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Manual for Training of Change Agents,

Safe Water Systems (SWS) project – A pilot intervention in Urban slums of

Dehradun and Haridwar

February 2004

Population Services International Dehradun, Uttaranchal

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TABLE OF CONTENTS

Introduction Acknowledgements Do's and Don'ts of training How to use the manual Training goals and objectives Training Schedule Day one session plans Day two session plans Day three session plans References

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INTRODUCTION This manual is designed to be used by a group of trainers. It will facilitate to prepare a group of volunteers to act as change agents in the community. This manual has been developed for the Safe Water Systems (SWS project) a pilot intervention in the Urban Slums of Dehradun and Haridwar, Uttaranchal, which is funded by United States Agency for International Development (USAID)/ AIDSMARK. The overall objective of this project is to reduce under 5 mortality due to diarrheal diseases in selected slum communities of Dehradun and Haridwar through improved hygiene, safer drinking water practices, and better management of diarrheal cases. This manual will be a tool for trainers and will enable them to implement interactive training using learner-centered methods. Researchers have proved that adult learners want to participate in the learning process, learn from their experiences, be challenged and draw their own conclusions from learning experiences. This manual follows the principles of the ‘Experiential Learning Cycle’ so that participants can effectively internalize learning.

ACKNOWLEDGEMENTS The change agents training manual for Safe Water Systems (SWS) Project has been developed by Ms.Jayashree Nair, PSI Training Manager with support from Ms. Shweta Verma, PSI Project Manager. This manual has been reviewed by Ms. Vibha, SWS-Project Director, Mr. Ajay Patel, SWS Project Manager- PSI Uttaranchal, who gave valuable suggestions. Dr. Jean Patrick DuConge, Program Director also provided vital inputs during the development of this manual.

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DO'S AND DON'TS OF TRAINING The following "do's and don'ts" should ALWAYS be kept in mind by the trainer during any learning session.

DO's

• Maintain good eye contact • Prepare in advance • Involve participants • Use visual aids • Speak clearly • Speak loud enough • Encourage questions • Recap at the end of each session • Bridge one topic to the next • Encourage participation • Write clearly and boldly • Summarize • Use logical sequencing of topics

• Use good time management • K.I.S (keep it simple) • Give feedback • Position visuals so everyone can see them • Avoid distracting mannerisms and

distractions in the room • Be aware of the trainees' body language • Keep the group focused on the task • Provide clear instructions • Check to see if your instructions are

understood • Evaluate as you go • Be patient

DON'TS • Don't talk to the flipchart • Don't block visual aids • Don't stand in one spot. Move around the

room

• Don't ignore the participants' comments and feedback (verbal and non-verbal)

• Don't read from the curriculum • Don't shout at participants

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HOW TO USE THE MANUAL This manual is to be used for training the change agents. The manual includes a training schedule for the three days training, clear suggestions on how each session should be presented along with the supporting material (appendices), which has been provided for the facilitator's convenience. Training schedule (pages-): suggests how the training is to be organized. The schedule shows which topics will be covered on each day within a stipulated time frame. In-depth look at each session: For each session, the following components are provided. Topic - indicates the topic of the session Time - indicates the approximate time devoted to the session Session Objectives - Describes what trainees will be able to do by the end of the session to demonstrate increased knowledge, improved skills and attitudinal changes. Content - provide a pointer to the sub-topics and important points to be covered during the session Training materials - provides a list to remind the trainer of the required training material for the session. Steps, duration and training methods – provides a window to see the steps during the session process alongwith specific timings and suggests appropriate training methods for the session. Pre training preparation - indicates any arrangements that the facilitator needs to make prior to the session. Appendix - contains additional information to explain or support the messages of the session. They are placed after the session wherever required.

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GOAL: To reduce under 5 mortality due to diarrheal diseases in selected slum communities of Dehradun and Haridwar through improved hygiene, safer drinking water practices, and better management of diarrheal cases. OBJECTIVES OF TRAINING OF CHANGE AGENTS: By the end of the training, the change agents’ will be able to:

• Describe the objectives and strategy of the project for which they will work. • Explain their role as change agents in the community. • Explain the need for prevention and management of diarrhea and their role in promoting key

messages on the issue of diarrhea prevention and management through interpersonal communication.

• Explain the need for and how to promote basic hygiene and sanitation practices in the community. • Understand and explain the product (Safewat/ Neotral) and the dosing pattern • Use the communication tools effectively (flipbook/flyer) • List the reporting and follow -up mechanisms, to be followed by them.

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Training schedule for training of change agents’:

Day one

Day two

Day three

9.00-9.30.a.m. Welcome and introduction

9.00-9.15.a.m Recap

9.00-9.15.a.m Recap

9.30-9.40.a.m. Expectation and objectives

9.15- 10.30.a.m. How to use the kits for water quality testing for chlorine totals, residuals, turbidity, PH and thermo tolerant coli form count.

9.15-11.15.p.m. Introduction to home visit- purpose, key activities to be done during each visit.

9.40-11.40.a.m. Pre-test (Tea will be served in between the session)

10.30-11.30.a.m. Introduction to Safewat- water disinfectant (Tea will be served in between the session)

11.15-1.00.p.m. Practicum (Tea will be served in between the session)

11.40 –12.10.p.m. Introduction to PSI, the project objectives and strategy

11.30-1.30.p.m. Diarrhea management, ORS preparation

1.00-2.00.p.m. Lunch break

12.10-1.00.p.m. Why change agents are required? Roles and responsibilities of change agents

1.30-2.30.p.m. lunch break

2.00-2.30.p.m. Follow -up mechanism

1.00-2.00.p.m. Lunch break

2.30-3.45.p.m. Film

2.30-3.00.p.m. Action plan

2.00-4.00.p.m. Introduction to diarrhea- what is it, causes and how to prevent it (Tea will be served in between the session)

3.45-5.15.p.m. Introduction to Inter Personal Communication (IPC) – -IPC materials- flipbook, flyers and POP materials -Essential techniques. (Tea will be served in between the session)

3.00-5.00.p.m. Post-test (Tea will be served in between the session)

4.00-5.15.p.m. At home- how to secure food and water, importance of clean surroundings, Introduction to handwashing-essential steps, when should we wash hands, source of clean water

5.00-5.15.p.m. Evaluation

5.15-5.30.p.m. Synthesis

5.15-5.30.p.m. Synthesis

5.15-5.30.p.m. Synthesis and Closure

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Day one Session number : 1 Topic : Introductory Session Duration : 30 minutes Objectives: At the end of the session, the participants will be able to: 1. Know each other a little more than their names. Content:

• Game- differentiator Training Materials:

• Flip chart, pens Steps, duration and methods:

Steps Duration Method 1) Getting to know each other 25 minutes Game-Differentiator 2) Summary and Evaluation 5 minutes Interactive discussion

Learning Process

Step-1 Getting to know each other 25 minutes

1.1 Inform participants that we are going to conduct an interesting exercise by which we all will get to know

each other more than just our names. 1.2 Ask participants to stand in a circle, make enough space for participants to move around. 1.3 Now the facilitator should use the following grid to pair up the participants and ask questions: Differentiator Ask/ Answer Find a person with a similar favorite food What's the riskiest thing you've ever done? Find a person wearing similar colors Who has greatly influenced your life? Find someone who has a similar height as you are What is something you hope other people say about you? Find someone who writes with the same hand What is something you've done that has made a big

difference in your life and you're proud of it?

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Facilitator can put up the above questions on a flipchart for the convenience of the participants and refer to them while conducting the activity. Once the activity is over thank the participants and ask them to take their seats.

Step- 2 Summary and Evaluation 5 minutes

2.1 Now ask participants regarding what was the need for such an exercise. Listen to responses and conclude by saying that these kind of activities helps in setting a positive learning atmosphere, which is extremely essential for learning to happen.

Pre-training preparation: - Read the scheme of the session thoroughly. - Prepare a flipchart on which the questions are written

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Day one Session number : 2 Topic : Asking expectations and sharing objectives of change agents training Duration : 10 minutes Objectives : At the end of the session, the participants will be able to: 1. List their expectation from the training 2. Explain the objectives of change agents training Content:

• Objectives of training Training Materials:

• Flip chart, pens

Steps, duration and method:

Steps Duration Method 1. List expectations from training and share the objectives of change agents training

10 minutes Brainstorming, presentation

Learning Process

Step-1 Expectations and objectives of change agents training 10 minutes

1.1 Inform participants that the active participation of all of them can only lead to the achievement of the training objectives.

1.2 Facilitator to let the participants brainstorm on their expectations from the training. Quickly list their responses on the flipchart.

1.3 Now share the objectives of the change agents training from a pre-prepared flipchart. (Refer to appendix 2.1: Objectives of change agents’ training.) Facilitator to clarify those expectations, if any of the participants that cannot be achieved during the training and focus on those that will be achieved through their active participation.

Pre-training preparation: - Read the scheme of the session and the appendices thoroughly. - Prepare a flipchart on which objectives of change agents training are written.

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Appendix 2.1: Objective of change agents training OBJECTIVE: By the end of the training, the participants will be able to:

• Describe the objectives and strategy of the project for which they will work. • Explain their role as change agents in the community. • Explain the need for prevention and management of diarrhea and their role in promoting key

messages on the issue of diarrhea prevention and management through interpersonal communication.

• Explain the need for and how to promote basic hygiene and sanitation practices in the community. • Understand and explain the product (Safewat/Neotral) and dosing pattern • Use the communication tools effectively (flipbook/flyer) • List the reporting and follow -up mechanisms, to be followed by them.

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Day one Session number : 3 Topic : Pre-test Duration : 2 hours Objectives: At the end of the session, the participants will be able to:

1. Assess their knowledge regarding diarrhea, hygiene and sanitation and hand washing. 2. Assess their skills on hand washing, ORS preparation and safewat.

