case some work has been recorded as having been done on individual days. However, when
we look more closely at the nature of the work, we see that it should have been done over a period
of five days, giving five injections. If the complete course of antibiotics is not given this may be
harmful: it will not be enough to treat sepsis if there is any; whenever antibiotics are prescribed,
the full course should be taken (many people stop taking them when they begin to feel better), so
if the worker is not giving the full course of injections, she is setting a very bad example and it
may be harmful to the patient. '
' Let us return to the motivation of couples for tubectomy operation. If we take the case of section
4 [Duranda section] (show on the OHP) we know that the 67 cases all come from section 4.
Although at first we thought the achievement was quite high in the sector, we realised that as a
percentage achievement of the total number of eligible couples, the worker in section 4 ranked
lowest. The supervisor could ask 'why was the performance so poor ?' We do not know which
parts of that section the cases come from. Perhaps they come from only one or two villages (Show
map on OHP) How could we find out where most of the cases came from ? It will be possible to
find out the names of the village they come from by referring to the survey report, or by asking the
worker him/herself. The supervisor should then think why the other villages are being neglected or
perhaps being resistant. If the problem can be solved, then perhaps the worker
can improve the percentage achievement of motivation of eligible couples; that would then
improve the total achievement of the sector.'
Trainer’s notes________________________________
Factors to be taken into account when looking at the map of Duranda section are: difficulty in
communications due to the sector being split by the river, distance from the sub-centre might also
be a factor. Other reasons for poor achievement might be due to the villages being poor, low caste,
the village leaders may be opposing the services, or because of seasonal labour the villages might
be absent from their homes much of the time. Ask the participants what kind of reasons they think
lead to poor achievement on their sectors.
' To summarise this section, by careful reading of the records we can find out how much work has
been done and how effective it has been. We may also be able to see
if there are any problems in implementing the work.'
4 Maintaining records
' The different records kept at sector level and below can be a very useful tool for supervising work,
but only if they are accurate and can easily be understood. Systems vary from district to district,
but the following hints on maintenance of records apply to any system. '
30
Discuss these points, giving examples where possible.
I
workers collecting data (eg VS) and recording work done should be clear about:
a. the reason for collecting and recording the information
b. the correct procedure for collecting and recording this information
c. how the information will be used at sector and section level
If the workers have difficulty in understanding the procedure for maintaining records, help them by
explaining it carefully.
II
information should be recorded during collection, or as soon after as possible to avoid errors
(and check people don't falsely make records up at home)
III
records should be legible whether in English or Oriya. If TBA/VHGs are illiterate, some
special arrangement needs to be made to record their work
IV
descriptive reports (eg tour diary) should be written as precisely as possible. 'Gave health
education' is not a useful enough piece of information
V
physical maintenance of records; good storage, hard cover, use dot-pen etc.
VI
coordination of information collection.If the TBA and the ANM both report the same birth
the records sent on to PHC will be inaccurate. A method of coordinating the collection of
information is required (this is dealt with in the module on meetings).
5 Using findings of indirect supervision
' As the Health Assistant has several different methods of finding out indirectly about work done,
he may sometimes be able to cross check his information. For example the MPW may have
recorded in his tour diary chlorination of three wells on a particular day; visiting the area a few days
later, the Health Assistant might find that householders in that area don't know anything about the
wells being chlorinated and have not noticed any change in the taste of the water. Has the worker
falsely recorded these visits ? '
' As with direct supervision, the Health Assistant needs to be selective about the feed back to the
workers. But it is not possible to give feedback directly and immediately. Some mechanisms of
using findings from indirect supervision are:
I seeking clarification ofproblems and/or commenting at sector meeting
' Before you start shouting at the worker for not managing to achieve his/her target you should first
try to find out if there are any problems in implementing the work. In the case of the post
operation penicillin injections you could first find out whether the worker has an adequate supply
of the injections. Or you might ask if the patient wanted the injections. And so on. If there is a
problem like this you should try to solve it with the help of the worker. However, if you are
convinced that the problem is with the worker then a different course of action should be taken.
We will discuss that in the module on Managing Staff.'
II arranging to do direct supervision (for one of the two reasons given below):
a, to investigate the problem better
’If the women of the village complain that the worker is not doing thorough check-ups on ante
natal mothers, you might feel that you should go with the worker yourself to see how she is doing
the work. If she is not doing thorough check-ups, then she might need some training. As the
village women had complained about her work, it would be better not to do the training in that
village. If the worker appears to be doing the work well, then you need to investigate the reason for
the complaints of the village women. Perhaps the worker has been impolite; or she may not be
acceptable to the villagers because of her caste. In each case, your action as the supervisor will be
different'
b, to provide on-the-spot training
'You may learn from the PHC staff that the worker is not making clear blood slides from fever
cases, which is making it very difficult for the technician to examine the slides. The best way to
solve this problem might be to go to the field with the worker and teach him on the spot how to
make a good blood slide.
We will be talking more about this kind of teaching in the next module.'
III having a private discussion with the worker
' It may be more tactful to discuss problems with the worker in private, rather than in front of
everyone at the sector meeting. This will avoid embarrassing the worker, or perhaps reduce the
possibility of him/her getting support from his/her colleagues.'
We will talk more about this in the module on Managing staff.'
"O
ns G
31
Ask the participants if they have any other methods of their own of feeding back to the worker
what they find from their indirect supervision.
6 Exercises
These exercises are done in groups.
1
The group is shown a record of work done which they are to verify by visiting the field
where the work was done eg blood-slide collection, chlorination of wells
2
The group is asked to go to a sub-centre and cross check the records of one kind of work
done eg TT injections for ante-natal mothers.
3
The group is to find out if, and how, the information from the records is being used for
supervision and coordination, by interviewing the health assistants, some of the workers and TBAs
and VHGs in a sector and also checking their own records.
If there is time the aforementioned exercises should be conducted in the field. If it is not possible to
go to the field the exercises should be adapted so they can be used in the classroom.
Discuss the reports of the group leaders.
7 Summary of module
Distribute and explain the reference notes for the module.
32
I
I
for participants
reference notes
4 Indirect supervision
1 The reason for indirect supervision
Direct supervision is probably the most effective form of supervision, as the health assistant can
see exactly what is going on and can give feedback immediately to the worker. However, the health
assistant cannot be with each worker all the time. So he/she needs to be able to use other methods
for finding out about the work being done.
2 Different methods of indirect supervision
When looking to see if chlorination of a well has been done, the health assistant could:
a.
b.
c.
d.
visit the site: taste the water, see if the well is clean
talk to nearby householders and VHGs: ask if anyone came, ask what he did and
what he said
check the records of the worker, cross check the tour diary with the register
ask verbally at the sector meeting about the chlorination of the well
These methods can be applied to most work done by MPWs.
3 Using records
Records may help you to answer three questions:
I
II
III
is the worker working ? (yes/no)
how much work is he/she doing ? (quantity)
how effective is his/her work ? are there any problems ? (quality)
Intelligent verification of records may help the health assistant to find out whether the work is
being done effectively or not, or they may show that there is problem with implementing the
work.
4 Maintaining records
Records will not be useful for indirect supervision (or any other work) if they are not kept
accurately and well ordered. Some hints on maintaining records :
workers should know and understand the reason and correct procedure for collecting records:
I
where there are problems the health assistant should be ready to explain the system to the workers.
II
information should be recorded as soon after collection as possible to avoid the possibility
of error.
m records should be legible
IV
descriptive reports (like the tour diary) should be precise so it is possible to find out exactly
what has happened.
V
records should be kept in good physical condition
IV
there should be coordination of recording information between all health staff at sector level
33
5 Using information from indirect supervision
Some of the ways that the health assistant can act on the information from his/her indirect
supervision are :
seeking clarification of problems and/or commenting at the sector meeting
I
arranging to go with the worker to do direct supervision (spot-check)
II
EITHER
a. to investigate a problem more thoroughly
OR
b. to provide on the spot training
discuss the problem with the worker privately before going to the field or bringing up the
matter at the sector meeting
Ill
34
5 Training
time 3 days
Learning objectives
On completion of the module the participants will be able to :
1
2
3
4
5
6
7
know some of the conditions that bring about learning with adults
teach using guided discussion
use visual aids that are typically available at sector level
teach by doing a demonstration
assess learning and provide feedback to the learners
prepare a structured teaching session and teaching notes
conduct a 15-minute training session
Description of the module
The supervision process as described in the previous modules will often show the need for some
sort of training to be given to the workers, VHGs and TBAs. This module aims to prepare the
health assistant to do this kind of teaching, whether for a small group at the sub-centre, or for an
individual worker in the field. First some points are discussed about what makes adults want to
learn and how a person can help people to learn.
Guided discussion can help the teacher to find out what the learners already know and to build on
this; this is demonstrated and explained. The way to demonstrate skills is shown and discussed. The
need to find out how much is being learnt is shown with some hints on how to do this. Some
practical points on using the kind of visual aids that might be available to the health assistant are
given. With these ideas on teaching the participants are shown how to prepare a training session.
This is then done practically. Lastly, the participants teach their lessons, if possible to an invited
audience, and their teaching is critically observed by colleagues and later discussed.
Teaching materials
i
2
3
4
5
6
7
8
9
OHP charts 1-11
Picture of child with abcess from vaccination
Materials for demonstrating sterilisation of a syringe
Flip chart (for visual aids demonstration)
Selection of teaching aids for micro-teaching
Questions to ask when preparing a lesson (for participants)
Videos of demonstration and return demonstration
Teaching observation forms (for participants)
Reference notes for participants
Steps of the module
OHP 1
1 Introduction
' We have seen that one of the ways the health assistant can provide feedback from supervision to
the worker is through training. (Show OHP slide of process of supervision) This can be with one
individual while working in the field, or with a group of workers, for example, at the sector
meeting. We will discuss ways in which you can improve your teaching, so that your staff will be
able to improve their work performance.'
35
OHP 2
2 Conducting in-service training
' Health assistants are concerned with two kinds of learning : (Show OHP)
A
/----new knowledge and skills eg initial training for the TBA introduction of new ideas, like
a.
ORS
correcting knowledge and skills for example finding from supervision that the female
b.
^worker or the TBA does not cut the cord with a clean blade
y
' As many of the VHGs and TBAs have already been trained, the health assistant probably does
more of the second type of teaching. This may be done either on-the-spot in the field, or, if many
workers are making the same mistakes, as part of the sector meeting, in a group together. Two
points are now made about conditions which will help to make the learning of the workers, VHGs
etc more successful.'
Adults will only leam successfully if they feel the need to leam (children may only leam
because the teacher says they must).
I
Say that a training will be given to VHGs on vaccination. Show the following four points about
the subject of vaccination and ask which points should be taught to the VHG:
OHP 3
rr2
3
OHP 4
the vaccine against tuberculosis was discovered by the Frenchmen Calmette and Guerin
the method of giving injections
how to keep immunisation records
how to explain to a mother that vaccinations will protect her child against diseases
Select useful and relevant points for teaching. Discuss which of the points on vaccination are must
know, nice to know etc as in the OHP slide.
' This means that the job functions of the VHG need to be considered (both the official and the
actual job functions). Another example of relevance to the job is teaching ANMs to sterilise
instruments, not in an autoclave, but with equipment they have at the sub-centre. '
Explain that in 'in-service training' there is little point in spending a long time teaching things that
the staff already do well; these are not the needs of the learners. The health assistant will find out
these needs from making supervisory visits.
Ways of making the teaching relevant to the job of the worker : (Show on OHP)
OHP 5
if possible, take the 'classroom' to the field (that means teaching people to do things in the
rrsame situation
that they work in)
bring the field to the classroom (using actual equipment used in the field, role-plays of field
situations and so on)
don't give long theoretical explanations
3
use real examples from your own experience in the field whenever possible.
V
2
II
People can leam difficult things if the teacher understands how to help them learn.
Example of Sikh mechanic. (Show picture on OHP) Discuss OHP 6 how the Sikh mechanic has
probably had no formal training, and yet he can repair trucks, which is a complicated job that we
could not do.
How> is he able to learn these skills 1
' He learns by watching others and by them explaining what they are doing in a way that he can
understand. He probably would not be able to understand the technical terms and diagrams used in
an engineering college, but he understands what his workmates teach him because they explain
things in ways that are meaningful to him. In the same way a TBA may not understand a cross
section diagram of the womb nor understand some of the medical terms, but if she is taught in
ways that she can understand she can leam how to do routine deliveries safely and to detect signs
that a delivery will be complicated and should be referred to the medical officer.'
Explain, by giving examples, the following ways of helping people to leam (particularly those
with little or no formal education) (Show on OHP)
36
OHP 7
a.
b.
Use simple methods of explaining think
Use simple diagrams, pictures etc.
Use simple words: mother tongue not English; local rather than technical terms.
y
Summarise the points so far.' Most training that you will do at sector level will be to revise the
knowledge and skills of the workers, TBAs etc. We have briefly discussed ways you can help them
to learn. Now we will discuss some kinds of teaching that you can use. '
3 Using guided discussion to review knowledge or skills
' People will learn better if they are involved in the lesson. That means they will do things, ask
and answer questions, as well as listen to the teacher. They will become more involved if they are
contributing to the lesson by answering questions and giving suggestions.
By asking questions to find out what the learners know the teacher can avoid wasting a lot of time
teaching things that the learners know or can already do competently.'