Content: • Knowledge and skills assessment Training Materials: • Flip chart, pens, questionnaire, checklists for ORS, hand washing and Safewat. Steps, duration and method:

Steps Duration Method 1. Knowledge assessment 30 minutes Questionnaire 2. Skills assessment- Hand washing, ORS and Safewat. 1 and ½ hour Demonstration

Learning Process

Step-1 Pre-test 30 minutes

1.4 Inform participants that they will be given a questionnaire, ( refer to appendix 3.1 for details) which needs to be filled according to whatever their present level of understanding is. The same questionnaire will be administered to them at the end of the training in order to assess their post training learning. The answer key is also given below. Facilitators can refer to the key to score the answers.

1.5 Distribute the questionnaire and after the participants have completed filling it, collect the same back

and do the scoring. By the end of the day the facilitators need to share with the participants the maximum and minimum scores obtained.

Step-2 Skill assessment- Hand washing, ORS and Safewat

1 hour and 30 minutes

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1.1 Facilitator to divide the large group into two small groups of 10 each. Using the relevant checklists for hand washing, ORS preparation and Safewat (Refer to appendix 3.1 for details) assess each participant’s present level of skills. Share that this is pre-test. So they need not worry. There will also be a post- test after the training on the last day to assess what they have gained through training.

2.2 Facilitator to ensure that the pre and post test assessment form for all the participants is tabulated and

kept for records. The details of what percentage had good skills and what percentage had poor skills should be shared with the participants by the end of the session. Highlight that by the end of the training all of them need to improve their skills on both hand washing and ORS preparation. Hence they need to pay good attention when the information will be shared during the specific sessions for the same.

Pre-training preparation: - Read the scheme of the session thoroughly. - Prepare enough photocopies of the pre-test questionnaire for all the participants. Ensure that the

answer key part is not photocopied alongwith the pre/post test form. Appendix 3.1 Pre-test questionnaire

Name of change agent: ________________ Pre-test score (%)- ------------------------- Share the questionnaire with the change agent and inform her/him that this is to assess the level of knowledge that they will gain during the course of the training. Ask her/him to tick "3" all correct response/s for each question in 25 minutes. 1) Hand washing is important during the following instances:

a) Before cooking food b) Before eating food c) Before feeding children d) After touching animals e) After defecation f) After cleaning the child’s defecation g) After touching dirty objects

2) Possible ways of ensuring hygiene and sanitation in and around the house are as follows: a) Hand washing with soap and water b) Keeping the food covered c) Raw food should be stored at proper place away from rats d) Ensuring that drinking water is disinfected before use e) Keeping the drinking water and food covered

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f) Cut and cooked food should always be covered and not left out in the open g) Defecation should be in a toilet or latrine h) Before feeding children or touching food always wash hands i) Ensure that animal faeces are kept away form the house, paths, well and children’s play areas.

3) Breastfeeding: a) Should be started one week after birth. b) Should be started one day after birth. c) Should be started soon after birth. d) Should be stopped when child has fever. e) Should be continued when child has diarrhea.

4) Most cases of diarrhea in children can be prevented by:

a) Taking appropriate antibiotics b) Stopping all food and water c) Stopping breastfeeding d) Using clean water for drinking, washing hands after toilet and before eating food e) None of the above

5) Diarrhea with some dehydration in children is managed by:

a) Appropriate antibiotics b) Stopping all food and water and giving antibiotics c) Stopping all food and water, giving antibiotics and ORS. d) Treating with ORS, providing home care and advising mother when to return immediately e) All of the above f) None of the above

6) The home available fluids which can be given to a child suffering from diarrhea are as follows:

a) Milk b) Yoghurt c) Fruit juices (sweetened) d) Lemon drink e) Soft drinks f) Dal and vegetable soup g) Coffee h) Fruit juice (Unsweetened) i) Plain clean water

7) Water is safe to drink if it is: a) Boiled b) Treated with water disinfectant c) From government water supply system d) All of the above

8) The most common reasons of diarrheal diseases are:

a) Eating food that is dirty or stale b) Drinking dirty water

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c) Eating with dirty hands d) Using dirty vessels, utensils and equipments

END

TO BE FILLED BY THE FACILITATOR Qn. No. 1 2 3 4 5 6 7 8 Total %

Score

RLK: YES/NO

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Day one

Session number : 4 Topic : Introduction to PSI, the SWS project objectives and strategy Duration : 30 minutes Objectives: At the end of the session, the participants will be able to:

1. Explain briefly about PSI as an organization. 2. Explain the objectives and strategy of the SWS project for which they will be working.

Content:

• Introduction to PSI • SWS project objectives and strategy

Training Materials:

• Flip chart, pens Steps, duration and method: Steps Duration Method 1. Introduction to PSI 15 minutes Presentation,

question-answer 2. Introduction to SWS project objectives and strategy 15 minutes Presentation

Learning Process Step-1 Introduction to PSI 15

minutes

1.1 Facilitators to make a brief presentation on what PSI as an organization stands for and the key activities that are being undertaken by PSI. ( refer to appendix 4.1 (a) for details)

1.2 After the presentation ask participants what they understood by asking simple questions. Listen to responses and clarify wherever required.

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Key message:

PSI’s mission is to empower low-income people to lead healthy lives through the informed use of health products and services, made accessible and affordable to them.

PSI social markets the following products and services:

• Masti and deluxe Nirodh condoms • Pearl and Mala-D low dose contraceptive pills for women • Neotral and Neotral orange (WHO recommended formulation) oral rehydration salts • Safewat water purification solution • Vitalet Multivitamins and vitalet –Preg Iron Folic Acid tablets • Newborn clean delivery kits (for home deliveries) • Depo- provera injectable contraceptives • Saadhan franchise of medical providers

Step-2 Introduction to SWS project objectives, strategy 15 minutes

2.1 Trainers to share with the participants the objectives of the Safe Water Systems (SWS) project. Let

participants clarify any doubt they may have. 2.2 Now share the strategy of the SWS project to achieve these objectives. Give participants an

opportunity to ask questions if any. Clarify the doubts of participants. Now share the different activities under this project. Also share handouts on it with the participants.

Key message:

Objective of Safe Water Systems Project: To reduce under 5 mortality due to diarrheal diseases in selected slum communities of Dehradun

and Haridwar through improved hygiene, safer drinking water practices, and better management of diarrheal cases.

Integrated approach- community, health provider and trade. Different types of activities that will be conducted under this project- • Distribution of safewat and disinfectives • Behaviour Change Communication (BCC) • Community Mobilization • Water Quality Monitoring • Social Marketing of ORS

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Pre-training preparation: - Read the scheme of the session and the appendices thoroughly. - Prepare a flipchart on which the program objectives, goals and strategy are written. Appendix 4.1: (a) Introduction to PSI Population Services International (PSI), India is an Indian non-profit and non-governmental organization established in 1988 with a mandate to assist the Government of India in the fields of reproductive health, HIV/AIDS prevention, and maternal and child health. PSI’s mission is to empower low-income people to lead healthy lives through the informed use of health products and services, made accessible and affordable to them by the subsidized application of communications and marketing resources and techniques.

PSI utilizes social marketing to deliver health products, services, and information that enable low income and other vulnerable people to lead healthier lives. Social marketing is one of the strongest tools for empowering low-income people to lead healthier lives. Social marketing harnesses existing commercial and non-profit channels to get people the information they need, to make health products and services widely available at low cost and motivate people to use them and engage in healthful behaviour. PSI- India promotes the following social marketing products and services:

• Masti and deluxe Nirodh condoms • Pearl and Mala-D low dose contraceptive pills for women • Neotral and Neotral orange (WHO recommended formulation) oral rehydration salts • Safewat water purification solution • Vitalet Multivitamins and vitalet –Preg Iron Folic Acid tablets • Newborn clean delivery kits (for home deliveries) • Depo- provera injectable contraceptives • Saadhan franchise of medical providers

(b) SWS project objectives and strategy: SWS project Objectives: The overall objective of this project is to reduce under 5 mortality due to diarrheal diseases in selected slum communities of Dehradun and Haridwar through improved hygiene, safer drinking water practices, and better management of diarrheal cases. SWS implementation strategy: In the slums of Dehradun and Haridwar, PSI proposes to combine primary and secondary preventive interventions.

• Hygiene promotion (handwashing)/ food hygiene through community based activities

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• Social marketing of safe water systems designed for improving water quality at household level • Prevention and management of diarrheal cases through communications, social marketing of oral

rehydration salts, and promotion of appropriate oral rehydration therapy. Communications and marketing of ORS will be done through local trade and health providers. The focus of the current project will be hygiene promotion and social marketing of safe water systems. PSI proposes to combine three programmatic approaches:

• Community based approach- Volunteers will be recruited within the community, and imparted initial training on hygiene /sanitation /diarrheal case management. These change agents (who in this case are the participants themselves) will be asked to conduct house visits, to convey key hygiene and sanitation messages, to inform their peers on the availability of household water treatment and oral rehydration salts in their neighborhood, and to actively participate in community events. Community mobilization and communications on issues related to hygiene, sanitation, safe drinking water, and the importance of ORT in the management of diarrhea in under five will be facilitated.

• This component will be build on the saadhan health providers network set up in the same area. All 96 networked health providers have received training on hygiene, water, sanitation and management of diarrheal cases, and will be asked to provide counselling on these topics every time an oppurtunity arises (a consultation for diarrhea for instance) The health providers (approach) will be asked to participate in local community meetings and events and will be encouraged by regular referrals from community agents.

• These efforts will be combined with the classic social marketing trade approach, where Safewat and neotral will be distributed through regular distribution channels, i.e. traditional (chemists) and non- traditional (general stores) retailers. The products will be made available and distributed through local retailers and chemists etc. and backed up by media, outdoor events, and communications at retail points.

Different types of activities that will be conducted under this project-

• Distribution of safewat and disinfectives • Behaviour Change Communication (BCC) • Community Mobilization • Water Quality Monitoring • Social Marketing of ORS

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Day one

Session number : 5 Topic : Why change agents are required Roles and responsibilities of team

leaders and change agents Duration : 50 minutes Objectives: At the end of the session, the participants will be able to:

1. Explain where they fit into the project 2. Explain the specific responsibilities as envisaged for them in the project

Content:

• Why change agents are required • Roles and responsibilities of team leaders and change agents

Training Materials:

• Flip chart, pens, handouts Steps, duration and method: Steps Duration Method 1. Introduction to why change agents are required 20 minutes Interactive presentation,

question-answer 2. Specific responsibilities of change agents’ 30 minutes Interactive presentation

Learning Process

Step-1 Introduction to why change agents are required 20 minutes

1.1 Facilitator to ask participants regarding their comprehension of why they were recruited as change

agents in the project. Listen to their responses and then share the rationale for having change agents in the community.

1.2 Clarify that as shared earlier, in order to reduce under 5 mortality due to diarrheal diseases in selected slum communities of Dehradun and Haridwar, change agents will be required to act as volunteers to bring about the awareness in the community with regard to hygiene promotion, social marketing of safe water systems, prevention and management of diarrheal cases through communications, social marketing of ORS and promotion of appropriate Oral Rehydration Therapy.

1.3 Also share that in order to achieve this the change agents will be required to conduct home visits, and convey key hygiene and sanitation messages, in addition to participating in community events.

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Community mobilization and communications on issues related to hygiene, sanitation, safe drinking water and the importance of ORT in the management of diarrhea in children under the age of five would also be facilitated. Since they will be in direct day-to-day contact with the community, they can act as ambassadors of change.

Step-2 Specific responsibilities of team leaders and change agents 30

minutes 2.1 Now inform the participants that each of them will be expected to carry out a specific set of

responsibilities in their role as team leaders and change agents. Share the specific responsibilities that will be expected from each of them. (Refer to appendix 5.1 for details) At this point the facilitator can also share that each month the change agents will work for a specific issue and key messages related to that will be shared by the project coordinator.

2.2 Ask participants to clarify any doubts they may have. Share handouts on it. Pre-training preparation: - Read the scheme of the session and the appendices thoroughly. - Prepare a flipchart on which the roles and responsibilities of team leaders and the change agents are written. - Photocopy handouts for all participants. Appendix 5.1: ROLES AND RESPONSIBILITIES OF TEAM LEADERS AND CHANGE AGENTS:

Team Leader

1. Participate during the training of trainers and prepare self to conduct training of change agents. 2. Conduct the training of change agents. 3. Follow-up the change agents on a regular basis 4. Provide mentoring support to the change agents on a regular basis 5. Assist the change agents during household visits to effectively use IPC materials. 6. To plan and co-ordinate the activities of 10 change agents within their area of operations. 7. Assist the change agents during home visits in the initial phase of the project and help Change

Agents collect data through respective inspection forms. 8. Plan, fix schedules and help change agents in organizing community events, School Hygiene

Program and VAT Program to promote Safewat and ORS along with hygiene promotion. 9. Identification of retailers and shops interested in social marketing products and co-ordinate with

sales team. 10. Accompany PSI staff during visits and research activities. 11. To document and report on regular basis and submit reports received from change agents. 12. Meet Project Supervisors and Project Officer fortnightly to discuss experiences and problems faced

in implementation of activities.

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Day one Session number : 6 Topic : What is diarrhea , causes of diarrhea and prevention of Diarrhea Duration : 2 hours

Objectives : At the end of the session, the participants will be able to: 1. Explain what is diarrhea. 2. Explain the meaning of dehydration. 3. Explain the causes of diarrhea and how it spreads. 4. Explain how it can be prevented. Content: • What is diarrhea • What is dehydration • How diarrhea spreads- the causes • How to prevent diarrhea Training Materials: • Flip chart, pens, plant one which has been watered everyday and other one, which has not been

watered for few days. Steps, duration and methods: Steps Duration Method

1.What is diarrhea and dehydration 30 minutes Interactive discussion, demonstration 2. How does diarrhea spread- the causes 30 minutes Story telling 3. How it can be prevented 20 minutes Brainstorming and interactive

presentation 4. Evaluation 10 minutes Question- answer

5. Practicum 30 minutes Role-play and large group discussion

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Learning Process

Step-1 What is diarrhea and dehydration

30 minutes

1.2 Ask participants for what do they understand by diarrhea. Listen to the responses and then share the following:

Diarrhea is defined by all as “more than normal” i.e more than three times in a day and “thinner than

normal” (liquid form) stools.

Key Message 1: What is diarrhea? Diarrhea is passing loose stools ( liquid form) more than three times in a day.

1.1 Also ask what happens to the body during diarrhea? Listen to responses. Share that due to

diarrhea there is loss of fluids, nutrients and salts from the body. And in case we do not immediately replace the vital elements, the body starts to shrink and gets dehydrated and mal nutrition happens.

1.2 Ask what do they understand by dehydration. Listen to their responses and show the participants

two plants one which has not been watered for few days and the other one, which is fresh and green as adequate and timely water was being given. Ask the participants what differences can they see between the two. Listen to the responses and share that just like the plant looked dry and lifeless due to lack of water, the human body also during diarrhea goes through the same situation and becomes dehydrated and if it is not controlled timely, dehydration due to diarrhea can also become one of the causes of death.

Message 2: What happens to the body during diarrhea? Body gets depleted of vital fluids, salts (i.e gets dehydrated) and nutrients hence mal nourished. What is dehydration? Loss of fluids, salts from the body which when not replaced the body shrinks and gets dehydrated.

1.3 Now ask the participants what can be the consequences of diarrhea. Listen to their responses then

share the following information.

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Message 3:

Consequences of diarrhea: 1. The child’s health - for example, child gets malnourished, dehydrated and hence the immunity power of the body decreases and becomes vulnerable. 2. The child’s development -physically the child will be weak which will have an effect on the mental development and a child who is always sick will have a poor social life. 3. The socio- economic effect- there will be extra expenditure on the parents as repeated consultation with doctor, the burden of care will be more and the likelihood of siblings getting infected is high too.

1.4 Now ask participants for their comprehension of the above messages. Listen to their responses. Add, clarify wherever required. Step-2 Causes for diarrhea

30 minutes

2.1 Share that during baseline survey conducted at Dehradun and Haridwar, all parents were asked the

linkage between water quality and likelihood of getting diarrhea. Surprisingly very few i.e. only one out of 15 parents spontaneously felt that poor quality of drinking water causes diarrhea.

2.2 Now share that we will together identify the reasons due to which diarrhea happens.

Ask the participants the following questions: • Have they ever heard that at a particular point of time many people in their community suffer from

diarrhea? • Have they observed that many members of a family simultaneously suffer from diarrhea? • What in their opinion is responsible for several people living together in a family or in a community

suffering simultaneously with diarrhea?

Write all the responses from the group on the flipchart.

2.3 Now share the following story with the participants. Facilitator to ensure that all the participants are following the story. Hence read it slowly.

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Story of the community in which you will work: Rani is the resident of an urban slum. The common source of water is the public tap where all the nearby residents come to take water. The usual practice is to fill the water in cans and buckets. The pipeline is usually not checked for months together by the municipality. There is a leak in the pipe and at the point of leak cowdung and other animal faeces is lying, which is slowly getting mixed with the water. However as long as the community is getting water people are not bothered to get the leak repaired. Rani also as usual goes with her neighbour Krishna to fetch water from the pipe. Rani’s son Shyam comes home from play and takes a glass and dips in the bucket and takes water to drink. After drinking this water Shyam runs back to play. However after sometime he comes back home sharing that he has acute pain in the tummy and that he has passed loose stools. Rani also suffers from diarrhea. To her surprise Rani finds that Krishna’s family also gets affected by diarrhea. Shyam relieves himself behind his house. Flies sit on his stools and the germs, which cause diarrhea, stick to their legs. Some of these flies enter a sweet shop and sit on the sweets. People who buy and eat sweets from this shop also get diarrhea. 2.3 Now ask the group the following questions one at a time. Listen to answers and clarify before moving to

the next question. 1. What was the reason due to which both Rani and Krishna’s family gets diarrhea? 2. Could anyone control the situation and prevent diarrhea? If yes, how? 3. How does diarrhea spread in the community? 4. Could the spread of diarrhea in the community be controlled. If yes, how?

2.4 Highlight that diarrhea spreads through consumption of contaminated water and food. Germs are

passed by the thousands and carried from contaminated water and food to the body of the person. It could happen through dirty hands, fingernails, dirty utensils, consuming contaminated water and food etc.

Message 3: Causes of diarrhea: 1. Drinking contaminated water: Pipe water is not always safe. Drinking water, if it is left open gets contaminated. Also the drinking water should be handled properly by using a clean ladle with long stem. 2. Consuming contaminated food: flies sit on dirt and when they sit on the open food, the food also gets contaminated. 3. Using dirty hands: if we do not wash our hands prior to cooking, feeding children or eating food and after defecation, the food we handle can get contaminated. 4. Dirty environment: unclean toilet as germs are present in stools and if toilet is not kept clean flies will sit on the stool and spread the germs, lack of proper disposal of garbage and water leads to filthy environment around the house.

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2.5 Now share that all the above causes of diarrhea can be prevented through spreading awareness about

the need to prevent such situations to occur. Change agents have a major role to play in doing this. 2.6 Ask participants questions on the above. Listen to responses. Add, clarify as required.

Step-3 Prevention of diarrhea

30 minutes

3.1 Now ask participants what can they do in their families and as change agents in the community to

prevent diarrhea. Listen to their responses and then share that you can provide useful and practical messages on healthy behavior designed to prevent diarrhea in the future.

3.2 Share that you can do this by sharing information on how to prevent diarrhea.

Message 3:

Prevention of diarrhea:

1. Handwashing- always wash hands with soap and clean water before cooking, before feeding children, before eating food, after defecation, after touching animals or dirty objects.

2. Clean drinking water-ensure that water is taken from a clean source and is treated before consumption. The treatment of water could be either by using chlorine in recommended dosage, or by using a water filter or by boiling the water before consumption.