Trainer's notes
___________________________
This section uses an example of a training session to demonstrate how guided discussion can be
used. This should be explained to the trainees and they should be requested to play the parts of
students. Make sure that the students realise this is an example of a teaching method and do not get
carried away with the content of the lesson.
a.
Start by creating the situation: show a picture of a child with an abcess from
immunisation.
b.
Ask questions about the child: ' What can you see in the picture? What has happened?
How did this happen? '
Make sure that the picture is understood. In this stage of the lesson the problem is established.
c.
Ask:' How could this be prevented ? What are the correct procedures ? ' The solution to the
problem is brought out here.
d.
Having established the correct way to give injections without causing abcesses the learners
try the correct procedures practically. Get the trainees to practise injecting lemons under
supervision of other trainers.
Review the teaching stages. Ask: ' Who contributed most of the information. What role did the
teacher play? ' Show that he was building on the knowledge and skills
that the learners already had.
Ask:' What questions did the trainer ask ? What was the purpose of asking these questions ? '
Explain that the questions were guiding the learners. They were helping the learners to review
their knowledge and skills relating to giving injections. The teacher's job was mainly to ask the
right kind of questions. If none of the learners can answer a question then the teacher can explain
(or 'teach') the right answer. (You might explain that the questions asked could not usually be
answered by yes or no. The questions required the students to think in order to give an answer.)
4 Demonstration of a new skill
' Most of the teaching that you will do at sector level is related to skills. The best way to teach a
skill is through demonstration. We will discuss some points about helping people to learn a skill
from a demonstration.'
The trainer carries out a poorly prepared and unclear demonstration.
Ask: ’How could the demonstration be improved?'
Video ref:
List the points on the OHP
Show the video of a demonstration of sterilising syringes done well.
Discuss the good and bad points about the two demonstrations. From this discussion the following
points should be brought out: (Show on OHP)
37
OHP 8
rr
Get everything ready and make sure it is in working order before the demonstration.
2
Make sure the learners can see everything in the demonstration.
3
Plan to stop after major steps (if possible) to check that learners are following.
4
Anticipate the parts of the demonstration that might be difficult Give good explanations
and check that the learners understand.
5
Once the learners have observed the demonstration they should try themselves under the
supervision of the trainer.
|6
Summarise the main steps of the demonstration.
Each group is given one topic for which they are to prepare a demonstration. They are required to
list:
1
the materials needed
2
the steps of the demonstration indicating those they think will be the most difficult for the
learners to follow.
The topics are:
I
ORS for VHGs
II
cord cutting and dressing for TBAs
III
dressing a wound for workers (male and female)
Group leaders report back and discuss with the main group.
5 Assess the learning and provide feedback
' The reason why you teach your staff is either because they make mistakes or because they are
learning a new skill. In both cases you want them to learn how to carry out these skills
competently. To find out if they can carry out these skills competently you should observe them
using these skills in the field. If they are making mistakes, then you should show them how to
correct their mistakes. ’
Video ref:
Show the video of a learner, back in her sub-centre after training, doing the task that was
demonstrated earlier in the module (ie sterilisation of syringes).
Parts of the task are performed incorrectly.
Ask: ’How was the task carried out?’
OHP 9
List comments on the OHP using the following format:
r problems and mistakes
action to be taken
y
List the points of feedback on the OHP in the format shown above.
Ask: ' How could the trainer have corrected these mistakes by providing feedback ? '
The trainees do a role-play of the trainer providing feedback to the trainee, demonstrating faults
practically.
OHP 10
Ask: ' How could the Health Assistant follow up the performance of this worker when doing this
skill? ' (Refer to the discussions in the module on indirect supervision) Demonstrate the link
between supervision and training with the OHP slide.
6 Use of visual aids
' It will often help our teaching if we can show a picture or diagram. Let us discuss a few points
about showing what we call 'visual aids'. ’
The trainer uses a visual aid (eg a flip chart on nutrition) badly. He shows it to only some of the
class and does not explain the meaning of the picture.
38
Ask: ’ How well was the visual aid used? Could everyone see it? Did everyone understand it ? If
not, why not? ’
Points to cover
the visual aid must be visible to all
I
check that the learners understand the visual aid (eg what is in the picture)
II
do not use too many visual aids - this will confuse the learners
in
put the visual aid away when it has fulfilled its purpose
IV
Ask several participants to practise showing a visual aid so that everyone in the class can see it
clearly and to practice helping people to understand what is in the picture and what the meaning of
the picture is.
Trainer's notes___________________________ _
You need to select visual aids that are a little difficult to understand, at least at first, but the
participants using them should be briefed beforehand about their meaning.
7 Preparation of a training session and teaching notes
' Now that we have discussed some of the basic skills for teaching let us look at how we can
prepare a lesson for teaching.'
OHP 10
Ask: ' How should the topic for the training session be chosen? ' (Refer to the discussion on the
uses of a supervision checklist from the module on direct supervision. Show the link between
supervision and training on the OHP.)
Show how preparing teaching notes can be a way of planning a training session. Using the
example of a lesson on how to test urine for albumin, show how the following questions can be a
guide to planning the session: (Show the questions on the OHP)
OHP 11
What is the purpose of this session? What should the learners be able to do at the end of
the session?
II
What materials are needed for teaching and practice for the learners?
How is the topic going to be introduced? How to create interest from the start? (Think
in
back to the reason for selecting this topic.)
IV
What are the main points to be taught for this topic? What questions are you going to ask
if guided discussion is being used? What demonstrations are required? What do the learners need tc
practise?
V
How can you check if the learning has been successful? What can you do if it is not? J
Fill in the answers to these questions regarding the planning of a lesson on how to test urine for
albumin with the help of the trainees.
Trainer's notes__________________________
The following is a guide to the kind of answers you might give to the questions above :
the learners will know the reason for testing urine for albumin and they will be able to
I
carry out the test using equipment they normally take to the field
test-tube and holder, spirit lamp and spirit; matches; sample of urine; dilute acetic acid;
II
water and soap
show real mother (or picture) with oedema; talk about a recent ante-natal case in the sector
in
who had oedema or pre-eclampsia
a. albumin in the urine of a pregnant mother can be a sign of pre-eclampsia which can lead
IV
to still-birth or even death of the mother
b. it is possible to detect the presence of albumin in the urine by doing the following test
c. demonstration of testing urine for albumin using field equipment
d. learners practise testing urine for albumin
39
Questions to ask:
- what are the possible dangers to pregnant mothers ?
- what is the significance of albumin in the mother's urine ?
- how do you test urine for albumin ?
- for how long should the urine be heated ?
- how do you know if albumin is present ?
- what advice should you give to a mother if you find albumin in her urine ?
V
by return demonstration and asking questions about why urine should be tested for
albumin; if the learners do not understand, do the demonstration again and check the way they are
doing the tests in the field
8 Micro-teaching
I Introduction
’ We have talked about different aspects of teaching. The only way to really learn how to use the
new ideas that have been introduced is to use them. Therefore in this section you will prepare
lessons in groups and you will teach them to nursing students, VHGs etc.'
II Preparing the lesson
A topic for teaching (15-20 minute session) is given to each group. The group prepares a teaching
plan and decides what visual aids they would like to have. This is discussed with the trainer sitting
in on the group and those visual aids that are available are provided to the groups.
Choice of topics:
1
How to make ORS to TBA
2
How to measure HB% to TBAs
3
How to dress a wound for VHGs
4
Need of Family Planning to VHGs
5
What is tubectomy to TBAs
6
Control of leprosy to MPWs
The trainees then practise teaching their lesson within the group. The other members of the group
act as students but also discuss the teaching and the content of the lesson critically, so as to ensure
the best performance in front of the class. The trainers should ensure that this stage is carried out
thoroughly as it is important that the 'teachers' are reasonably confident before they teach to their
'students'.
III Teaching observation form
Explain the use of the teaching observation form referring to the material taught in the module.
This mainly covers the use of teaching points that have been discussed in this module. It will be
used by one group at a time, or all the participants, while a member of a different group is
teaching. Explain the purpose of the form and give examples of the kind of comments to be made.
IV Teaching the lesson
The 'teachers' are given 10-15 minutes to teach their lesson. Do not hesitate to stop the lesson if it
goes on much longer, as otherwise there will not be enough time for each person to teach their
lesson. The 'teachers' should be selected at random, so that everyone is prepared to teach.
V Discussion of the lesson
After each 'lesson' time should be given for the trainees observing to fill in their forms - 3 or 4
minutes. The discussion that follows should be well-controlled by one of the trainers to get the
maximum benefit from the comments made by the trainees. After the observers have reported on
the teaching the other trainees should be invited to add comments.
The trainer may add one or two important observations if he/she thinks they have been omitted.
But be brief. It is important that throughout more emphasis is put on the positive aspects of the
teaching.
Trainer's notes________________________________
It might be preferrable to divide the participants into two groups for teaching, with trainers in each
group, and to run the micro-teaching sessions in parallel. This would give time at the end of the
module for practising teaching on a one-to-one basis as might be done by a supervisor with a
worker.
40
VI Summing up
Throughout the micro-teaching the trainer should be taking notes on the important points that
come out of the discussions of the teaching. He/she should use these for summarising the major
points from the micro-teaching exercise.
The assessment will be based on the performance in the micro-teaching.
9 Summary of the module
Distribute and explain the reference notes for this module.
I
41
for participants
Questions to ask when preparing a training session
task:
42
1
What is the purpose of this session?
What should the learners be able to do at the end?
2
What materials are needed for teaching, and for the practice for the learners?
3
How is the topic going to be introduced?
4
What are the main points to be taught for this topic?
5
How will you check that the learning has been successful?
for participants
Teaching Observation Form
Topic
Date
Teacher
Observer
1 Introduction of the topic :
a. relevant
b. interesting
c. too long
2 What main points were/were not covered ?:
3 Visual aids properly used (what is wrong ?):
4 Has the learning been successful ?:
If ’yes', why ? If 'no', why not ?
5 Other comments or suggestions:
43
for participants
reference notes
5 Training
1 In-service training
I
most of the training done by health assistants is to improve or correct knowledge and skills
that workers have (or should have) learnt during their initial training or new skill required due to
changed situation.
II
adults only learn successfully if they feel the need to learn; therefore you should only teach
things that are relevant to their work
III
people with little or no formal education can learn difficult things if they are taught using
simple explanations, and simple pictures and diagrams and everyday language instead of technical
words or English.
2 Guided discussion
You can involve the learners in the lesson by asking questions first to find out how much the
learners already know. In this way you can guide them through the learning process without
unnecessarily repeating things that they know, but explaining things that they do not know.
3 Demonstration
You will need to teach many different skills at sector level. This can be done best through
demonstration. The following points should be observed when carrying out a demonstration :
1
Get everything ready and make sure it is in working order before the demonstration.
2
Make sure the learners can see everything in the demonstration.
3
Plan to stop after major steps (if possible) to check that learners are following.
4
Anticipate the parts of the demonstration that might be difficult. Give good explanations
and check that the learners understand.
5
Once the learners have observed the demonstration they should try themselves under the
supervision of the trainer.
6
Summarise the main steps of the demonstration.
4 Assessing learning and providing feedback
It is important to check how your workers are now using the skills in the field that you have
taught them Visit them in the field and correct their mistakes if necessary.
5 Using visual aids
Visual aids can help make your teaching clearer. When using them remember the following points:
I
the visual aid must be visible to all
II
check that the learners understand the visual aid (eg what is in the picture)
III
do not use too many visual aids - this will confuse the learners
IV
put the visual aid away when it has fulfilled its purpose
6 Preparing a lesson
The following checklist can be used for the preparation of a lesson :
I
What is the purpose of this session? What should the learners be able to do at the end of
the session?
II
What materials are needed for teaching and practice for the learners?
III
How is the topic going to be introduced? How to create interest from the start? (Think
back to the reason for selecting this topic.)
IV
What are the main points to be taught for this topic? What questions are you going to
ask if guided discussion is being used? What demonstrations are required? What do the learners need
to practise?
V
How can you check if the learning has been successful? What can you do if it is not?
44
Summary of Managing
Work
° °
time 1 hour
Provide the following summary of the past three modules :
I
One of the roles of the Health Assistant as the manager of the sector is to ensure that the
work is done efficiently and effectively. The first thing the Health Assistant needs to know is what
work is being done and how it is being done.
2
This can be found out in various ways:
I
Work can be observed by the Health Assistant actually while it is being done. This can be
called direct or concurrent supervision. It is useful to use a checklist for this kind of supervision:
it guides the observer to look at the different elements of work; it serves as a record of how the
work was done which can be used for follow-up supervision or to identify topics for training. The
checklist can be written at the front of a notebook and used for every kind of work done by the
worker.
II
The site where work has been carried out can be visited after the work has been done. This
is called consecutive supervision. The Health Assistant can sometimes see if work has been done
properly, or at all, and may talk to the local people to find out about the work done.
III
Records, if used intelligently, may tell the Health Assistant not only about whether work
has been done or not, but how effectively it has been done. They may also indicate that problems
exist in implementing the work.
IV
With a variety of sources of information about if and how the work has been done, the
Health Assistant should often be able to cross-check the information. This will provide more
accurate and often more useful information on which to act.
3
The Health Assistant needs to be able to sort out all the information available to him/her.