3. Personal hygiene-keep yourself clean, take bath everyday, wear clean clothes. 4. Clean environment- ensure proper disposal of faeces through usage of latrines. Do not

defecate out in the open. Proper disposal of garbage and waste water should also be ensured.

5. Cooking and storage of food- proper care to be given while you deal with food at each stage one needs to ensure that the food being handled in a clean manner. The storage of food should also be properly taken care of. It should not get contaminated by contact with rats, lizards, cockroaches, dust, flies etc.

6. Exclusive breastfeeding upto 5-6 months- clean water (i.e; either boiled, filtered or chlorinated) should be given to the child after this age. Bottle-feeding should be avoided.

Step-4 Evaluation

10 minutes

4.1 Now ask participants the following questions:

• What is diarrhea? What happens to our body when we suffer from diarrhea? • Causes of diarrhea? • How can we prevent diarrhea?

Listen to responses, clarify the answers as required.

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Step-5 Practicum

30 minutes

5.1 Now share with the participants that we will conduct a role-play to see how you will be able to convince

the community members regarding the above messages. 5.2 Ask for four volunteers from the group for a role-play. Give each person the following roles-

1. Change agent 2. Team leader 3. Rani- the mother 4. Munnidevi- mother-in-law of Rani

Now share the following role-play situation: Rani’s mother-in-law holds a powerful position in the household and she is the decision-maker. The mother-in-law does not attach much importance to diarrhea and is not interested to listen to anyone counselling her. Rani is however interested to listen as her son frequently gets diarrhea and she takes him repeatedly to the nearby doctor. Her child has become weak and looks malnourished. The mother-in-law does not welcome the change agents. 5.3 Facilitator to help the participants understand the above situation and share that they will be given 7

minutes to conduct the role-play. During the role-play, the change agent needs to convince Rani and her mother-in-law regarding the following: What is diarrhea and dehydration, causes of diarrhea and how to prevent it. Inform all those who are observing the role-play that after the role-play is over, they will need to discuss what was done well by the change agent and what could have been improved.

5.4 Conduct the role-play. Thank the participants for their active participation. Now take feedback from the

participants who were observing the role-play. Ensure each person is given a chance to respond. After the feedback from the participant, facilitator to de-brief and highlight the key points for improvement.

Pre-training preparation: - Go through the sessions properly in advance - Prepare flipcharts for all the relevant points that needs to be shared during training. - Get all the training materials required.

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Day one Session number : 7 Topic : At home- how to secure food and water and the importance of

hand washing. Duration : 1 hour and 15 minutes Objectives: At the end of the session, the participants will be able to:

• Explain the meaning of food hygiene and importance of the need to secure food and water across various stages of food preparation.

• Explain the importance of hand washing • Demonstrate when and how to wash hands

Content: o What is food hygiene? Importance of the need to secure food and water, how to maintain food hygiene

at household level across various stages of food preparation o Steps to hand washing and when to wash hands Training Materials: • Flip chart, pens,handouts Steps, duration and method:

Steps Duration Method 1. Importance of the need to secure food and water. How to maintain food hygiene at household level across various stages of food preparation.

30 minutes Interactive discussion

1. Essentials of hand washing 30 minutes Demonstration

2. Evaluation 15 minutes Question-answer

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Learning Process

Step-1 What is food hygiene? Importance of the need to secure food and water. How to maintain food hygiene at household level across various stages of food preparation.

30 minutes

1.1 Facilitator to ask participants to share their experiences of what is commonly observed in their

community regarding practices related to food and water. For example, is water kept covered? What about raw and cooked food? Listen to participants’ responses.

1.2 Now ask why do we need to ensure that the food and water are kept in clean containers and stored properly. Listen to responses and then share that dust, flies, unclean hands , unclean utensils contaminate the food and if food or water gets contaminated due to any of the above factors, the chances of the people consuming it falling sick is really high. Highlight that the most common disease due to consumption of contaminated food and water is diarrhea. Also share that baseline survey shows that clear water often means clean water and that diarrhea is associated with eating food outside and not always with water quality and that cleanliness is maintained inside the home but not always outside.

1.3 Share that since the above factors are preventable and can happen with awareness, the change agents have a very important role to play in educating the community to become sensitive to the need to store water and food properly without letting them getting contaminated.

1.4 Now ask participants how can you ensure food safety across various stages of preparation. Listen to responses. Also highlight how can you keep water clean.Now share the points as given in appendix 7.1 A with the participants. Also share how to keep water clean. Share handouts on it.

Key message:

Purchase and storage of raw materials

• Purchase all raw materials very carefully ensuring that the color appearance, body, texture etc correspond to the specific characteristics or nature of fresh raw materials.

• Use clean, non-contaminating containers with lids. Do not use rusted, cracked, chipped or damaged container for storage of any ingredient

• Consume first the raw material bought first and do not mix old one with new Cleaning/ washing of raw material

• Wash fruits and vegetables thoroughly with clean water and preferably disinfect the water with Safewat at recommended dilution levels

• While cleaning fruits and vegetables, remove parts or items that are in rotten condition and then use.

Pre-preparation Wash your hands well and hygienically peel, grind, cut and mix raw materials, as appropriate, using only clean knife, equipment and utensils. Keep cooked food separately away from raw food.

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Preparation/cooking/serving

• Keep cooked food off the ground to protect from ants, lizards and cockroaches etc • Always use clean potable water for cooking and serving and to be on safe side, use

Safewat in recommended concentration • Do not keep and mix food leftovers of previous day with fresh cooked food • Never place cooked food on a plate or in a utensil that previously held raw materials eg,

raw vegetables, meat, poultry, eggs, seafood • Always serve food in clean utensils • Use a serving spoon to serve do not use hands directly. Wash your hands thoroughly with

soap and water before serving food. • Keep the food covered.

HOW TO KEEP WATER CLEAN:

• Always use water for drinking and cooking from a deep tubewell, handpump or the tap, which has been disinfected, either by using a water disinfectant such as safewat in recommended dosage or by boiling or using a water filter. The water should be stored in a clean container/pitcher with proper lid.

• The surroundings of the handpump and the open well should be kept clean and clothes

should not be washed around it resulting in collection of water. Building latrines and open defecation should not be allowed near the water source.

• Wastewater should be allowed to go to proper drains and not let it go out in open

drains, which creates puddles and allows rotting of household garbage.

Step- 2 Importance of hand -washing, when to wash hands and the steps to handwashing

30 minutes

2.1 Now ask participants regarding what they have been observing in the community. When do people

generally wash their hands? List responses. 2.2 Now share that during the baseline survey done in Dehradun and Haridwar it was found that the hand

washing practices were very poor among the community members and this is one of the major causes of people falling sick. Highlight that during the survey it was also found that both hand washing practices and household level water disinfection and storage have been shown to be effective interventions to reduce the incidence of diarrhea at household level.

2.3 Now share the importance of keeping your hands clean. Share that it is essential to wash hands during the following situations:

• Before you start to cook, • Before you start feeding children, • Before you eat food, • After defecation, • After washing your child after defecation,

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• After touching dirty objects, • After playing with animals etc.

Key message:

It is essential to wash hands during the following situations:

• Before you start to cook, • Before you start feeding children, • Before you eat food, • After defecation, • After washing your child after defecation, • After touching dirty objects, • After playing with animals etc.

2.4 Tell the group that you will demonstrate how hand washing should be done. Facilitator to demonstrate

to the participants the actual hand washing using soap, water and clean dry towel. Talk about each step in the demonstration as given in the following boxes:

Steps of hand washing: • Wet your hands /forearms thoroughly with running water. • Holding your hands up above the level of your elbow, soap your hands and lather well, covering all

surfaces. • Weave fingers and thumbs together and slide them back and forth. Do not forget the area under

the fingernails and between the fingers. • Wash for at least 15-30 seconds. • Rinse hands under a stream of clean, running or poured water until all the soap has been removed. • Air dry hands completely or dry them with a clean dry towel/cloth.

Do not use clean hands to turn off the tap or touch contaminated items otherwise you will need to wash your hands again.

2.5 Now share that each participant should also practice hand washing as shared above. They need to

demonstrate this to the community members during home visits. Let each participant practice and the facilitator helps the participants.

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Key message:

Steps of hand washing: • Wet your hands /forearms thoroughly with running water. • Holding your hands up above the level of your elbow, soap your hands and lather well,

covering all surfaces. • Weave fingers and thumbs together and slide them back and forth. Do not forget the area

under the fingernails and between the fingers. • Wash for at least 15-30 seconds. • Rinse hands under a stream of clean, running or poured water until all the soap has been

removed. • Air dry hands completely or dry them with a clean dry towel/cloth.

Step- 3 Evaluation 15 minutes 3.1 Now ask participants the following questions: • What is food hygiene • What are some of the key things you can do to ensure food safety across various stages of food

preparation? • When should we wash hands? • What are the steps to hand washing?

Listen to response, clarify whenever required. Pre-training preparation: - Read the scheme of the session thoroughly. - Ensure that soap, water and a clean dry towel is made available in advance - Prepare flipcharts for all the relevant points that needs to be shared during training. Photocopy relevant handouts

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Appendix 7.1 ENSURING FOOD SAFETY ACROSS THE VARIOUS STAGES (PROCESS) Purchase and storage of raw materials

• Purchase all raw materials very carefully ensuring that the color appearance, body, texture etc correspond to the specific characteristics or nature of fresh raw materials.

• Use clean, non-contaminating containers with lids. Do not use rusted, cracked, chipped or

damaged container for storage of any ingredient • Consume first the raw material bought first and do not mix old one with new

Cleaning/ washing of raw material

• Wash fruits and vegetables thoroughly with clean water and preferably disinfect the water with Safewat at recommended dilution levels

• While cleaning fruits and vegetables, remove parts or items that are in rotten condition and then

use. Pre-preparation Wash your hands well and hygienically peel, grind, cut and mix raw materials, as appropriate, using only clean knife, equipment and utensils. Keep cooked food separately away from raw food. Preparation/cooking/serving

• Keep cooked food off the ground to protect from ants, lizards and cockroaches etc • Always use clean potable water for cooking and serving and to be on safe side, use Safewat in

recommended concentration • Do not keep and mix food leftovers of previous day with fresh cooked food • Never place cooked food on a plate or in a utensil that previously held raw materials eg, raw

vegetables, meat, poultry, eggs, seafood • Always serve food in clean utensils • Use a serving spoon to serve do not use hands directly. Wash your hands thoroughly with soap

and water before serving food. • Keep the food covered.