There may be many things that he/she has written on the checklist about the way a worker did a
particular job, but if all this is told to the worker at once, the worker will not be able to remember
everything and will not be encouraged by knowing he/she has made so many mistakes. So only the
major mistakes should be selected for feeding back to the worker.
If records are to be a useful tool for supervision they must be used intelligently. Often they will
indicate that something is wrong, but the Health Assistant will have to go to the field or talk to
the worker to find out exactly what the problem is.
4
With the information collected and the important bit selected, the Health Assistant must do
something if the quality of work is to be improved. This may mean helping the worker to solve
problems in the field or at the sector meeting; it may mean providing some form of training to the
worker if the particular skill is not known properly; it may mean taking disciplinary action.
5
All these points about supervision and training will help the health assistant to improve
the performance of the workers at sector level. Work performance is also related to factors that have
not been discussed here. In later modules ways of motivating staff to work well, and ways to
coordinate their work with that of their colleagues will be discussed.
45
6 Managing staff
time 1 day
I '
Learning objectives
On completion of the module the participants wUl be able to:
1
examine the attitude of a worker towards doing a task
2
understand how inappropriate attitudes can affect the quality of work
3
take action to change the attitude of a worker to doing a particular task
Description of the module
The section of the course on Managing Work covered ways of ensuring that work is done
effectively and efficiently. In some cases this may only require guidance by the health assistant to
help the worker improve his/her skills. In this module we discuss the problem that can be best
described as being due to the 'attitude' of the worker. Each of the participants will face different
problems with their workers. It would be presumptuous for trainers to expect to be able to solve
all these problems by quoting 'personnel management' theory. Instead, several case studies showing
different attitudes of workers are used to provoke discussion. With a little guidance from the
trainers the participants are expected to provide some solutions to the problems, based on their own
experiences. In conclusion some guidelines for dealing with staff management problems are given.
Teaching materials
1
2
3
4
5
Videos of case studies A & B
OHP charts 1& 2
Thermos flask
Worksheets for participants
Reference notes for participants
Steps of the module
1 Introduction
We have spent a lot of time looking at the work done by staff delivering the health services. We
have also looked at ways of improving that work done through helping the workers to solve their
problems and by providing training where the worker is lacking in skills or knowledge. To make
things simple, we will call the problems described above and in the section on managing work
'work problems'. However, many of you will feel that you might be able to solve all their
problems and give them as much training as they required, but still they would not work well.
Some people say the problem is due to their 'lack of attitude', or that the workers are not
'motivated'. We can call this kind of problem a 'staff management problem.'
' The health assistant can detect 'staff management problems' by observing the work of the staff.
Work problems' may may sometimes be symptoms of 'staff management problems' (or an
unsuitable attitude for the work). For example, in the module on indirect supervision we saw that
the population figures for Maligaon section were incorrect - a 'work problem' - but it seems quite
probable that the worker had been lazy and avoided going to the field - a 'staff management
problem'.
Before we can find the solution to any problem, we need to find out exactly what the problem is.
Saying that the worker has 'no attitude' vaguely describes the problem, but it needs to be described
more precisely if a solution is to be found. Even when we have understood the problem, we cannot
be sure of the best way of dealing with it. We may have to try several different things before we
get it right. So when we look at why a worker is not working properly, we should try to think of
two or three different ways of encouraging him/her to work more effectively.
'In this module we will look at three situations where the worker is not working properly. We
think that you may have workers like the ones in these situations, so you may have suggestions
about how to get the worker to cooperate more in the work.'
47
2 Ask the participants to observe the following case study on the video
Case study A
The video shows a female worker discussing her records with the health assistant. From the
records the health assistant finds that the worker has not been checking the foetal heart sound when
doing regular ante-natal check-ups. When the health assistant asks her why she has not been doing
this, she makes many different excuses. Though there may be some problems, it seems clear that
she is not really trying to check the foetal heart sound.
Discuss the case study using the tables and the questions below as a guide:
OHP 1
'x
Work
problem
Consequences
of the problem
Staff
management
problem
(attitude)
Possible
solutions to the
staff man.
problem
What is the problem here?'
What might happen if the FHS is not monitored? (What are the consequences?)'
Why do you really think the FHS is not being monitored?'
'How would you find out?' 'Do you have similar problems with your own workers. Give
examples.' Suggest that some workers may not be taking the haemoglobin of AN mothers, or
making proper stencils when visiting a household. What do you do about it? What do you think
the health assistant seen in the video could do about her worker not monitoring the FHS? Give
several alternative suggestions, as you can not be sure which one will work.'
Discuss the merits and demerits of each suggestion.
Point out that it will be bad to let the worker continue avoiding monitoring the FHS. Other
workers may follow her example . The health assistant must try something!
Trainer's notes______________________________
The 'work problem' here is that the FHS has not been monitored. If the FHS is not taken, the
worker might not realise if the baby has already died. So the consequences could be very serious.
The worker has given several different reasons why she has not taken the FHS, but it is rather
suspicious that for every case she has an excuse. So the real problem is not a 'work problem', but a
'staff management problem'. It may be because the worker does not want to carry the equipment
needed to the field, or because she does not bother to monitor the FHS. Whatever the reason, the
FHS is not being monitored and the health assistant must find a way to solve this problem. The
first thing that could be done is to check the truth in the excuses made by the worker. People who
give excuses for not doing work rely on the fact that the supervisor will not take the trouble to
check the validity of their excuses. If this is done once, the worker may hesitate to make such
excuses again. Next, the health assistant should find out if the worker understands the importance
of taking the FHS and help her if she has any difficulties (for example, with the technique, or
persuading people to allow her to examine them, or problems with carrying or obtaining the
necessary equipment). The health assistant should follow up the worker to check that she is still
taking the FHS after several weeks.
3 ’Let us look at a second kind of staff management problem.' Ask the
participants to observe the following case study on video:
Case study B
The video shows a woman at her home. She is suffering from a bad headache. She sees the health
worker walking past and calls him over. He does not really listen to her complaint and just hands
her some medicine without explaining properly how it should be taken. He leaves in a hurry to go
somewhere else. Though he has given medicine to the woman, he has not told her how to take it,
or what do to if her headache does not get better. He has not been very helpful to the woman.
Exercise 1 (If the participants are having difficulty with the ideas in this module, it may be better
to do this exercise with the class, rather than in separate groups.
Divide the participants into THREE groups. Ask them to prepare the answers to the following
questions using worksheets provided for them. You should record them on the OHP on a table as
given below:
48
Work
problem
Consequences Staff
of the problem management
problem
(attitude)
Possible
solutions to the
staff man.
problem
'How is the worker behaving?'
What happens when the health worker behaves like this?’
Why do you think the health worker is behaving like this? How would you find this out?'
'Do you have similar problems with your health workers? Give examples.'
What do you do about it?'
'How would you encourage this worker to be more helpful to village people when they are sick?
Give several alternative suggestions as you cannot be sure which one will work.'
Discuss the merits and demerits of each suggestion.
Trainer's notes______________________________
The worker seems unwilling to stay long with the patient; perhaps he has a lot of work to do? He
does not talk to her in a sympathetic manner; he says that she is always complaining of headaches.
The woman may have a serious complaint, but he is ignoring it, merely giving medicines. If he
speaks to people in the village in this manner, they will not like it and the worker will find it
difficult to get their cooperation.
The health assistant should explain to the worker how the woman might feel when treated like
this. Then the worker might understand better the possible consequencesof acting in this manner.
If this appears to be a problem with most of the workers in the sector, it might be better to bring
the matter up at the sector meeting, or some similar occasion. It might be possible to act out this
kind of situation in role-play; by doing this it is much easier to talk about how people might feel.
It is difficult to explain in words how the worker should talk to the village people; it is much
easier for the health assistant to go to the field with the worker and set an example him/herself.
4 'Let us look at a third example of a staff management problem.' This case
study is presented by a narrator and two actors.
Case study C
Alatpur in Keonjhar district is a small tribal village under Padampur PHC. In the morning almost
all the people go off to the jungle to collect firewood, leaving their small children and old parents.
A female health worker (who took up her post only six months ago), had made a schedule to visit
the village once a fortnight, is now visiting their village carrying her thermos flask as she is
planning to give TT injections to pregnant mothers. She moves round the villages and finds only
children and some old persons. Asking them she finds out that people have gone off for cutting
firewood to earn their food. She becomes angry and tells the old people that these people are very
bad and they have never been in the village during her visits. She says she has made three visits to
the village, but each time she finds no-one and returns without any achievement The TEA is
ungrateful; she has not given her the list of pregnant mothers and she is not present now, so her
time has been wasted.
On her return she met with the TBA who tells the female worker that
- she did not tell her (the TBA)
- she did not find a suitable time to meet with the village people
- she has no patience to wait until the mothers return from the jungle
- her visit to the village has been wasted
Exercise 2
Use the same table as given for the previous case studies and have the participants work in the
same groups.
'What is wrong with the work of the ANM?'
Why might this be so?’
What might happen if the worker continues to work like this?'
’Do you have similar problems with your own workers? Give examples'
'How could you help the worker in the case study to do her work better? Give several suggestions.'
49
Trainer’s notes_______________________________
The worker is probably thinking about her work in the wrong way. She thinks that the people
should be there when she decides to visit; it would be better if she realised that they had work to do
and tried to come when it was convenient for them. Or she could have gone to the fields where they
were working. She went to do her work and met with a problem (the people were not there), but
she did not try to solve the problem herself. Instead she returned to the sub-centre having made a
wasted visit
It is not an easy thing to do, but part of the work of a manager is to help his/her workers to think
for themselves. This means that they should feel responsible for their work. It might be possible
to help them to feel more responsible for their work if they are allowed to help make decisions or
plans about their work, either at the sector meeting, or when the health assistant visits the worker
at the sub-centre. It also helps if the health assistant takes an interest in the quality of the MPWs
work, and given praise when he/she solves problems on his/her own.
5 Summary discussion
'We have talked about different attitudes of the workers in this module. However, attitudes are
vague things and it is not always possible to be precise about the exact nature of the staff
management problems that you face; also, you cannot expect to be able to solve all of these
problems. But when faced with staff management problems, examples of which have been shown
in the three case studies, the health assistant might use the following questions to help solve the
problem: (show on OHP)
OHP 2
fl
II
m
IV
50
What is the 'work problem?'
Why is there a 'staff management problem?'
What are the likely consequences of this 'work problem?' How serious are they?
How can I solve the problem using some of the following techniques:
a. Setting a good example myself (acting as a role-model).
b. Helping the worker to understand the harmful consequences of his/her way of working.
c. Providing training.
d. Getting the workers to act out problems in role-play to learn by experiencing being 'in
the other person's shoes'
e. Helping the worker to solve problems him/herself.
f. Verifying excuses given by the worker, etc, etc.
y
for participants
Exercise 1
Work
problem
Consequences Staff
of the problem management
problem
(attitude)
Possible
solutions to the
staff man.
problem
’How is the worker behaving?’
'What happens when the health worker behaves like this?’
Why do you think the health worker is behaving like this? How would you find this out?’
’Do you have similar problems with your health workers? Give examples.’
What do you do about it?’
’How would you encourage this worker to be more helpful to village people when they are sick?
Give several alternative suggestions as you cannot be sure which one will work.’
Exercise 2
Work
problem
Consequences Staff
of the problem management
problem
(attitude)
Possible
solutions to the
staff man.
problem
What is wrong with the work of the ANM?’
Why might this be so?’
What might happen if the worker continues to work like this?’
’Do you have similar problems with your own workers? Give examples.’
’How could you help the worker in the case study to her work better? Give several suggestions.’
-jm- no
6
■9 r LIBRARY
AND
»<
DOCUMeNTATION
<
UNIT
ng a
>
J
i
51
for participants
reference notes
6 Managing staff
i
Sometimes your workers will know the skills they need and have enough supplies and
equipment, but still they are not doing the work effectively. Sometimes we say this is due to their
'lack of attitude'. It is often possible to improve the attitude of the worker, but first it is necessary
to understand what their present attitude is and why it is like this.
We can see people's attitude in the way they do things. You have seen examples of the way a
worker was making excuses because she had avoided monitoring the foetal heart sound; the way a
worker had little sympathy for the woman suffering from headaches; and the worker who went to
do the immunisation, but did not take the responsibility for seeking an alternative way to do the
work when she came across a problem.
2
When faced with staff management problems, examples of which have been shown in the
three case studies, the health assistant might use the following questions to help solve the
problem:
I
What is the 'work problem'?
II
Why is there a 'staff management problem'?
III
What are the likely consequences of this 'work problem’? How serious are
they?
IV
How can I solve the problem using some of the following techniques:
a Setting a good example myself (acting as a role-model).
b Helping the worker to understand the harmful consequences of his/her way of working,
c Providing training
d Getting the workers to act out problems in role-play to learn by experiencing being 'in
the other person's shoes'.
e Helping the worker to solve problems him/herself.
f Verifying excuses given by the worker.
52
7 Conducting Sector Meetings
time 1 day
Learning objectives
On completion of the module the participants will be able to:
1
know the value of sector meetings for management purposes
2
create a good atmosphere for running a meeting
3
plan a well-structured meeting
4
help the meeting to reach decisions
record, report and follow up decisions made
5
encourage workers to attend the sector meeting
6
Description of the module
The health assistants (male and female) are jointly responsible for the field health programme in
their sector. In the weekly sector meeting they can review the previous week's health activities
done by the MPW (male and female), VHG and TBA. They can plan and coordinate the
programme for the following week. Problems in implementing the work can be identified and may
either be solved or referred to the medical officer in-charge. The sector meeting is an opportunity
for developing the skills and attitudes of the staff and regular meetings will help to develop a team
spirit among them.