HOW TO KEEP WATER CLEAN:

• The contaminated water is the main cause of commonly occurring diarrhea and dysentery in infants and children, which take a high toll of morbidity and mortality. Always use water for drinking and cooking from a deep tubewell, handpump or the tap, which has been disinfected, either by using a water disinfectant such as safewat in recommended dosage or

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by boiling or using a water filter. The water should be stored in a clean container/pitcher with proper lid.

• The surroundings of the handpump and the open well should be kept clean and clothes should not be washed around it resulting in collection of water. Building latrines and open defecation should not be allowed at least within 10 meters of the water source.

• You may have noticed that the household water is allowed to flow out in the streets and in open drains, which creates puddles and allows rotting of household garbage. In case the wastewater cannot be connected to the covered drains, small soakage pit should be made for each house.

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Day one

Session number : 8 Topic : Synthesis Duration : 15 minutes Objectives: At the end of the session, the participants will be able to:

1. List the key learning points for the day

Content: • Learning points for the day

Training Materials:

• Flip chart, pens Steps, duration and method:

Steps Duration Method 1. Key learning points for the day 15 minutes Interactive discussion

Learning Process

Step-1 Key learning points for the day 15 minutes

1.1 Facilitator to ask the participants to come up with the key learning points for the day. Listen to the responses of the participants and add, clarify wherever required.

1.2 Also share with the participants that tomorrow we will begin the day with recapitulation of the key learnings so they need to come prepared for it. Share that they can use any creative method to present the learnings for the day. Ask for volunteers who will present the key learnings for the day. Ensure at least four volunteers are there in the group. Share that the role of these volunteers would be to interact with all the other participants after the day one training is over and to take feedback from them regarding the key learning points and also identify those points where more clarity is required.

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Day two

Session number : 1 Topic : Recap Duration : 15 minutes Objectives : At the end of the session, the participants will be able to: 1. List the learning points from the previous day and clarify their understanding.

Content: Participants responses Training Materials:

• Flip chart, pens

Steps, duration and methods:

Steps Duration Method 1. Recapitulation 15 minutes Creative (upto the participants)

Learning Process

Step-1 Recapitulation 15 minutes

Ask the volunteers to present the key learning points from the previous day. Facilitator to add clarify any points that were not understood properly. Also ask participants regarding any suggestions they

have from the previous day to make the training more useful for them. For example; were the facilitators going too fast or too slow, any suggestion for improvement. etc. Facilitators to listen to

responses and take necessary actions accordingly.

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Day two

Session number : 2 Topic : How to use the kits for water quality testing for turbidity, PH, residual chlorine and presence or absence of coliform bacteria. Duration : 1 hour and 15 minutes Objectives : At the end of the session, the participants will be able to: 1. Demonstrate how to use the kits for water testing for turbidity, PH, residual chlorine and presence

and absence of coliform bacteria in a sample.

Content: Usage of water testing kit Training Materials:

• Samples of water testing kits, samples of water from different sources for testing


Steps Duration Method 1. Usage of water testing kits 45 minutes Demonstration and interactive discussion 2. Practicum by participants 30 minutes Demonstration

Learning Process

Step-1 Usage of water testing kits 45 minutes

1.1 Facilitator to explain what the water testing kit is all about. Let each participant see the kit properly. 1.2 Highlight that during baseline survey an overwhelming majority of respondents

8 out of 10 people contacted shared that they usually assess water quality through appearance only. 1.3 Now show the participants clearly that by using the kit, water would be tested for the following: PH, residual chlorine, presence or absence of coliform bacteria in a sample. Explain the above terminology in simpler terms so as to enable the participants to understand the same. 1.4 Now share how for each particular input, the testing is to be done. (Refer to appendix 2.1 for details)

Also share that the water testing kit will be used by the change agents on a regular interval to check the contamination in water and also to sensitize the people on water and sanitation related issues.

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1.4 Now the facilitator to demonstrate the use of each of the water testing kit to the participants carefully mentioning how to assess each component in the water that will be tested. Let participants ask questions to clarify their doubts. (refer to appendix 2.1 for details)

1.5 Now let the large group form into four small groups. Each group can then be given few testing kits

along with water samples. Facilitator to ensure that the participants are able to demonstrate the use of the water testing kits properly. Clarify any doubt the participants may have.

Step-2 Practicum on usage of water testing kits 30

minutes 2.1 Now the facilitator to ask few participants to role-play a situation where they try to convince the

community regarding the importance of testing water to assess the quality and also demonstrate how to do the testing and show the results to the household.

2.2 After the role-play ask for feedback from the observers and then the facilitator also to share feedback

on what was done well and where there was possibility for improvement. Pre-training preparation: - Read the scheme of the session thoroughly. - Ensure different samples of water and the testing kits prior to the training - Prepare flipcharts for all the relevant points that needs to be shared during training.

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Appendix 2.1 Procedure for pH Testing

pH value gives an idea of the intensity of the acidic or basic nature of a water sample. pH scale for aqueous solutions lie between 0 – 14. A pH below 4.0 gives sour taste and above 8.0 an alkaline taste. Water having higher values of pH increases scale formation in water heating apparatus. Disinfectant capacity of chlorine reduces if the water is alkaline.

pH Scale

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Highly Acidic Neutral Highly Alkaline

You Need 1. pH Paper 2. Sample collection bottle How to do it :

1. Fill sample collection bottle with water sample. 2. Take small piece of pH paper. 3. Dip pH paper into bottle. 4. Let it dry for few seconds. 5. Compare the colour with pH colour chart. 6. Record corresponding pH value.

Permissible Limits: Potable water = 6.5 to 8.5 Fresh water (aquatic life) = 6.5 to 9.0 Irrigation water = 4.5 to 9.0 Marine water (aquatic life) = 6.5 to 8.5

Procedure for Residual Chlorine

Chlorine is widely used for disinfection of water. For effective disinfection, dose of chlorine, optimum contact period and residual chlorine are required to be known. You Need: • Sample Collection bottle and pH Paper • Cylinder

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• Ortho Toludine Solution • Whatman filter paper How to find out Residual Chlorine : If the sample is coloured or turbid try to get a clear sample by passing the sample through the whatman filter paper given in the kit.

1. Transfer 10 ml of water sample. 2. Check pH of the solution. 3. If pH is less than 9 add 4 drops of Ortho – Toludine if pH is more than 9 add 8 – 10 drops. 4. Compare the colour with standard colour chart as below : (Residual Chlorine (mg/l)

0.1 0.5 1.0 Permissible Limits Drinking water = 0.2 mg/l minimum Precautions : • Ortho-Toludine is a hazardous chemical. Handle it carefully. • Avoid its contact with skin, eyes or any other sensitive body parts. • In case of accidental contact, wash it immediately with a large amount of water. Coliform Testing Coliforms are a group of bacteria, which are readily found in soil, decaying vegetation, animal feces, and raw surface water. These indicator of presence of coliform bacteria during the test may or may not be accompanied by pathogens (i.e., disease-causing organisms). Coliforms, rather than the actual pathogens, are used to assess water quality because their detection is more reliable. Pathogens appear in smaller numbers than coliforms, so are less likely to be isolated. Drinking water found to contain coliforms is considered biologically contaminated. • The Coliform Bottles gives the preliminary information of presence or absence of coliform bacteria. • It does not differentiate the faecal coliform and coliform bacteria. • It does not detect the particular species of bacteria present in the sample. • It gives the idea about the presence of bacteria in the given sample. • It is for instantaneous monitoring of sample. • It gives the idea about the water quality that the water is drinkable or not. • It is mainly based on field-testing, where one cannot take all the sophisticated instruments for bacterial

check. So once the confirmation will come out that the sample is contaminated or not, one can go for detailed laboratory tests.

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How to test: 1. Fill the coliform bottle with sample water, directly from the source, till the arrow mark on the sticker of

the bottle. 2. Close the lid tightly and shake. 3. Keep the bottle at 35* C temperature for 48 hours. 4. If the bottle turns black within this period, the water is contaminated with coliform bacteria.

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Day two Session number : 3 Topic : Introduction to Safewat Duration : 1 hour Objectives : At the end of the session, the participants will be able to:

1. Explain what is Safewat 2. Demonstrate how it is to be used and where it will be available. 3. Explain the shelf life and clarify the misconceptions regarding it.

Content:

• What is Safewat, its use, shelf life • Where will Safewat be available • Misconceptions regarding Safewat smell and taste

Training Materials:

• Flip chart, pens, samples of Safewat, vessel and water, safewat demonstration checklist Steps, duration and methods:

Steps Duration Method 1. What is Safewat, how it is to be used, where it will be available, explain the shelf life and clarify misconceptions.

30 minutes Interactive presentation, demonstration

2. Practicum by participants 30 minutes Role-play and large group discussion

Learning Process

Step-1 What is Safewat, how it is to be used, where it will be available, explain the shelf life and clarify misconceptions.

30 minutes

1.1 Facilitator to introduce the participants to the product named Safewat. Share a sample of the bottle with

all the participants. Clarify that Safewat is basically a water disinfectant that contains chlorine in recommended dosage. It is an effective and inexpensive intervention to provide safe drinking water. Share samples of the products with the participants and let them all have a look.

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Key message:

What is safewat- It is a water disinfectant that contains chlorine in recommended dosage.

1.2 Now share that during baseline survey 9 out of 10 persons contacted in Dehradun and Haridwar said

that they did nothing to improve water quality. Out of the respondents who mentioned that they have taken some measures to improve the quality of water 7 out of 10 said they boiled water to improve water quality while rest 3 out of 10 filtered water. Highlight that one of the major causes of diarrhea is contaminated water.

Key message:

Baseline survey results on water quality assessment at Dehradun/ Haridwar Did nothing to improve water quality 9 out of 10 persons contacted

Out of those who said they did take measures to improve water quality Those who boiled water 7 out of 10 persons Those who filtered water 3 out of 10 persons

1.3 Now share that safewat would be available with the retailers. The health providers who are part of the

Saadhan network will also stock this product. The cost of one bottle of safewat would be Rs. 9.00 + sales tax+ local tax. (Approximately Rs.10/- per bottle). Highlight that this bottle will be enough for disinfecting 1000 litres of water.

1.4 Now the facilitator should demonstrate the use of Safewat. Share the copy of the checklist with the

participants. (refer to appendix 3.1 for the same) Highlight that this checklist will enable them to remember the steps to demonstration of safewat and can be used to learn the steps in future. Share a copy of the checklist with all participants. Ensure that actual sample is used with one litre of water. Facilitator to ensure that during the demonstration the participants are clear about the following: • Contents of safewat-chlorine in recommended dosage • Dosage pattern- 1 drop / litre of water • Vessel to be used- any vessel can be used • Steps of purifying water using disinfectant-( Safewat):

1. Clean the jar/ container in which you will fill the water. 2. From a clean source fill the water in the jar/container 3. Open the Safewat bottle carefully.

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4. Add 1 drop of liquid from Safewat bottle for every 1 liters of water, for 5 litre- 0.5 ml (5-6 drops), 10 litre- 1ml, 20 litres (2 ml).

5. Shake the water jar/ container well, in which you have added safewat. 6. Use water after 30 minutes. 7. Use a ladle with long stem to take the water from the jar

• Available with retailers and health providers • Shelf life-12 months from date of manufacturing • Share that you can use the safewat disinfected water for the following- drinking and for making ice,

for washing hands, to wash vegetables and fruits, for preparing ORS, for cleaning teeth. • Precautions- Do’s and Don’t of safewat-

Do’s (Safewat) Don’t (Safewat) Always use safewat in water in recommended dosage

Do not keep safewat under direct sunlight

Keep safewat in a cool and dry place Keep safewat away from reach of children

Also share that during home visit each change agent will be expected to demonstrate the use of safewat. Ensure that the precautions are also shared carefully with the participants.

Key message:

Dosage for safewat- 1 drop per litre of clean water Steps of purifying water using disinfectant- (Safewat): 1. Clean the jar/ container in which you will fill the water. 2. From a clean source fill the water in the jar/container 3. Open the Safewat bottle carefully. 4. Add 1 drop of liquid from Safewat bottle for every 1 litres of water 5. Shake the water jar/ container well, in which you have added safewat. 6. Use water after 30 minutes. 7. Use a ladle with long stem to take the water from the jar. Where is safewat available- with retailers and health providers who are part of saadhan network. What is the shelf life of safewat- 12 month from the date of manufacturing.

Precautions to using safewat- Always use it in recommended dosage Keep it in a cool and dry place Do not keep safewat under direct sunlight Keep safewat away from reach of children

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1.5 Now ask few volunteers among the participants to re-demonstrate the use of water disinfectant to improve the quality of drinking water and explain the key messages that needs to be communicated during demonstration. Let the participant complete the demonstration and then the facilitator should invite feedback from the large group. Add / clarify points that have not come up during the discussion.

Also share that there are other ways of purifying water such as by boiling the water for 20 minutes after the first boil starts or by filtering the water using a water filter.

1.6 Now share that after adding Safewat to water, there is going to be a slight difference in smell and

taste of water due to the chlorine content. Share that if we consider the health benefits of Safewat, one should and will get used to the slight change in smell and taste. It is highly essential for the change agents to share this with the community as due to the initial difference in smell and taste of water, some of them may discontinue to use it. Whereas if they are mentally prepared and aware of the difference in smell and taste, the chances are high that they will continue to use it and also propagate it to others.

Key message: Does using safewat cause change in taste and smell of water-

Yes, it does. The slight difference in taste and small of water is an indication that water is pure to drink.

1.7 Now ask the participants, whether they would be ready to demonstrate the steps to the community members? Also ask the following questions:

• What is safewat? How much does it cost? • What is the recommended dosage? • Where would it be available? What is the shelf life? • What are the steps to purifying water using safewat? • What the precautions to using safewat? • How would you deal with the change in smell and taste of water?

Step-2 Practicum 30 minutes

2.1 Ask few participants to role-play a situation where they try to convince the community regarding the benefits of using safewat, the water disinfectant. 2.2 After the role-play the facilitator to invite feedback from the observers regarding what was done well and where there were chances of improvement. Facilitator to add to this once the feedback from all others have been elicited. Pre-training preparation: - Read the scheme of the session thoroughly. - Ensure samples of safewat, container and water are available for demonstration. - Prepare flipcharts for all the relevant points that needs to be shared during training.

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Appendix 3.1 Checklist for demonstration of Safewat (the water disinfectant)

Name of trainee :________________ Dates of Training ___________________ Pre –test score (%): ------------- Post –test score (%): --------------

No TASK/ ACTIVITY FU 1 Shares that safewat is a water disinfectant and contains -chlorine in recommended

dosage

2 Shows a bottle of safewat and clarifies that one bottle will cost Rs. 10/- and will be enough to disinfect 1000 litres of water. Lets the participants touch and see the bottle.

3 Clarifies that one needs to use only - 1 drop / litre of water

4 Shares that any vessel can be used for this purpose

5 Clearly specifies the steps of purifying water using disinfectant- (Safewat): 8. Clean the jar/ container in which you will fill the water. 9. From a clean source fill the water in the jar/container 10. Open the Safewat bottle carefully.

Add 1 drop of liquid from Safewat bottle for every 1 litre of water 11. Shake the water jar/ container well, in which you have added safewat. 12. Use water after 30 minutes. 13. Use a ladle with long stem to take the water from the jar

6 Shares that safewat will be available with retailers and health providers

7 Highlights that the shelf life of safewat is -12 months from date of manufacturing

8 Shares that you can use the safewat disinfected water for the following- Drinking For making ice For washing hands To wash vegetables and fruits For preparing ORS For cleaning teeth.

9 Highlights the following precautions with the community- -Always use safewat in water in recommended dosage -Keep safewat in a cool and dry place -Do not keep safewat under direct sunlight -Keep safewat away from reach of children

10 Shares that by using safewat, there will be some difference in taste and smell of

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water but this is a positive indication that water is pure for drinking 11 Also shares that other ways of disinfecting water are by either using a filter or by

boiling water for 20 minutes.

% SCORED PTS – YES/NO

CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible scores are 11. For example if a trainee has performed satisfactorily on 9 tasks, she/he will score 9 points. To calculate the percentage, the formula will be (9/11)*100 = >80%. A trainee performed to standards (PTS) if she/he scores 80% or above.

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Day two Session number : 4 Topic : Diarrhea Management Duration : 2 hours Objectives : At the end of the session, the participants will be able to: 1. Explain how to manage a child with diarrhea 2. Explain the meaning of Oral Rehydration Therapy (ORT) 3. Demonstrate the preparation of ORS and specify the amount of ORS to be given to children.

Content:

• Diarrhea management with ORT/ ORS • How to prepare ORS

Training Materials:

• Flipchart, marker pens, samples of Neotral (ORS), one litre jug, water and spoon


Steps Duration Method 1. Diarrhea management- What is ORT? 30 minutes Interactive presentation 2. Demonstrate the preparation of ORS

40 minutes Demonstration, Interactive discussion

3. Practicum 35 minutes Role-play 4. Evaluation 15 minutes Question-answer

Learning Process

Step-1 Diarrhea management- What is Oral Rehydration Therapy (ORT) 30 minutes

1.1 Facilitator to ask the participants to share their experiences of what they have seen in the community in

cases of diarrhea. What do people generally do when a child gets diarrhea? Listen to their responses. 1.2 Now share that the basic principle to manage diarrhea is to replace the loss of fluids, and salt and to

maintain adequate diet. Loose –motions may take its own time and will stop in due course. There is no need to give anti-biotics /pill/syrups as diarrhea is caused by a virus and antibiotics do not have any affect on them. Also share that most cases of diarrhea can be managed at home through Oral Rehydration Therapy (ORT).

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1.3. Now clarify the meaning of Oral Rehydration Therapy. Share a packet of Oral Rehydration Salt (ORS) with the group. Share that ORS is used to replenish the vital salts that are lost from the body during diarrhea. However alongwith ORS home available fluids such as milk, yoghurt drink (Dahi ki lassi), lemon drink, dal, vegetable soup, fruit juice (unsweetened), plain clean water should also be given. This process of administering both ORS and the home available fluids is called the ORT.

Key message: What is Oral Rehydration Therapy (ORT)? Administration of home available fluids such as milk, yoghurt drink (dahi ki lassi), lemon drink, dal, vegetable soup, fruit juice (unsweetened), plain clean water. and Oral Rehydration Salts (ORS) 1.4 Now share the following information with the participants to sensitize them to the severity of diarrhea.

Share that during the baseline survey done at Dehradun and Haridwar, the following information was found. Share the information as given in the table below:

Situation assessed Present situation in

Dehradun/Haridwar Ideal situation

Persons suffering from diarrhea

1 out of 6 person contacted

None

How many used pills/ syrup during diarrhea

4 out of 5 person who had diarrhea

None

How many were given nothing to eat during diarrhea

2 out of 8 persons

0

How many used ORS during diarrhea

1 out of every 10 person

10

How many knew correct preparation of ORS

3 out of 5 person

5

How many persons were taking ORT

7 out of 10 person

10

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1.5 Share that the above statistics states that there is a gap between the ideal situation and the present

situation. The change agents can contribute to improve this situation through household visits and sharing the correct information regarding diarrhea management.