This module covers the purpose of the sector meeting and ways of making it an effective
management tool. The need for a well-planned meeting conducted in an atmosphere where all
members can discuss problems freely is shown. Ways of using these meetings for solving
problems and making decisions are discussed. The participants have practice in conducting 'mini
meetings'.
Teaching materials
i
2
3
4
5
Video of a sector meeting
Video of decision-making in a meeting
OHP chart 1
Checlist for observing role-play meeting for participants
Reference notes for participants
Steps of the module
1 The purpose of the sector meeting
Begin by asking the participants if they conduct sector meetings on a regular basis, or even at all.
Ask why some people do not conduct sector meetings.
Ask participants who say they are conducting sector meetings what the purpose of the sector
meeting is. Record their responses on the OHP.
Trainer's notes______________________________
Possible responses on the purpose of the sector meeting:
- supervision and monitoring of work done.
- planning of work (regular programmes, camps, etc.).
- training staff to improve their skills (based on observation from supervision).
- coordinating work of different staff (eg collection of vital statistics, motivation of eligible
couples).
- identifying and solving problems in implementing programmes (through discussion, by checking
records, etc.)
- making decisions about the implementation of programmes.
- creating a team spirit
- developing a competitive attitude amongst workers etc, etc.
53
'Meetings of any kind take people away from their daily work. If ten people attend the sector
meeting, then almost ten 'man days' of work have been lost for the sector achievemenL If the
meeting successfully improves the quality of work done, then the time is well spent If the
meeting is only for the workers to hand in achievements to the health assistant and for idle chit
chatting, then much valuable time will have been wasted. Sector meetings can only achieve the
functions listed above if they are conducted effectively and efficiently. We will first observe part of
a sector meeting on video and then discuss some ways to make the sector meeting more
successful.'
Video ref:
2 Observing a sector meeting
The participants are asked to observe exceipts of a sector meeting on video. This will be discussed
afterwards only briefly. Ask: ' Is this like your sector meetings? How are they different?' However,
the trainer should refer to relevant parts of it when discussing the points about conducting meetings
given below.
3 Planning and preparation of the meeting
'Before the meeting starts, the health assistants (male and female) must be clear what they want to
achieve by this meeting. This means that the activities and the topics for discussion must be
planned in advance.'
'If a meeting is too long people will become bored and lose interest If this happens, the meeting is
no longer useful. The health assistant should decide which items are necessary for the meeting and
only discuss those items. People may pay less attention towards the end of the meeting, so it is
better to put very important items for discussion near the beginning of the meeting.'
The health assistant must therefore make a list (agenda) with time required of the important
activities and points for discussion. The most important items should come towards the beginning
of the list.'
Ask if an agenda was used in the meeting shown on the video. What was the consequence of this?'
Discuss how the health assistant could prepare an agenda for the sector meeting, and what items
they might put on the agenda.
What other things might you need for your meeting, eg records, charts?'
4 Creating a good atmosphere
'As we have mentioned above, the sector meeting should help to develop a team spirit amongst all
the staff at sector level. If the staff are to work together as a team, it is important that everyone
should be involved in discussions, planning, problem-solving and decision-making. This will only
happen if the meeting has an atmosphere that makes people want to contribute and work together.
The health assistant, as chairman of the meeting, can do several things to create such an
atmosphere.'
OHP 1
I
the seating arrangement
'It is easier for people to discuss things with each other if they sit facing each other. A small group
of people can sit in a circle. This makes discussion easier and also helps people to feel more
involved in what the group is doing.'
Discuss the seating arrangement in the sector meeting on the video. What were the consequences?'
Discuss ways in which the participants could arrange the seating for meetings in their own sectors.
Show an arrangement on the OHP.
II
involving everyone at the meeting
'What happens if only one or two people speak at a meeting? What benefit do those who remain
silent get from the meeting?'
Discuss the involvement of the different staff in the sector meeting in the video.
'What were the consequences of this?'
'How can the health assistant ensure that all participate in discussions?'
'The health assistant can ask those remaining silent what they think of the topic being discussed,
or they may be asked to comment on something one of the more talkative staff has just said.
However, care should be taken not to do this in a threatening manner.'
III clear communication in the meeting
'If people are to discuss a problem in order to find a solution to it, the background and the nature of
the problem must be clearly explained to the meeting (problems often remain unsolved or are
incorrectly solved because the meeting has not fully understood what the problems are). This can
54
only happen if everyone is listening. It is therefore necessary for the health assistant to ensure that
only one person talks at a time.’
Discuss how clear the discussion in the sector meeting on the video is. 'What are the
consequences?’
Ask the participants if they have noticed such problems in either their sector meetings or the
monthly meetings at the PHC.
Summarise the three points about creating a good atmosphere at a meeting.
Video ref:
5 Making decisions
The participants observe a second video of part of a meeting in which ways of coordinating the
efforts of the male and female MPWs are being discussed. A decision appears to have been reached,
but it is not exactly clear what the decision was.
Ask the participants to write down what decision was taken at the meeting. Discuss in the class.
Discuss the reasons why the decision made seemed unclear. ’What might be the consequence of
this?’
The health assistant should summarise the decision made before moving on to the next item on
the agenda.’
Discuss what happens after a decision is made.
How is it recorded?
How is it reported to the PHC?
How can it be followed up to ensure that the decision is being implemented?
’Recording of decisions in the meeting register needs to be clear and precise. It is not useful to
record that ’a plan was chalked out for an opinion leaders’ camp’. The actual plan needs to be
recorded, otherwise it will not be possible to check whether it has been done according to the way
it was planned and discussed in the meeting.’
6 Role-play of conducting a meeting
The purpose of the exercise is to practise some of the things that have been taught about running a
successful meeting.
The participants are divided into two groups. They select a topic to discuss in a role-play of a
meeting. Each group works together for 10 minutes to prepare their arguments.
Explain to the participants that one member from each group is chosen as the Health Assistant
who will run the meeting. He/She must ensure that the best seating arrangement is used; that
communication during the meeting is clear, and that members of the meeting are equally involved
in the discussions; that a decision is made and recorded.
The second group will act as observers of the meeting. They will be given a checklist and will be
requested to observe the following points in particular:
1 how was the seating arrangement?
2 how clear was the communication between different members of the meeting?
3 were the members of the meeting equally involved?
4 what decision was made by the meeting?
5 was the decision clearly stated and recorded?
The ’meeting' will discuss the topic for approximately 10 minutes. They will then be asked to stop
and the group observing will comment on their performance. List the comments on the OHP.
A second group will then conduct their meeting and the first group will observe. This will then be
discussed.
The trainer summarises the good and bad points about the two meetings.
7 Motivating the workers to attend the sector meeting
'We have discussed ways in which you can make your sector meetings more effective. But some of
you may be thinking that all this would be very nice, but you cannot get your workers to attend
the sector meetings at all. How do you think you could motivate your workers to attend the sector
meeting?’
Discuss the following suggestions (according to the situation) for motivating workers to attend the
sector meeting:
I Make the meeting attractive:
- chance to learn
- appear to be useful
- try not to make it boring
55
- try to solve personal problems
II Introducting the idea of sector meetings:
- start by organising meetings once a fortnight then later make the meetings weekly
- one good and useful point per meeting
- talk to each worker personally before first meeting so not a failure
- ask for suggestions for training topics
8 Summary
Distribute and explain the reference notes for the module.
56
i
",
for participants
Checklist for observing role-play meetings
1 how was the seating arrangement?
2 how clear was the communication between different members of the meeting?
3 were the members of the meeting equally involved?
4 what decision was made by the meeting?
5 was the decision clearly stated and recorded?
57
for participants
reference notes
7 Conducting sector meetings
1 The purpose of the weekly sector meeting is for
- supervision and monitoring of work done
- planning of work (regular programmes, camps, etc.)
- training staff to improve their skills (based on observation from supervision)
- coordinating work of different staff (eg collection of vital statistics, motivation of eligible
couples)
- identifying and solving problems in implementing programmes(through discussion, by checking
records, etc.)
- making decisions about the implementation of programmes
- creating a team spirit
- developing a competitive attitude amongst workers
2 Weekly sector meetings will only be useful if they are conducted effectively and efficiently. In
order to encourage free, frank and useful discussion the health assistant should pay attention to the
following points:
I
planning and preparation:
so that the health assistant can be guided by the agenda and the most important points of the
meeting can be covered
II
the seating arrangement:
so that it is easy for everyone to join in the discussion
III
involving everyone at the meeting:
so that good planning and decisions can be made and workers will feel more responsible for their
actions if involved in this way
IV
ensuring clear communication :
so that everyone understands problems being discussed, information given, decisions made
V
making decisions:
so that action can be taken based on these decisions and problems are not aimlessly discussed
VI
motivating workers to attend meetings:
so that they will feel that the sector meeting can help them to improve their work and the
acheivements of the sector as a whole
58
8 Educating and motivating target groups
time 2 days
Learning objectives
On completion of the module the participants will be able to :
1
know some general principles of giving health education
2
practise using general principles to select and adapt health education messages in a given
case
3
plan out a health education programme
4
to direct and assist others (workers and villagers) to impart health education
5
identify problems in respect of motivation for acceptance of services and find out possible
solutions
6
assess the beliefs and circumstances of an eligible couple and adapt his/her approach to
motivating them to adopt family planning measures accordingly
Description of the module
The module is in two parts. In Part 1 the need for health education is introduced through a case
study about scabies. The following steps for teaching about health are suggested and illustrated
with examples : understand the health message thoroughly; set a good example yourself (if
possible); understand the beliefs and practices of the target audience; adapt the health message so
that it is appropriate to the target audience. This is followed by an exercise based on a second case
study to practise using these steps. The need to follow up health education work is discussed and
ways of involving the workers, VHG/TBAs and local inhabitants in giving health education are
suggested.
In Part 2 of the module, the problem of persuading people to accept programmes provided by the
health service is discussed, in particular the family welfare programmes. The main steps in
motivating target couples are also covered.
Teaching materials
i
2
3
4
Case studies A & B
OHP charts 1-5
Worksheets for participants
Reference notes for participants
Steps of the module
PART I (1 day)
OHP 1
1 What is Health Education and why is it necessary ?
Present the following case study by telling the story and showing the picture on the OHP.
Case study A
Mr Tikam Das, a daily wage earner, works in an agricultural firm. He gets Scabies infection from
a co-worker. He gets heavily infected with Scabies and finds it difficult to work. So, he
contacts an MPW(M) for the remedy. The MPW prescribes Benzyl-Benzoate emulsion to apply
locally.
Mr Das follows the advice and the infection subsides. But, he is not fully cured. After some
time his wife complains of the same trouble. His 2-year old child also gets the infection. This
continues indefinitely.
59
OHP 2
Discussion on why this situation occurred; what the health worker did; how the problem could be
prevented; need for effective health education of people as part of the service of primary health care.
(Refer back to Introduction to the Course.)
' Health education is teaching people to understand how illnesses occur and what they can do to
prevent them and how they can lead a healthy life. However, it should only be given where there is
a need, otherwise it will simply be ignored. Now we will look at some of the stages of preparing
to give health education.'
OHP 3
2 Understanding the health message properly
'Sometimes the health woricer may 'know' the health message, but may not fully understand it.'
Discuss these examples of possible lacunae in understanding of health messages :
-substitutes for ingredients of ORS
-locally available antiseptic solution for minor wounds
-nutrition during pregnancy
-hand-washing if no soap is available
'Do your workers know these things ? '
'It will help the person giving health education to clarify the meaning of the health message if
he/she answers the following questions : (Show on OHP and explain using the example of ORS)
-what is the overall meaning ?
-what are the details ?
-what is the relative importance of the different details ? (what if I have not got...?)
Trainer's notes________________________________
The overall meaning of the message about rehydration solution is that when a child has severe
diarrhoea, the body loses a lot of liquid and this has to be replaced otherwise the child will die. The
details of the message are that glucose and salt should be added to water - glucose to give energy
and salt to replace lost minerals. Glucose can be got from sugar, honey, molasses, etc. The details
also include the quantities of the different components of the mixture and the amount and frequency
of the dose. The highest priority is to give fluid - any kind of fluid, even if glucose and salt are
not available. The next priority is glucose; giving salt alone may make the child sick and thereby
vomiting all the fluid given.
3 Setting the example yourself
' If the MO does not use an agenda in the PHC meeting, you may not use one in your sector
meeting, either. For some health messages someone who acts as an example (a role-model) is
important. '
Discuss possible ways for health workers to act as a role-model for messages about:
-latrines, sanitation
-cleaning wounds with salt water
-immunisation
-family planning
-not smoking
' It is difficult to persuade people to do things if you do not appear to be convinced of their value
yourself. ’
' Also, if you put these ideas into practice yourself, you will understand some of the difficulties of
implementation, and therefore make a better teacher. What difficulties have you yourself
encountered with :
-keeping a kitchen garden
-building a smokeless chula
-getting clean drinking water
-prevention of mosquitoes
4 Understanding the target audience: understanding their present beliefs and
practices, and the reasons for them
' Some people believe that when a child has diarrhoea you should stop giving fluids so that the
diarrhoea will dry up. This practice is very harmful, as the child could become so dehydrated that it
dies. There is a festival called 'anaprasana' when a child reaches the age of six months; the child is
ceremoniously given its first solid food. This practice is good, because this is when weaning
should begin. Some traditional beliefs and health practices are good and should be encouraged.