1.6 Now share that diarrhea can be managed properly if dehydration can be controlled. The process of

replenishment of fluid in the body through ORT (i.e; home available fluids and ORS) is called rehydration. The deaths due to diarrhea can be prevented if managed promptly and correctly. Stress that you can contribute to improving the situation by sharing information on correct assessment and proper management of diarrhea. Clarify that you will be working in this situation where awareness regarding how to manage diarrhea is very low. During home visits you will get a very good chance to meet with the mothers. By sharing correct information you can play a vital role in bringing about the desired awareness in the community.

1.7 Remind the participants that diarrhea is passage of watery stools frequently. Mothers generally know

that their children are suffering from diarrhea and are crucial to taking decisions to manage it. Clarify that if the diarrhea is of more than 2 weeks duration, the child has persistent diarrhea. This child needs special advice and care otherwise the disease can produce malnutrition. This child needs referral to a pediatrician or hospital. Also share that if the child has blood in the stool, it indicates dysentery and the child needs to be referred to the district hospital.

1.8 Now highlight that it is important to understand that only cases who have some dehydration during

diarrhea can be treated with ORS. Also highlight that it is de-hydration during that needs to be treated and is a cause of concern. Hence there is the need to emphasize on ORT/ORS.

Key message: Rehydration at home

ALWAYS ENSURE

1. ORS is given

2. Home available fluids should be continued

3. Refer cases if the case does not improve

within 24 hours or the following situations

occur- Every 1 or 2 hour loose stools are passed Unable to take fluid or breastfeed or take semi-solid

or vomits Less urination Fever Excessive thirst Blood in stool (dysentry) Roughness of face and tongue Repeated vomiting

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1.9 Now ask how would you look for signs of dehydration. Remind the participants what we saw in the two types of plants. Highlight that one plant was dehydrated and looked almost dead, while the other one looked fresh and green. Share that it is important that the mother of the child is able to look and feel for signs of dehydration. In order to identify signs of dehydration one can do the following:

Key message Signs of dehydration:

Look at the child’s general condition. Is the child “lethargic” or “unconscious”? Is the child restless and irritable?

Assess the child’s ability to drink. If the child does not take any water at all or vomits it out completely or is not able to keep any water down, the child is not able to drink. This is a general danger sign. If the child reaches out for the cup or the glass or if the child opens his/her mouth when water is offered or if the child begins to cry when the water is taken away, it means that the child is drinking eagerly.

One needs to check for sunken eyes. Look for sunken eyes: eyes are sunken or not sunken. Determine the normal appearance of the child’s eyes by asking the mother. Ask the mother if she thinks her child’s eyes look normal or unusual. Her opinion helps to confirm that the child’s eyes are sunken. The eyes of a child who is dehydrated may look sunken.

Step-2 Demonstration of how to prepare ORS

30 minutes

2.1 Now share that all those who suffer from diarrhea should be given ORS from the time they detect they

have diarrhea. This is the best way to manage diarrhea. Highlight the ability of ORS to save the child – among 100 dehydrated children who would have died from diarrhea 95% could be saved by administering ORS timely. Now ask where can you obtain ORS. Listen to responses and share the following:

ORS packets are available free of cost from government health facilities. ORS packets (Neotral) can be purchased from ISMPs who are part of the saadhan network in subsidized prices. A one litre plain pack of neotral costs Rs. 5.00/- and orange flavored sachets consisting of 5 sachet (each meant for one glass of water) will cost Rs. 7.50/- These can also be purchased from chemist shops. Also share that if anyone purchases an ORS packet from the market, it is also important to check that the packet conforms to WHO formula or composition. Major brands of ORS, WHO composition in the market: Electrobion, Woodwards ORS, Punnarjal, Relyte and Peditral, Neotral also conforms to WHO composition.

2.2 Share with the participants how to prepare ORS. Familiarize the participants to the checklist for demonstration of ORS preparation. Share a copy of the checklist with all the participants. (Refer to appendix 10.1 for details) Use a packet of neotral and demonstrate how to prepare ORS.

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1. Wash hands thoroughly with soap and water 2. Pour all the ORS powder from a 1-litre packet into a clean container 3. Measure 1 litre of clean/ safewat cleaned/boiled drinking water and pour it into the container in which you poured ORS 4. Stir using a clean spoon until all the powder in the container has been mixed with water and none is remaining at the bottom of the container

Key message: How to prepare ORS-

1. Wash hands thoroughly with soap and water 2. Pour all the ORS powder from a 1-litre packet into a clean container 3. Measure 1 litre of clean/ safewat cleaned/boiled drinking water and pour it into the

container in which you poured ORS 4. Stir using a clean spoon until all the powder in the container has been mixed with water and none is remaining at the bottom of the container

2.3 Now share the following points, which should be remembered while administering ORS. • Prepare fresh ORS each day • Ensure that small children are given ORS with the help of spoon and cup rather than bottle • Ask the mother to give 1 teaspoon of the solution to the child. This should be repeated every 1-2

minutes (An older child can drink it in sips should be given one sip every 1-2 minutes) • If the child vomits the ORS tell the mother to wait for 10 minutes and resume giving the ORS but

this time more slowly than before. • Breastfed babies should continue to be given breast milk in between ORS. • Any ORS which is left over after 24 hours should be thrown away. • After about 4 hours of giving ORS, reassess the child for dehydration. If the child is better,tell the

mother to give fluids that are available at home the same way she gave ORS and give ½- 1 cup ORS after every motion. Begin feeding the child even if dehydration persists, continue ORS. If the child’s condition deteriorates, immediately take the child to the hospital. On the way to the hospital, the mother should continue to give ORS to the child.

2.4 Now share the following additional information regarding ORS that needs to be shared with the

community- o Keep ORS covered, if not using it o Till diarrhea stops keep giving additional fluids, it can take 3-5 days for it to stop

• Without consulting a doctor, please do not provide the person suffering from diarrhea any medicine, only give ORS,

• Also remember that ORS is used only for replenishing vital fluids and nutrients in the body. Do not mix ORS in milk, Sharbat, soft drink etc, • Keep giving ORS till diarrhea stops.

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2.5 Clarify that the mother can continue to give home available fluids apart from ORS. The useful and harmful fluids as given below should however be kept in mind. Keep giving the child extra fluid at regular intervals till he/ she can take. As soon as stools are passed fluid should be replaced in the body through ORS and other home available fluids as given below. Share that certain home available fluids are harmful during diarrhea and hence extra care should be given on avoiding them.

Home available fluids

Useful/ can give Harmful/ should’nt give 1. Milk 2. Yoghurt drink (Dahi ki lassi) 3. Lemon drink 4. Rice, Kanji, Mand 5. Dal 6. Vegetable soup 7. Fruit juice (unsweetened) 8. Plain clean water

1. Soft drinks (Coca Cola, Pepsi, Limca etc.) 2. Fruit juices (sweetened) 3. Coffee

2.5 Apart from fluid intake the child should also be fed as much as the child would take. The semi-solid

food such as mashed potato, and kichdi can be given. If the child is reluctant to eat then feed small quantities more often than before. As soon as the child recovers the child’s appetite would return and the mother should feed extra foods to make up for the excessive losses during the disease.

Advise the mother to consult a doctor in case she finds that her child is : - Not able to drink or breast feed, becomes sicker; - Has blood in the stool; or drinks poorly. Step- 3 Practicum 35 minutes

3.1 Now ask participants to show how they would diagnose a child with dehydration and convince the

mother to give ORS to the child by demonstrating how to prepare ORS. Remind the participants to keep the checklist in mind. Also ask the participants to share the key points that needs to be remembered while administering ORS.

3.2 Let the volunteers role-play the situation. During the role-play inform others to observe the role-play keeping the ORS checklist in hand. After the role-play, thank the participants. Now take feedback from the large group who were observing the role-play. Facilitator also to help the participants understand what they did well and what could have been improved. Also highlight the following essential message for change agent to the community: • If the doctor is giving your child ORS, he is very good doctor and is doing the right kind of

treatment. • Do not ask the doctor for tablets/ I.V fluids. He will do it if danger signs are there. Loose motion will

stop on its own. Do not worry. Dehydration needs to be taken care off by ORS.

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Step- 4 Evaluation 15 minutes

4.1 Now ask participants the following questions:

What is ORS? How much does it cost? What is it used for? Where will it be available? How would you prepare it? What are the key points that need to be shared with the community

members regarding ORS? Facilitator to listen to the responses, add, clarify wherever required. Pre-training preparation: - Read the scheme of the session thoroughly. - Obtains enough packets of ORS samples, one litre jug, spoon and water to demonstrate

preparation of ORS to the participants. - Prepare flipcharts for all the relevant points that needs to be shared during training.

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Appendix 4.1

Checklist for demonstration of ORS

Name of trainee :________________ Dates of Training ___________________

No TASK/ ACTIVITY FU 1 Explored local perceptions about ORS and clarified misconceptions

- Shares that if the doctor advises your child ORS he is a good doctor and doing the right thing

2 Explains to the mother and family the importance of ORS to prevent diarrhea - Highlights the important role ORS plays in controlling dehydration.

3 Demonstrates how to prepare ORS in the following manner 1. wash hands thoroughly with soap and water 2. pour all of ORS powder from the packet into a clean container 3. measure 1 litre of clean drinking water and pour it into the container in which

you poured ORS 4. stir until all the powder in the container has been mixed with water and none

is remaining at the bottom of the container 5. ensures re-demonstration of the above

4 Advises the mother on the following points to be remembered while administering ORS:

1. Prepare fresh ORS every day. 2. Ensure that small children are given Ors with the help of spoon and cup rather

than bottle. 3. The mother should give 1 teaspoon of the solution to the child. This should be

repeated every 1-2 minutes ( an older child can drink it in sips should be given one sip every 1-2 minutes)

4. If the child vomits the ORS tell the mother to wait for 10 Minutes and resume giving the ORS but this time more slowly than before

5. Breastfed babies should continue to be given breast milk in between ORS 6. Any ORS which is left over after 24 hours should be thrown away 7. After about 4 hours of giving ORS, reassess the child for dehydration. If the

child is better, tells the mother to give fluids that are available at home the same way she gave ORS and continue to give ORS after every motion.