Some are harmful; it is these that the health worker should seek to change. '
60
washing hands with
X
X
X
harmful
ok
good
mud, soil
ashes
soap
Discuss different examples of health practices and beliefs and mark them on the scale.
For example: treatment of fever nutrition for antenatal mothers.
' Build on good points of present practices; don't unnecessarily condemn or contradict present
practices if they are not harmful.'
' You cannot expect acceptance of new ideas too quickly; change is a slow process. People will
adopt new ideas more quickly if they are appropriate to their situation, not too difficult to put into
practice and if they believe these new ideas will help them.'
5 Adapting the message to the situation of the target group
' If you have decided on what health education message is needed; and you fully understand the
meaning of the health education message; you have tried to do the things taught in this message
yourself; and you understand the situation of the people you want to teach it to (ie their present
beliefs and practices and their capabilites), you can decide what and how to teach regarding this
health problem. ’
Explain these ideas using the example of health education about latrines and defaecating.
Trainer's notes______________________________
Take the example of a poor family. In the morning the adult members climb up a little hill behind
the house and defaecate behind a group of trees. They think that it is good to defaecate away from
the house and they like the privacy provided by the trees. However, they do not realise that in the
rainy season the heavy rains washes the germs from their faeces down into the well below which
provides the drinking water for a small group of houses including their own. The children are
allowed to defaecate where they like - usually near to the house. There is enough space to build a
latrine at a reasonable distance, but the family says that they cannot afford the building materials,
and anyway they do not appear very interested. The health worker might start by saying it is good
that they defaecate away from the house, but he might explain that because the rain wash the
germs down into the source of drinking water, it would be better to find another place instead, but
equally far away. The health worker might also point out that the faeces of the children can just as
easily spread diseases via flies, hookworm, small children putting their hands into their mouths
while playing. If the children cannot go far from the house, they should be taught to defaecate
perhaps in one particular area, which should be kept clean, and if they defaecate elsewhere, it
should be cleaned up. If the family make these small changes in their lifestyle, it is possible that
after several years they might be persuaded to construct a simple latrine. But if the health worker
only talked to them about constructing a latrine now, they would reject that advice and make no
improvement in their sanitary arrangements.
Exercise 1 (see participants' worksheet)
Exercise done in groups. Then presentation and discussion.
On the basis of the above exercise, discuss with the class the ideas that it would be appropriate for
the Health Assistant to teach to Radhu Mallick and his family.
6 Teaching techniques
List and explain briefly, comparing to module on training where relevant. Explain that there are
some differences, as, unlike the learners as discussed in the module on training, these learners being
given health education may be learning these ideas for the first time. The technique of reviewing
knowledge is not so useful here and many things will need to be explained much more simply and
clearly.
-clarity (sight, sound, language and meaning)
-helping to understand rather than lecturing
-monitoring reception (asking questions)
61
7 Follow-up and problem-solving
’ If people meet a problem - sometimes even a very small one - they may reject the new idea. You
should try to visit people to whom you have taught new health practices to find out how they are
getting on - check they are doing these things as you taught them to (follow-up supervision).
-help solve their problems if you can
-explain things which have been misunderstood
-remind about things that have been forgotten
-don't appear to be 'testing' them
-decide on indicators of change
8 Planning to involve others to help with health education
You cannot do all the health education in your sector alone and without any kind of plan. You also
need help from your workers, VHG/TBAs and the inhabitants of the sector. Also you may need
some simple materials for the success of the programme.
When any health education programme is planned, sufficient thought should be given about how to
assess the impact so that further action can be taken. Below are given some points and a planning
pro forma to be used while planning and preparing a health education programme.
I
Orientation of staff and VHG/TBAs at sector meeting about need and methods of health
education (perhaps with demonstrations by you) and perhaps with the Village Health Committee.
II
Identify, through discussion at the meeting, one or two areas of health care being provided
which especially need the support of health education (do not try to tackle too many different health
education messages at once)
m Decide at the meeting what should be taught, and how. Give staff and VHG/TBAs specific
instructions for doing health education:
-for which situations
-how often
-make a report of persons 'educated' in tour diary
IV
Say you will follow up (supervise) their health education work and ensure that you base
your follow-up supervision on their tour diaries and/or verbal reports. Talk to the families who
have been 'educated'; find out what they have learnt
V
Periodically discuss health education work at sector meetings and VHC meetings; what are
the experiences of workers and VHG/TBAs; and what are your findings from your supervision.
The pro forma provided for the exercise below on planning for health education should be explained
by the trainer using any suitable example (except TB).
Exercise 2
Working in groups again using the case study of Radhu Mallick, the participants prepare a plan for
health education using the guidelines given on the worksheet.
9 Summary of points about health education
Explain the following summary of the module so far
Many health problems can be prevented by good health practices. Many of these good
health practices can be taught to people. It is the job of all primary health care staff to educate
people about good health practices.
i
Before teaching about good health practices you should ask yourself the following
questions:
a. is the health message appropriate and do I fully understand it ?
b. am I setting a good example myself ?
c. what are the beliefs of the people regarding this particular health problem ? what do they
do now ? for what reasons ?
d. now that I understand the target group, what is it appropriate to teach them regarding this
health problem ?
ii
m
62
It may be difficult for people to understand new health practices that are very different from
their own. Therefore you must ensure that:
a. your teaching is clear
b. you try to help people to understand
c. you check out how much of your teaching they have understood
IV
You may be successful in persuading people to try to use new health practices. But they
may meet with some difficulties while using them and may eventually reject them because of this.
You, or your workers, should visit them at home to help them with any difficulties they might
have and to encourage them to continue using the new health practices.
V
It is not possible for you to carry out successful health education in your sector alone and
without making a proper plan. Workers, VHG/TBAs and local inhabitants can be involved in
teaching about health. They can help to identify areas where health education is necessary. They
will need some instruction from you on ways of giving health education (as discussed in this
module) and, most important of all, they will need your supervision and support
PART II : family planning motivation (1 day)
1 Non-acceptance of programmes
' Part of the job of the health worker in a primary health care service (as described at the beginning
of the course) is to make the people aware of the benefits of programmes provided by this service.
In this part of the module we look at problems of motivating people to accept the family planning
services provided in the block.'
The following case study is presented on video:
Case study B
Situation-Sub Centre/Sector Headquarter.
The Health Assistant is asking the MPW(F) about why she failed to bring cases yesterday for the
Camp. MPW(F) gives the following explanations.
Worker: I met with Kalpana w/o Mr Subudhi and talked to her about the camp. She refused to
listen and told me to meet her husband. I met her husband Mr Subudhi. He again refused because
they still are waiting for a son even though they have had four daughters. He tried to argue with
me. So, I left............... ?
Health Assistant: What about Saba
9
Worker: Then I went to Mallick Sahi and met with Saba. The day before yesterday, she was ready
to come to the camp. But, yesterday she refused and told me that she had learnt from Pani that
after tubectomy every woman would get serious backache/headache and other bodily complaints
and her health would be run down. Pani got the information from Madhabi who got operated 5
years ago. She was not convinced at all so, I left
Health Assistant: Did you meet Mr Reshan Ali?
Worker: No, but, I know they would refuse on the grounds of religion.
' Do you have such problems with the family welfare programmes in your area ? ’
OHP 4
Discuss the programmes under family welfare as listed below (and shown on OHP) and list the
possible reason of objection in this format
the details of
the programme
Group 1
permanent FP
methods:
possible
reasons of
objection
the
possible
solutions
discussion in
the class
discussion in
groups
tubectomy and
vasectomy
Group 2
temporary FP
methods:
Cu.T, Nirodha
MTP
y
63
After the reasons for objection have been discussed, the participants can be divided into three
groups to think about the possible ways of countering the objections. The programmes of family
welfare are divided into two sections - each group will prepare one section for about 10 minutes.
For the presentation the group that has prepared the counter arguments will face a second group
who will play the role of villagers who are not in favour of the programmes. The trainer needs to
note the arguments used by both sides as this will be useful for discussion at the end of each
presentation and later in the module.
2 Stages of motivation
' We have seen some of the problems of motivating people to accept programmes both in the case
study and in the exercise that you have just done. It will help to look at some of the steps to be
taken by the health worker while motivating people to accept programmes. ’
OHP 5
Show the steps on the OHP.
Steps of motivation
Rapport
Awareness
Interest
Realisation of needs
Trial
VI
Evaluation
VII
Adoption or rejection
I
II
II
IV
V
People cannot be motivated to accept new ideas and practices unless they realise that they will
benefit from them. So the motives lying dormant in the individual are to be activated by some
process or methods. These are explained in the following example of a worker who is dealing with
a young mother in the last stages of her first pregnancy.'
Rapport
Here is a clear case for CuT insertion, but the motivation should start right from the ante-natal
services, by paying regular and sincere visits and by showing genuine interest in the case. All the
services available for the ante-natal period should be provided: regular health check-up, iron and
folifar distribution, TT injections, health and nutrition education, teaching of mothercraft etc.
Thereby the health staff will win the confidence of the mother in a gradual process.
Awareness
At the time of informal talkings, health education etc and at the time of delivery, scientific
information about the harm done to the new-born and the mother by having repeated pregnancies
should be given in clear and understandable terms. Emphasis should be placed on the harm to the
health of the child just bom if the mother gets pregnant again within 3 years. The mother will care
more for the health of the child than for her own health. The provision under family welfare
services to defer child birth should be discussed.
Interest
Examples of successful users under similar conditions should be discussed. The mother should be
well convinced that what she will do is for the health of the child.
Realisation of needs
By repeated discussions, citing of examples of successful users in the area and showing the health
of a child of the locality where birth-spacing has been maintained, efforts should be made to help
the mother realise the need for taking such a decision herself.
Trial
The point that it is not a whole-time method and it can be terminated at any time should be
stressed upon. Since it is a terminable method, why not try it ? - you could say to the mother.
Evaluation
During the period of trial regular visits should be paid and all details should be sorted out and
complied. Maybe a little white discharge, backache, more bleeding at the time of menstruation will
occur, but the mother should be reassured that these are usual features. The mother should be told
to wait patiently for 3 - 4 cycles to see if these problems disappear.
64
Adoption or rejection
If these common problems are solved efficiently it is more likely that the mother will continue to
use the CuT. If there is little follow-up support from the health worker she may complain and
reject the method of family planning.
Throughout the period the staff have to be very much cooperative and cordial with the mother and
extend all sorts of medical/advisory services to her and the child. The atmosphere should be
developed in such a way that the mother will feel that here is a genuine friend for her.
Trainer's notes___________________________
While explaining these steps the trainer should give many examples of why people have adopted
new pactices in other fields of life eg female education, use of chemical fertiliser.
At the end of this explanation the participants should work together in groups to plan out
strategies for solving the same problems as they did in the last group exercise, but this time using
ideas that they have leamt from the steps of motivation above. They will make their presentations
in the form of role-play which can be discussed by the whole class afterwards.
Summary of the module
Distribute and explain the reference note for both parts of this module.
65
for participants
Worksheet
1
Exercise 1
Read the following case study carefully then answer the questions given below.
Radhu Mallick, an illiterate, Harijan Village Cart Driver, lives in a one-room tenement in Village
Chandpur. He earns about Rs.20/- a day. He has his wife, a grown up daughter and two male
children under 5. His wife Rama, is an active TB case. She coughs and spits out blood at times.
But, they do not go to a doctor because they believe that it is hereditary and so could not be cured.
They believe so because the grandfather of Rama died of TB some years back. Therefore they go to
a traditional magic healer instead. He gives her a piece of stone to use. But Rama's condition
deteriorates 'till the sector Health Assistant visits her. The Health Assistant motivates her and
takes her to the PHC. Her name is registered. She gets free medicine and the doctor entrusts the
responsibility of further Health Education and follow-up to the Health Assistant.
I
What health education would be appropriate here?
II
What are the details of the health message ?
III
How could the Health Assistant act as a role-model ?
IV
What is the situation of the target audience ?
V
What are their present practices and the reasons for them ?
Exercise 2
Using the case study of Radhu Mallick make a plan for a programme of health education using the
following guidelines :
66
1
Health problem
2
Health education component
3
Target group
4
Understanding the audience: negative and positive factors
5
How to impart the health education: the methods
6
Materials necessary
7
Assistance required, if any
8
Actual date-wise programme
9
How to assess the impact
10
Remarks
forparticipants
reference notes
8 Educating and motivating target groups
i
Many health problems can be prevented by good health practices. Many of these good
health practices can be taught to people. It is the job of all primary health care staff to educate
people about good health practices.
2
Before teaching about good health practices you should ask yourself the following
questions:
a. do I fully understand the health message ?
b. am I setting a good example myself ?
c. what are the beliefs of the people regarding this particular health problem ? what do they
do now ? for what reasons ?
d. now that I understand the target group, what is it appropriate to teach them regarding
this health problem ?
3
It may be difficult for people to understand new health practices that are very different from
their own. Therefore you must ensure that:
a. your teaching is clear
b. you try to help people to understand
c. you find out how much of your teaching they have understood
4
You may be successful in persuading people to try to use new health practices. But they
may meet with some difficulties while using them and may eventually reject them because of this.
You, or your workers, should visit them at home to help them with any difficulties they might
have and to encourage them to continue using the new health practices.
5
It is not possible for you to carry out successful health education in your sector alone.
Workers, VHG/TBAs and local inhabitants can be involved in teaching about health. They can help
to identify areas where health education is necessary. They will need some instruction from you on
ways of giving health education (as discussed in this module) and, most important of all, they will
need supervision and support.
6
I
II
in
IV
v
VI
The following steps can be taken to motivate target groups to accept programmes:
Rapport
Awareness
Interest
Realisation of needs
Trial
Adoption or rejection
67
9 Project
time 1/2 day
Learning objectives
By producing a project the participants will be able to have a detailed and feasible plan of action for
carrying out at least one improvement in the management of their sector. They will also learn by
listening to and discussing the presentations made by other participants.
Description of the module
The module is conducted in two parts. Part I is to explain what the project is and for explaining the
guidelines for writing the project This should take place about half-way through the course after
the participants have got some idea of the management issues covered. The development of the
projects will be discussed in tutorial groups during the rest of the course. Part II will be at the end
of the course. The participants will present their projects to the class and these will be discussed
with the aim of helping the presenter to make improvements in the plan. If necessary this session
might be preceded by a time when the trainers assist the participants in the final preparation of
their projects.
Teaching materials
i
2
Guidelines for project planning for participants
Sample project for participants
Steps of the module
PART I
1 Introduction
Explain the following points about the project:
' The aim of the exercise is for you to produce a detailed plan of action which could be
implemented and is likely to improve the delivery of health services at sector level. The emphasis
throughout has to be on realism: ’What will actually happen ?’; Who will actually do it ?’ etc. It is
important to avoid general statements like ’Health education in the community will be improved.
The project should be done by participants in pairs and care should be taken to match participants
with similar problems in their sectors. Three copies of the project are to be made and one is to be
submitted to the trainers so that when they come on follow-up they will be able to look at and
advise on your project'
Explain the guidelines for planning the project given in the handout. Go through the example of
the project on ensuring that MPWs (female) monitor the foetal heart sound of pregnant mothers.
Trainer's notes _______________________________
This is not an easy module. The hardest part is for the trainers to explain to the participants how
the project should be written. If the guidelines provided are explained properly with the example
given and some additional examples the participants should understand what they are required to do.
The trainers should avoid confusing the participants by giving conflicting guidelines and advice.
69
PART n
One participant from each pair presents the project plan. (If there are many participants, they might
be divided into two groups with one trainer running the session for each group.) The trainer should
note down important points for discussion, but should neither interrupt the presentation
him/herself nor let the participants make comments until the end. The trainer should emphasise the
fact that discussion of the project should help the particular participant to improve his project and
not to make a catalogue of all the mistakes he has made. The example set by the trainer is
important here (see module on Managing staff!!).
When discussing the projects point out the ideas taught in this course that the participant has used
in the project. This is a useful way to revise the contents of the course.
<1
i
i
J
70
for participants
9 Guidelines for project planning
1
General points
The project should concern some change or improvement in the management of the sector that has
been covered by the training course. The project should be specific and achievable. It should be
planned so that no extra staff, money or materials will be required.
In this plan you should record all the steps necessary for thinking about and implementing
changes. It is therefore necessary to be specific about your plans.
The plan
1 What is the overall aim of the project ?
eg:
-Increasing attendance at the sector meeting
-Improving accuracy of collection of vital statistics
2 What specifically are the problems with the programme/work at present ?
Why is the project necessary ?
List the specific problems
3 What are the specific aims of this project ?
The main aim of the project might be to improve the collection of vital statistics in your sector.
This might not be possible straight away. It might be better to try make some small
improvements in one section first
eg:
-The woikers will fully understand the procedure of recording vital statistics
-The woikers will make regular visits to find out about recent births, deaths and marriages
-You will check the vital statistics recorded against the expected statistics for that section
4 Project details
In this section record exactly how you will implement this project For each stage think :
- what will actually happen ?
- who will actually do it ?
- what will they need ?
- how long will it take ?
- how will you check the success of this stage?
5 What problems are likely to be encountered ?
For each stage of implementation record the problems that are likely to occur eg lack of materials, exposition from the staff - and think how you might solve these problems.
6 How will you evaluate the project ?
After implementation is complete how will you find out whether your project has been successful
in achieving its aims ?
7 Wider implementation
What plans do you have for using the experiences from this project either in other parts of the
sector or for solving other problems ? These plans will naturally be dependent on your finding
from the evaluation.
Please make THREE copies of your project plan and leave one with the staff at the training centre.
71
for participants
Sample project plan
f
1 Overall aim of the project
To improve ante-natal services in the sector, in particular to ensure that the MPW(female)
monitors the foetal heart sound of all pregnant mothers regularly and correctly.
2 Specific problems
-FHS monitoring is not being done
-records are not being kept
-foetoscope is not being carried to the field
-workers do not understand the importance of monitoring FHS
-workers do not know how to monitor FHS accurately
3 Specific aims
I will select the worker most likely to cooperate in this project and use the village where her sub
centre is for the first stage of the project The specific aims are:
-the MPW (female) will understand the purpose of monitoring the FHS and will be able to do this
accurately
-the MPW (female) will monitor FHS of all antenatal mothers in the village from the 5th month
of their pregnancy
-the FHS monitoring will be properly recorded
-if the MPW (female) fails to hear the FHS she will inform the health assistant immediately and
the case will be referred to the PHC
4 Project details
The implementation of the project will be scheduled over a period of five months. I will start one
month after returning from this training course as I need some time to review the work done since I
left. These are the stages of my plan of action.
WEEK 1
I
II
First I will discuss the project with the MO in-charge and the MO responsible for
my sector and try to get their support
I will decide which MPW(female) to involve in this project I will discuss it with her to see
if she is interested. If she is not interested, I will approach another worker.
WEEK 2
in
I will inform the staff at the sector meeting that this project is starting and tell them in
which section it will be conducted. I will ask if they have any suggestions.
IV
I will check that the MPW (female) has got a foetoscope. If she has not, I will try to get
one from the PHC or borrow one from another section if one cannot be supplied
immediately.
WEEK 3
V
I will find out how much the MPW (female) knows about the purpose of monitoring FHS
and whether she knows how to do it If she does not know these things, I will teach her about it at
the sub-centre and then take her to the field and demonstrate how the foetoscope is used; then she
will try doing it under my supervision.
If she says she knows how to do it, I will take her straight to the field and observe her monitoring
FHS on an ante-natal case. I will correct her mistakes if necessary.
72
VI
The MPW (female) and I will list out all the antenatal cases in the village by referring to
the records and checking with the TBA. We will marie on the list those cases 5 months or more
into their pregnancy.
VII
I will make a programme together with the MPW (female) so that she is able to combine
her regular work with the work load of this project This should not require extra visits as she
should already be making regular ante-natal check-ups.
WEEK 4
VIII I will spend one day with the MPW(female) checking that she has no difficulties
monitoring the FHS. If there are no problems her regular schedule of this project will start.
MONTHS 2 - 5
IX
The project will continue for a further 4 months. I will supervise the FHS monitoring
work of the MPW (female) once in every week for one month; thereafter, two times in a month. I
will discuss the progress of the project with the medical officers at the monthly meetings. From
time to time we will discuss the project at the sector meeting.
5 Possible problems
It will not be easy to implement this project, but I shall try my hardest The medical officers may
say that it is more important to meet the targets or that I should not disturb the workers as they
might not like the extra work load. I will try to persuade them that very little extra work will be
required and that I will only involve a worker who is interested in the project
It may be difficult to get a foetoscope, but I know that there is one at the PHC which is never
used, so I will try to borrow that one for some time. Records are not maintained properly in the
sector and the registers are mostly damaged. If I cannot get a new register from the PHC I can
purchase a few sheets of paper. It may not be possible to check the FHS as often as I would like,
but we will try to do the monitoring as regularly as the other programmes allow. The staff at the
PHC may not take any interest when we refer mothers because we cannot hear the FHS, but I will
try to convince them at the monthly meeting that their cooperation is very necessary for the
success of the project.
6 Evaluation
We will compare the ante-natal records both before and after the project. These records will tell me
how many cases have been referred to the PHC because the FHS has not been heard. I will try to
judge the level of interest taken by the concerned worker, the PHC staff and the people in the
village where the project has been conducted.
7 Wider implementation
If the medical officers have taken any interest in the project, I will discuss the evaluation results
with them and ask them to suggest ways in which the project could be implemented on a wider
scale. I could either persuade the other MPW (females) to take up the monitoring of FHS and give
them the necessary preparation, or I might try improving a different aspect of the work. I would
still continue to follow up the work done in the first project village.
SmL Laxmipriya Devi Health Assitant (female)
PHC Balugoan, Puri Disc
73
Course Assessment
Pre-course questionnaire for Health Assistants
I
Date
Name
Question 1
What are the activities in a primary health care service connected with:
either malaria
or
childbirth
Question 2
Write any THREE important common management duties of HA(M) and HA(F)
1
2
3
Question 3
In your opinion, what are the common mistakes that MPWs make when carrying out the task of:
either chlorinating a well
or
examining an antenatal case
Question 4
either How could you know whether a well has been chlorinated 3 days before?
or
How could you know that an ANM has made a home visit to an antenatal mother?
Question 5
Perhaps some of your MPWs do not work very hard and sincerely. If this is true, what reasons can
you give for this?
Question 6
Do you keep a personal notebook of your work?
yes
no
If 'yes', what things do you write in it?
74
Question 7
Do you conduct sector meetings regularly?
yes
no
What are the main difficulties you face when running sector meetings?
Question 8
Suppose your worker is making many mistakes in taking blood slides. How do you propose to
tackle this situation?
Question 9
a. What health education do you give?
b. What problems do you face when giving health education?
c. How do you solve these problems?
Question 10
What major difficulties do you face when motivating people to accept family planning?
How do you solve these problems?
1
2
3
4
5
75
Course assessment
Post-course questionnaire for Health Assistants
Date
Name
Question 1
What are the activities in a primary health care service connected with:
either malaria
or
childbirth
Question 2
Write any THREE important common management duties of HA(M) and HA(F)
1
2
3
Question 3
In your opinion, what are the common mistakes that MPWs make when carrying out the task of:
either chlorinating a well
or
examining an antenatal case
Question 4
either How could you know whether a well has been chlorinated 3 days before?
or
How could you know that an ANM has made a home visit to an antenatal mother?
Question 5
Perhaps some of your MPWs do not work very hard and sincerely. If this is true, what reasons can
you give for this?
Question 6
Will you keep a personal notebook of your work?
yes
no
If 'yes', what things will you write in it?
76
Question 7
Will you conduct sector meetings regularly?
yes
no
How will you make your sector meetings more successful?
Question 8
Suppose your worker is making many mistakes in taking blood slides. How do you propose to
tackle this situation?
Question 9
a. Give one health problem that you intend to give health education for.
b. What points will you take into consideration when giving health educationon this problem.
Question 10
Give five difficulties you face when motivating people to accept family planning?
1
2
3
4
5
77
Appendix A
Teaching techniques
Introduction
This course uses a variety of teaching methods and equipment. Some notes are provided below on
the use of methods and equipment based on the experience from a number of courses. A note on the
teaching approach that appears to work well is also included.
1 caching approach
The participants on these courses are usually experienced field workers. They are therefore well
acquainted with the type of management problems covered by this course, and will also have found
some solutions to these problems themselves. What they require from this course is the chance to
talk about the kind of problems they actually face in their sectors and, through interaction with the
trainers and the other participants, to find new or better ways of solving their management
problems. This course provides a framework in which this process can take place. Examples of
problems or management tasks are presented through case studies, video, etc. Some general
guidelines are provided by the trainers. But what the participant really needs to learn is how he/she
can solve the problem in his/her own particular case - not just the case presented by the trainers.
For example, how can the participant get his own workers to attend the sector meeting regularly.
For this kind of learning to occur, the trainers must ensure that the initial case that is presented
acts as an introduction to the topic and a stimulus for the participants to discuss actual problems
similar to this one that they face in their sectors.
Group work
Learning in groups is a new experience for many people. It can make learning more effective and
can be a good way of making training more effective and relevant. A few useful guidelines are
given for the trainers to help learning in groups be more successful.
1
The task: Unless the task assigned to the group is made clear from the beginning much
time and energy will be wasted. The task can initially be explained by the trainer leading the
session. It can then be presented on a worksheet and/or explained by the trainers when participants
are in their groups.
2
Seating: Participation of all members of the group is made easier if they sit in a circle or
round a table.
3
Group leader: A group leader should be nominated to lead the discussion and to make sure
that everyone's views are heard and taken into account.
4
The report: One person should be nominated as reporter for the group. This person should
take notes of the main points of the discussion, questions answered, plans made, etc, and should be
responsible for making the presentation. The group leader should help the reporter from time to
time by clarifying and summarising points or decisions made by the group. The report presented
should represent the general opinion of the group and not the personal view of the reporter.
5
Participation: Group work is designed so that experiences and views can be shared. It is
important that all members of the group should be given a chance to contribute to the discussion.
If this is not happening, the trainer assigned to the group can occasionally request the group leader
to invite comments from those remaining silent
6
The report This should communicate the essential points of discussion/decisions of the
group. It is intended that participants from other groups will also learn from the presentation, so
they should be asked to pay attention and not to spend the time preparing their own reports, and the
reporter should direct the presentation not only to the trainers but also to the other participants.
Finally, the success of the group work depends on task being clearly explained and the trainers
giving useful guidance without dominating the discussion.
79
Role-play
Role-play can be used to enable the participants to practise management techniques taught in this
course. For example, one participant can play the role of a supervisor giving feedback about work
performance to a worker ( played by another participant). The other participants can com nt on
the way the supervisor deals with the worker.
The 'players' must be clear about the purpose of the role-play and the kind of things they
1
should say and do.
2
The role-play should not be interrupted, but the participants observing and the trainer
should make notes on the role-play for discussion afterwards.
3
The role-play should not go on too long and should not deviate too much from the original
idea (the trainer can intervene for these reasons if necessary).
4
The most important part of the role-play is the discussion afterwards. The trainer should
summarise the things that have been learnt from discussing the role-play.
Overhead projector
The overhead projector (OHP) is used in this course for showing prepared transparencies and for
listing responses of participants during discussions.
1
Prepared transparencies should be handled with care so that they are not smudged
(particularly in hot weather when hands are sweaty) and they should be stored flat with paper in
between each transparency so that they do not stick together.
2
OHP pens dry up very quickly. The caps must be replaced as soon as writing has finished.
If the pens do dry up, put the cap on for a minute or two and then try writing again.
3
As it is not easy to project the picture high above your head you should make sure that
participants can see it. Yoy may need to stand aside from time to time. Ask one of the other
trainers to tell you when you are blocking participants' view.
4
Do not crowd too much writing onto one 'frame' of the OHP. Use a fresh 'frame' (either a
new transparency or move the acetate roll on) for a new point or topic.
Check that your handwriting is legible few those sitting at the back of the class.
5
Video
Write the relevant counter number for your VCR in the margin marked 'Video ref so that
1
you can easily locate the video material.
2
Get the video equipment ready before your module starts to avoid delay.
Before showing the video explain to the participants roughly what it is about and what
3
particular points they should observe.
4
Most of the video material is short If the participants have not understood it the first time,
rewind the tape and show it again.
5
Try to avoid any discussion during the video (except perhaps when showing the sector
meeting which is quite long) as this will disturb participants' concentration.
6
Most of the videos are merely intended to stimulate discussion about what actually happens
in the participants own sectors. Therefore you should try to prevent the participants getting too
deeply involved in the case shown in the video. We know very little about the background of the
people and events in the videos, so it is pointless to try to establish exact reasons why, for
example, the worker has not done the job properly. In the participants' own sectors they will have
a good understanding of their workers and the working environment, and they will be able to
establish these things much more easily. This is what really needs to be discussed, after initial
stimulation by the video.
Field visit
A field visit should be a learning experience for the participants. If this is to be successful, they
must fully understand what they are supposed to do in the field, the activity in the field (for
example looking at records or observing people working) must be well organised so that it is
possible for the participants to carry out their tasks, and findings of the field visit should be
discussed later in the classroom to reinforce the learning part of the experience.
1
One tutor should be assigned to each group to guide them in the field. The tutor him/herself
must fully understand the purpose of the assignment.
2
Worksheets should be given to the participants to help them collect information
systematically and produce a structured report on the visit.
3
When observing work in the field neither the tutor nor the participants should interfere or
comment aloud on the work in progress. You need the full cooperation of the staff in the field for
the success of these visits, so you should avoid upsetting them.
80
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4
In drawing conclusions from the field visit the emphasis should not be on how badly the
work is being done, but on how the health assistant could 'manage' the situation so that the
quality of the work could be improved.
Summing up
Everybody likes to feel that at the end of a module, lesson, field visit, group activity etc that they
have learnt something. Some people feel that they have leamt things when they have written a few
pages of notes that have been dictated by the teacher. Learning is planned to occur through a
different process in this course. This process relies on the ability of the trainer to organise a
learning activity, like a discussion or role-play so that the participants learn something related to
the topic being taught. This means that the trainer must carefully listen to and observe the learning
activity, making notes on the important points and bringing then up in discussion afterwards. The
reference notes for participants are a useful guide for summing up the main points of the module.
81
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Appendix B
Material required for Management course
Module
OHP
Video
Introduction
1 well picture
2 PHC wheel chart*
3 map of Chopra sector0
4 job responsibilities*
5 plan of the course*
Case study A
Materials
Handouts
reference notes
2
Managing
work:
Introduction
3
Direct
supervision
4
Indirect
supervision
5
Training
checklist
1 table*
2 process of sup.*
1 process of sup.*
2 checklist of sup.*
3 qualities of sup.*
4 table*
reference notes
1 immunisation
2 blood-slide coll.
1 process of sup.*
2 tour diary0
3 population chart*
4 % coverage chart*
5 map of Chopra sector0
reference notes
standard checklist
imm. checklist
reg. & records
reference notes
1 process of sup.*
2 2 kinds of leam.*
3 vacc. for VHGs*
4 must know0
5 relevance of teaching*
6 Sikh driver
7 helping people leam*
8 demonstration*
9 feedback*
10 sup. and training
11 planning and teaching
1 demo of sterilis.
2 steril. by ANM
equipment for
sterilisation
flipchart
abcess picture
material for
micro-teaching
teaching prep
teaching obs. form
reference notes
6
Managing
staff
1 table*
2 solving staff
1 FHS reporting
2 attitude to patient
thermos flask
worksheet
reference notes
7
Meeting
1 seating0
1 sector meeting
2 decision making
8
Education and 1 scabies picture
1 FP report
motivation
2 PHC wheel chart*
3 understanding the health message*
4 FW programmes chart*
5 steps of motivation*
9
Projects
10
Course
assessment
checklist
reference notes
worksheet
reference notes
guidelines for
project planning
sample project
plan
questionnaires
* = material in main text, ° = material in Appendix B
83
H
Chopra Sector
Naniya
f Upgraded
x^Sub^centre
Section B
0
Chopra
Section A
=^LjSection D 1
f
□□□
□°
Chopra Sector
O Upgraded Sub-centre
84
u
Supervision & Training
supervision
87
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SEATING
ARRANGEMENT
FOR
SECTOR MEETING
88
u
Appendix C
Reference materials
1 Disinfection of wells
Wells are the main source of water supply in rural area. The need often arises to disinfect them,
sometimes on a mass scale, during epidemics of cholera and gastroenteritis. The most effective and
cheapest method of disinfecting wells is with bleaching powder.
Materials required
Good quality bleaching powder - 1/2 kg with carrier
1
2
Two buckets (medium size)
3
One rope (for pulling water)
4
One empty 5 cc penicillin vial.
One notebook and pen or pencil
5
One scale or tape measure (optional)
6
Steps in disinfection
1
Select the well for disinfection (the MPW should have the detailed list of private and public
wells of each village of his area).
2
Explain the purpose in detail to the people/householder (in case of private well). Ask them
if they are using the well water. Observe the condition and surrounding of the well. If it is dirty try
to clean it with the help of the people. Check the inside of the well. If any dirty things are there in
the water, remove these first.
3
Find out the volume of the water in the well.
a. measure the depth of water column ....(H)metres
b. measure the diameter of the well (D)metres
Take the average of several readings of the above measurements.
c. calculate the volume of water
Volume of water in cubic metres =
x H x 3.14
4
(One cubic metre = 1,000 litres of water)
Then calculate the amount of bleaching powder required to disinfect the well. Using good quality
bleaching powder 2.5grams, or half a 5cc penicillin vial, is required for disinfection of 1,000 litres
of water.
4
The correct amount of bleaching powder required for disinfecting the well is placed in a
bucket and made into a thin paste. More water is added until the bucket is nearly 3/4 full. The
contents are stirred well and allowed to settle for 5 to 10 minutes.
When the lime settles down, the chlorine solution is transfeired to another bucket and the lime is
discarded. (The lime sediment should not be poured into the well, as it increases the hardness of
well water.)
5
The bucket containing the chlorine is lowered some distance below the water surface, and at
least l/2metre above the bottom of the well, and the well water is agitated violently both vertically
and laterally. This should be done several times so that the chlorine solution mixes intimately with
the water inside the well.
6
A contact period of one hour is allowed before the water is drawn for use.
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2 Oral rehydration solution
Diarrhoea death is very common among children. Therefore it is essential to prevent mortality
among children due to this. The children die due to dehydration from diarrhoea, and this can be
corrected if the mother can be taught the use of rehydration solution in time.
1
Ingredients according to WHO formula :
Glucose
20 grams )
Sodium chloride 3.5 grams ) mixed with
Sodium bicarbonate
2.5 grams ) one litre
Potassium chloride
1.5 grams ) drinking water
The WHO formula comes in pre-packaged form. The packet is opened and poured into one litre of
drinking water.
2
Ingredients according to home-made formula :
Common salt
Sugar
one level teaspoon
eight level teaspoons
Mixed with one litre drinking water.
It may be required to make ORS without using a spoon :
Common salt
Sugar
one pinch (three fingers)
one scoop with hand
Mixed with one glass (200cc) of drinking water.
Using ORS :
1
2
3
4
5
6
7
8
9
Before use taste it and make sure it is not saltier than the taste of tears.
Do not boil the mixture.
Keep it out of sunlight.
Do not keep the mixture for more than 24 hours.
Make fresh mixture daily and in small quantities, so that it will not be kept for along time.
Do not give a large quantity at a time.
Usually one glass of ORS is required after each motion for a child.
Use a clean glass and spoon.
If vomit occurs, do not discontinue, try for some time to give a small quantity (may be in
sips) and if it does not subside then discontinue.
3 Wound dressing
Wounds daily need dressing. If they are not dressed daily they may lead to further complications and
turn into an ulcer.
Preparation
1
2
3
4
5
6
7
8
9
90
Gauze
Bandage
Cotton
Dressing forcep
Antiseptic ointment or powder
Two bowls
Warm boiled water
Soap, nail brush, water
Some medicine
h
Procedure
1
Ask the patient to sit comfortably.
2
Take some warm boiled water in a bowl and add some antiseptic. Put some cotton swab and
dressing force (which was boiled before).
3
Then clean the wound very slowly. Use one swab once and throw it. Clean the sluff and
surrounding part of the wound first.
4
Then take a swab and squeeze it and give final cleaning and put some ointment. Then cover
the wound with a piece of gauze and cotton. Then bandage it.
5
Give some healh education regarding the cleanliness and if necessary for dry fomentation
(if swelling is there). If there is pain give some medicines, and give advice for TT injection if
necessary.
4 Sterilisation of syringe
Sterilisation is a process of destroying or removing microbial life, including spores.
Preparation
1
2
3
4
5
6
7
Stove
Matches
Saucepan with cover
Soap with case
Water
Syringe cc with two (thick - thin) needles (size and number as per requirement)
Cotton, gauze pieces for wrapping the syringe
Procedure
1
Wash the syringe and needle with soap and water.
2
Check the needle.
3
Wrap the syringe separately (piston and syringe) and then along with a force (if available)
put in a saucepan with some water. See that everything is completely submerged.
4
Light the stove and keep that saucepan on it. Be sure that bubbles come and it reaches
boiling point, and from that time it should be boiled for 10 to 15 minutes. Put off the stove. Now
the syringe is sterilised.
5
Wait 'till it is cool. Then remove the syringe with the help of the sterilised forcep. Never
touch any part of the needle or nozzle at any time.
5 Blood slide collection
Preparation
1
2
3
4
5
6
7
8
9
10
11
12
Pricking needle (2 or 3 nos)
Cotton
Spirit (rectified)
Slide-box containing 10-15 slides.
Pencil
Slide stand
A piece of clean cloth.
MF no.2 register
Kit bag
Stencilling chalk or gem
Chloroquine tablets
Other medicine for fever.
91
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Procedure
1
On reaching the village, start work from holding no.l.
2
Meet the head of the household and explain the purpose of your visit and the necessity of
taking blood slide from fever cases.
3
Ask the householder the following questions :
I
Are you alright ?
II
Has anybody suffered from fever in your household in the last 15 days ?
III
Did any visitor come to your house who was suffering from fever ?
IV
Does anybody suffer from fever now ?
If the answer is "no", move on the the next house. If there is fever, ask the patient to come.
When the patient is present, behave gently and select the tip of the left-hand ring finger for
pricking (or any other finger if the ring finger is not suitable.)
When selected, the finger should be swabbed with a spirit swab and then dried in the air.
Clean the slide with a clean cloth.
The needle point should be washed through spirit swab and allowed to dry.
Hold the finger tip and press a little.
Prick the finger and leave the hand.
Bring the slide and once again press the finger to collect blood.
Collect blood for thick and thin smear in one slide.
Ask the patient to hold the spirit swab for a few minutes.
Bring another clean slide and with the help of one end of the second slide draw a round mark for
thick smear and press and slide gently but quickly for a thin smear.
Put the slide on the stand and watch for fly nuisance.
Fill up the MF 2 form.
Hand over medicine as per age and ask the patient to take the medicine in your presence. Ask the
patient to take some food first if he/she has an empty stomach.
Put the serial number on the smear and keep it in the slide box.
Sign the stencil, mark the number of fever case.
Ask the patient to consult with a doctor, if the fever does not subside within 1 or 2 days.
6 Antenatal checkup
The primary aim of antenatal check-up is to achieve at the end of a pregnancy a healthy mother and
a healthy baby. Ideally this should begin soon after the antenatal mother is identified and continued
throughout the pregnancy.
Equipment
Notebook, pen, foetoscope, Tallquist chart, spirit lamp and spirit, matches, test-tube and holder,
dilute acetic acid.
92
Procedure
Before entering into the house knock on the door and greet the mother. Then inquire
1
about her welfare. Tell her the purpose of your visit. Then take a detailed history of pregnancy
(past, present. General and Obstetric).
Ask her to lie down comfortably, with adequate privacy, and examine her from head to foot
2
- eyes for pallor
- tongue, cleanliness of teeth, caries teeth, bleeding gums etc.
- breast for cracked nipples
- nails for pallor
- oedema of the feet, varicose veins
- ask whether the mother has taken TT injection
3
Palpation of abdomen
a. Ask the mother to loosen the undergarments. You uncover the abdominal portion, you stand on
the right side of the mother facing towards her, then palpate keeping two palms on the abdomen
and see the height of the uterus by slowly moving the left palm (the palm keeps to a certain
height). If it is 20 weeks then the height will be below the umbilicus. It is called fundal grip.
b. Then go for lateral grip. Keeping one palm fixed on one side you feel the other side, whether it
is back of the foetus or front, from that the lie or position of the baby can be determined. The back
of the foetus should feel flat and the front should feel uneven.
c. Then see the pelvic grip by keeping your left palm on the fundus and the right palm on the
pelvic region. The grip will tell you whether there is a round hard thing which is the head, or a soft
mass ie breech, and if there is nothing, the lie is transverse. The presentation will be vertex and
breech respectively.
d. Then monitor the FHS putting the foetoscope on the side of the abdomen, where you feel the
back of the foetus. You count the FHS per minute.
4
HB% Then you ask the mother to sit and you test the HB% by Tallquist method.
5
Urine testing for albumin
Ask the mother to collect urine in a clean test-tube. Keep 3/4 level urine in the test-tube and boil
the upper part of the urine twice or thrice and see whether there is a pale ring or not. Add a few
drops of acetic acid to it If albumin is present, the pale ring will disappear.
6
Health education
Ask the mother about her diet, whether she is taking some extra protein. Advise her to take small
fish or fruits, leafy vegetable etc as and when available. Haematenics like folifar etc need to be
given. Then tell the importance of antenatal check-up. The mother can come to the sub-centre or
you visit her according to the schedule of visit in a month or in a fortnight. Always encourage her
to come to the sub-centre, so that you can know the weight, height and other findings.
Give her some knowledge about the problem and complications (warning signals) during the
pregnancy, before or at the onset of labour pain.
Ensure about the right place for delivery (domiciliary or institutional). Keep everthing ready which
is needed for the newborn child. Impart some knowledge about family planning.
7 Copper ’T’
The control of conception by introducing a foreign body into the uterus is not new in medical
science. There are more than 75 types of IUDs in different shapes and sizes including loops,
spirals, coils, rings, copper covered and fluid filled devices. Of all the IUDs, copper-T (Cu.T) is
more acceptable.
Preparation of articles
1
2
3
4
5
Cu.T (in sterile pack)
Cu.T regisiter (incentive register)
Forms (1 set)
Incentive money
Stamp pad
93
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6
7
8
9
10
11
Stove with kerosene and matches
Bowl (one)
Soap, soap-case and nail-brush
Bucket with water and mug
Intruments Vulselum
1
Sponge holder 1
Scissors
1 pair
Speculum
1
Cotton swab and Tr. Iodine
Procedure
1
Clean the instruments listed in item 10 above with soap and water. Boil these in a bowl for
15-20 minutes in water. Then cover it and wait until it cools.
2
Select the case
3
If the case is suitable to accept the Cu.T, ask her to lie down on a table taking right
position and ensuring privacy. Wash your hands with soap and water and scrub nails with the nail
brush.
4
Examine the patient, see that the cervix is healthy, do a PV examination, check that there
is no complication.
5
Ask your assistant to cut open the Cu.T pack and you have to fix the Cu.T inside the
inserter. Before insertion the uterine sound should be inserted to measure the length of the uterine
canal and its direction.
6
Fix the speculum, ask your assistant to hold the upper lip of the cervix and insert the Cu.T
very slowly. Check that there is no pain or bleeding.
7
Touch the mouth of the cervix with a cotton swab soaked with Tr. iodine.
8
Then ask the case to sit comfortably.
9
Fill up the form register and take necessary signature/thumb impression of the case.
10
Give the incentive money and medicines. Educate her to check the Cu.T position and to
come again after 7 days.
11
Advise her to report immediately if any problem arises.
12
Advise her to avoid sexual contact with her husband for 10 to 15 days from the date.
8 Cord cutting and dressing
In the case of a normal infant the umbilical cord should be cut and tied when it has stopped
pulsating. The advantage is that the baby derives about 10 ml of extra blood if the cord is cut after
pulsation ceases. This is particularly important in India where anaemia is frequent. Care must be
taken to prevent tetanus of the newborn by properly using sterilised instruments and cord ties. The
cord should be cleaned daily with rectified spirit untill it drops off.
Preparation
1
2
3
4
5
6
Artery forceps
2 nos.
Scissors
1 pair
Cord-tieing thread
Cotton
Iodine or Gentian violet
Steriliser or bowl for boiling
Procedure
1
When you receive the baby with placenta you have to squeeze the placenta towards the
umbilicus of the baby.
2
Then clamp the cord with the artery forceps 2 inches from the umbilicus and clamp the 2nd
artery force leaving 1/2 inch distance from the first one.
3
Tie the cord just below the first artery force very tightly and cut the cord. Release the artery
forceps. Take a cotton swab and see that there is no bleeding.
4
Take a swab and with some iodine or gentian violet touch the cord thoroughly.
5
After a while give a bath to the baby in lukewarm water.
6
Give some health education to check the bleeding and sepsis of the cord.
94
9 Urine test for albumin
Equipment
1
2
3
4
5
7
8
Test-tube and stand
Spirit lamp and spirit
Matches
Dilute acetic acid
Dropper
Soap and water
Test-tube brush
Procedure
1
Collect the urine sample or ask the patient to bring mid-stream urine in a clean test-tube at
that time.
2
Put it into a clean test-tube up to 3/4 level.
3
Light the spirit lamp.
4
Hold the test-tube with urine with the test-tube holder in inclined position and boil the
upper part of the urine for one to two minutes. Take it off the heat and then put out the lamp.
Look for a pale ring. Add a few drops of dilute actic acid. If the pale ring does not disappear then
it is albumin. If it disappears then it is due to phosphate.
6
Throw away the urine sample and clean the test-tube.
7
Record the findings against the name of the patient and advise her accordingly.
10 Haemoglobin testing
In the routine antenatal examination after complete physical examination an obstetric examination
is carried out to check any abnormalities. The urine is tested for albumin and sugar, blood for
HB%.
Equipment
1
2
3
4
5
Tallquist chart/book
Notebook to write and record
Cotton
Spirit bottle, needle
Needle
Procedure
1
Select the patient.
2
Ask the patient to sit comfortably. Explain to her the purpose of testing HB%.
3
Then ask the patient to show her ring finger. Clean it with spirit cotton. Wait until it is
dry, then hold the finger and give a sharp prick. Press the finger from below the level of where it
was pricked.
4
From the Tallquist book tear one piece of paper and soak the blood in it. Then match that
of colour chart and determine HB%.
5
Record the % of HB written on a piece of paper, so that she consult the Medical Officer
accordingly.
11 Immunization schedule
Vaccines are an effective, safe and relatively cheap tool for the control of many infectious diseases.
The decision to withhold immunization from any child should not be taken lightly since the longer
the completion of the schedule is delayed, the longer the child is exposed to the risk of getting the
disease. In areas where health services are limited and the morbidity and mortality from vaccine
preventable diseases are high, children should be immunized as early as possible.
95
No. of doses
Beneficiaries
Age
Infants
3-9 months
DPT ]
Polio]
BCG
3
3
1
9-12months
Measles*
1
18-24months
DPT
Polio
1 (booster)
1 (booster)
5-6 years
DT
Typhoid
1**
2
10 years
TT
Typhoid
I**
1**
16 years
TT
Typhoid
!**
I**
TT
1**
Children
Vaccine
Pregnant women 16-32 weeks
* Measles vaccine is available only at selected centres
NOTE
* Interval between doses should not be less than 4 weeks.
* Minor coughs, colds and mild fever are not a contraindication for vaccination.
* The recommended course of each vaccine must be completed as early as possible.
* DPT and Polio vaccines are given to the child at the same time. BCG vaccine can be given with
any one of the three doses, or separately, but the site of the injections of the DPT and BCG
vaccines should be different
Contraindications and reactions
Malnutrition, low-grade fever, mild respiratory infections or diarrhoea and other minor illnesses are
not a contraindication to vaccination. Diarrhoea should not be considered a contraindication to
OPV, but to ensure full protection, doses given to children with diarrhoea should not be counted as
part of the series and the child should be given another dose at the first available opportunity.
Immunization of children so ill as to require hospitalization, and those with high grade fever or
otherwise acutely ill may be deferred until a decision is taken by a Medical Officer. The
immunization status of hospitalized children should be checked and they should be given the
appropriate immunization before discharge if they have not been vaccinated previously.
A second or third DPT injection should not be given to a child who had a severe adverse reaction to
the previous dose. Instead, a single dose of DT vaccine may be given.
The health workers should be asked to consult the Medical Officer in case of doubt.
Reactions
Despite safety of vaccines used in EPI, complications can sometimes occur. Although their rates
are difficult to estimate precisely, it is known that they are far less frequent than the complications
caused by the diseases themselves.
Reactions after vaccination are in general mild and of a short duration. These may be :
* Mild fever
* Local pain and swelling at the site of the injection
* Malaise, fretfulness
*Transient rash after measles vaccine
* A lump or papule appears in the third or fourth week after BCG vaccination. It is generally not
painful, but is tender to touch. The papule increases in size to 6 to 10 mm in diameter by the sixth
week. The nodule softens with the formation of pus. No treatment is necessary. At the end of 10 to
12 weeks only a small scar is visible.
96
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In rare cases convulsions or collapse after DPT vaccination have been observed. In such cases
further doses of DPT should be stopped and the Medical Officer consulted. DPT vaccine should be
limited to children under one and DT vaccine to children under six as the severity of the reactions
may increase in the older age groups.
Abcess formation is usually due to the use of unsterilized or inadequately sterilized syringes and
needles. The injections are painful if blunt or barbed needles are used.
The parents should be informed of the expected side-effects so that they do not worry. If there is
any anxiety they should be encouraged to return to the health centre for consultation.
97 •
11
12 Statements showing targets of Health for all by 2000 AD
and their planwise phasing
National averages
Index
1985
1990
Crude
death rate
14.1
11.0
10.4
9.0
Infant
mortality rate
129
80.9
>60
Perinatal
mortality rate
60-109
Pre-school (0-5yrs)
death rate
35-40
Maternal
mortality rate (MMR)
5-8
Life expectancy at
at birth
20-25
58.0(M)
57.7(F)
33.2
29.5
27.0
(1978)
(1983) (1988)
21.0
44
60
22.0
35
Mean age at first
marriage (female)
17.21
(1971)
20
Net reproduction
rate
1.67
1.9
(1978)
Family size
% pregnant
mothers receiving
antenatal care
(estimated)
% of deliveries by
TEA (estimated)
4.3
rural
urban
64
10%
Percentage effective
couples protected
Natural growth
rate
10
>2
30%
Crude birth rate
(per 1,000)
1995
30-35
52.6(M)
51.6(F)
Birth weight below
2500g
98
2000
1980
1.79
1.66
(1983) (1988)
1.26
2.3
56.4
46.3
10.15
100
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National averages
1980
Index
1985
1990
1995
2000
% population
with protected
water supply
rural
urban
10
80
100
100
100
100
% population
with sound
excreta disposal
rural
urban
34
25
80
50
100
87
83
80
83
100
100
100
100
Immunization status
(% coverage of
pregnant mother
and infant)
a. TT
b. DP
c. Polio
d. BCG
21
51
18
65
60
70
43
70
% coverage of PHC
for 50,000 population
30.8
50
(1983) (1988)
% coverage of sub-centres
for 5,000 population'
71
(1983)
100
(1988)
60mil
(1983)
60mil
(1983)
100
(1988)
100
(1988)
% coverage nutritional
supplement
(Iron and folic acid)
a. Expectant mother
b. Children
80
(1993)
100
% coverage by Vit A
prophylaxis
99
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Reference books
Primary Health Centre Training Guide Series
Ministry of Health and Family Welfare, Govt India, New Delhi, 1981
Manual for Health Worker Male Vols I & H
Manual for Health Worker Female Vols I & II
Ministry of Health and Family Welfare, Govt India, New Delhi, 1977
Organisational Aspects or the Primary Health Centres in India
Dr BK Shee MD, Jagatsinghpur 1985
Teaching for Better Learning
FR Abbatt, WHO 1980
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