8. Begin feeding the child even if dehydration persists, continue ORS. If the child’s condition deteriorates; take the child to the district hospital. On the way to the hospital, the mother should continue to give ORS to the child.

5 Shares the following additional information regarding ORS - 1. Keep ORS covered, if not using it 2. Till diarrhea stops keep giving additional home available useful fluids, it can

take 3-5 days for it to stop 3. Without consulting a doctor, please do not provide the person suffering from

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diarrhea any medicine, only give ORS, 4. Also remember that ORS is used only for replenishing vital fluids and nutrients

in the body. 5. Do not mix ORS in milk, Sharbat, soft drink etc, 6. Keep giving ORS till diarrhea stops.

Total Scores obtained (Maximum 5 Point) % SCORED PTS – YES/NO

CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible scores are 5. For example if a trainee has performed satisfactorily on 4 tasks, she/he will score 4 points. To calculate the percentage, the formula will be (4/5)*100 = 80%. A trainee performed to standards (PTS) if she/he scores 80% or above.

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Day two Session number : 5 Topic : Film- Why sanitation and Swachhta ke bhag Duration : 1 hour and 15 minutes Objectives: At the end of the session, the participants will be able to: 1. Visualize and explain the key messages that needs to be communicated to the community.

Content: • Film Training Materials: • T.V, Video, cassette Steps, duration and methods:

Steps Duration Method 1. Film 45 minutes Film viewing 2. Debriefing 30 minutes Interactive discussion

Learning Process

Step-1 Viewing film 45 minutes

1.1 Facilitator to share with the participants that we are going to watch two films named why sanitation, components of sanitation (17 minutes). The second film Swachhta ke bhag is a (27 minute film). The film portrays typical situations in and around our community relating to hygiene and sanitation. This film will sensitize us to the need to become more conscious of taking appropriate measures to maintain hygiene and sanitation, which goes a long way in maintaining good health of the people residing in the community.

Step-2 De-briefing 30 minutes

2.1 Now conduct a de-briefing regarding the film. Ask participants for their observation. Facilitator to stress

on the key points related to hygiene and sanitation as depicted in the film. Share that when they discuss with the community members, they need to share the importance of hygiene and sanitation in relation to reducing diseases such as diarrhea.

Pre-training preparation: - Obtain TV, Video and Cassette before hand. - Check the working status of the same

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Day two Session number : 6 Topic : Introduction to Interpersonal skills and the Communication materials that

would be used during the field visits. Duration : 1 hour and 30 minutes Objectives: At the end of the session, the participants will be able to: 1. Explain the communication materials that will be used by them during such IPC meetings. 2. Explain what is Interpersonal Communication (IPC) and list the essential techniques required for

interpersonal communication 3. Demonstrate how to communicate with the community on the key health issues for which they will work Content: • Communication materials, flipbook, flyers, posters, stickers, IPC skills, flipbook, poster, flyers, stickers/ Training Materials: • Flip chart, pens, IPC skills assessment checklist Steps, duration and methods:

Steps Duration Method 1. Introduction to IPC materials that would be used during such meetings.


2.What is Inter Personal Communication and the essential techniques for it.

25 minutes Interactive discussion, role-play

3. Practicing IPC 45 minutes Role-play and discussion

Learning Process

Step-1 Introduction to IPC materials that would be used during such meetings. 20 minutes

1.1 Facilitator to share all the IPC materials with the participants. Ensure that each participant gets a copy of the entire materials that will be used for IPC. (refer to appendix 6.1 for details) 1.2 Facilitator to let the participants understand the usage of each of the IPC material. Let the participants

ask questions, clarify the doubts.

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Key message:

IPC communication materials available for change agents are as follows: Flipbook Flyers- safewat and hand washing POP materials- Poster and stickers

Step-2 Interpersonal Communication and the essential techniques for it. 25 minutes

2.1 Facilitator to ask the participants regarding what do they understand by Interpersonal Communication. Listen to their responses.

2.2 Now share that Inter-personal communication is a face-to-face verbal or non-verbal exchange of

information and feelings between two or more people. 2.3 Clarify that all the participants in their role, as change agents will essentially have to do a lot of Inter

Personal Communication. Share that during IPC they will be using the communication materials as shared above. However to ensure that they use the materials effectively, they need to be familiar with the essential IPC skills.

2.4 Now share the essential IPC skills as given in appendix 6.2. Facilitator to explain to the participants

each of the points as given in the appendix. Share that we will also do a role-play to see how to practice the same. Also share the IPC skills assessment checklist as given in appendix 6.3. Share that this checklist will help them to assess how effective they were and where they could possibly improve.

2.5 Now the facilitator should conduct a role-play to demonstrate the essential techniques for IPC to the

participants. Ensure that all the key points related to IPC skills are stressed during the role-play. The role-play situation could be that of a change agent visiting one of the household to share information on diarrhea management. Hand over a copy of the IPC skills checklist to all the participants. Let the participants use the checklist to assess the IPC skills. Ensure that after the role-play is over, a discussion is conducted on the key IPC skills using the checklist for the same.

Key message:

Essential IPC skills- Effective questioning • Asking questions for which you will get answer more than a yes or no i.e open-ended questions • Also asking some questions for which you get an answer in either yes or no i.e close ended questions • Asking questions which encourages the respondent to give further information than you already have

i.e; probing questions

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Listening is as important as sharing information. Through listening to community members you can find out information you need to assist them with problems, and help them to make decisions. When you listen do active listening which is characterized by paying attention to what is being said and also observing non-verbal communication of the community member. Giving full attention is demonstrated by actions such as having eye contact and nodding. Reflection is observing the emotions and reflecting them back to him/her. Reflection helps the change agent check whether the emotions observed are correct. Also repeating back to the community member what you heard him/her say in a short form. For example: I heard you say that Safewat will be a very effective method for disinfecting water. I hope I heard it right? Repeating what you heard helps in clarifying the understanding between the two parties. To prevent miscommunication when listening to a community member’s problem or when sharing information with a community member, it is useful to summarize or paraphrase what has been said. It is important for change agents to use words that motivate and ensure a community member of approval. Praise and encouragement help build a community members sense of confidence and reinforces desired behaviour. Information should be given clearly and in simple language so that the community member understands. Using visual aids and other IEC materials effectively- People understand more from what they see than they hear. There is a saying that a “picture is worth a thousand words”. So, when talking with community members use visual aids (example, the flipbook, posters, flyers etc) and other IEC materials whenever possible.

Step-3 Practicing IPC 45 minutes 3.1 Now let the participants practice IPC skills through role-plays. The role-play will give the participants

enough oppurtunity to practice the use of IPC skills. Facilitators to refer the role-play checklist while facilitating the process ( refer to appendix 6.4 for details) Clarify that during role-play participants should make use of all the relevant IPC materials. For example; to demonstrate preparation of ORS they need to take an actual sample with water.

3.2 Divide participants into small groups of three each. Inform that in each group during role-play one

person will become the change agent, the other the household member and the third the observer. Each person should keep changing the roles during the role-play till each has got the role of a change agent. Ask participants to pick up any of the following topics- • Diarrhea management • Safewat • At home-how to secure food and water

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Give participants 15 minutes to prepare for their role. Let the role-play begin and during role-play each person observes the other using the IPC checklist. After the role-play the observer shares the feedback. Facilitator to help the participants during preparation. Conduct the role-play and ask participants to use the IPC skills checklist while observing the role-play and provide feedback on what were the specific things that were done well by them and specific points that need improvement with respect to usage of IPC material, content delivery etc. The facilitator should keep moving from one group to the other and observe the participants and share specific feedback using the IPC skills checklist in hand. Pre-training preparation: - Read the scheme of the session and the appendices thoroughly. - Prepare flipcharts for all the relevant points that needs to be shared during training. - Photocopy the IPC skills checklist for all the participants. Appendix: 6.1 Inter personal Communication Materials: The change agents will be using a number of communication materials such as Flip book- Flip book is an interactive tool which will be used by the change agents while doing the interpersonal communication at the household and community level. This is key for message delivery. Safewat flyer: This contains information on diarrhea, how it spreads, Safewat the product and dosing. The change agents will use this during their IPC sessions, so they need to understand the content and how to use the flyer. Handwash flyer: This contains information on diarrhea, how it spreads, steps of handwashing, handwashing instances, Safewat and dosing. POP material: The Change agents need to be acquainted with the point of purchase material like product poster, sticker etc. Appendix 6.2 Essential IPC skills- Effective questioning- will help to obtain useful information from the community member. Questioning is a way to determine what service the community member wants or how he/she is feeling, what the community member already may know, or what problem he/she may have. Open-ended questions- encourage the client to offer information, concerns and feelings freely. For example: Who told you about the referral system? What did you learn from the exercise? When did you first hear about it? How did you learn it? etc. The basic point is you get answers, which are more than a yes or no. There is usually some explanation, which also accompanies the answer.

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Close-ended questions are useful for obtaining specific information. They can be answered in just a few words. Usually the answer ends with either a yes or a no. Examples are as follows: Do you like the taste? Is any member of your house suffering from diarrhea? Probing questions encourage the respondent to give further information, and to clarify an earlier point. They require tact in wording and tone used so as to not be judgemental. For example: How do you know that? Why do you think that happens? What made you think like that? Change agents should be good listeners. Listening is as important as sharing information. As a change agent, who is providing people with information, it may be difficult to remember that it is important to listen. Through listening to community members you can find out information you need to assist them with problems, and help them to make decisions. When listening to community members, listen actively. Active listening is characterized by paying attention to what is being said and also observing non-verbal communication of the community member. Giving full attention is demonstrated by actions such as having eye contact and nodding. Reflection is observing the emotions and reflecting them back to him/her. Reflection helps the change agent check whether the emotions observed are correct. Summarizing and paraphrasing means repeating back to the community member what you heard him/her say in a short form. For example: I heard you say that Safewat will be a very effective method for disinfecting water. I hope I heard it right? Repeating what you heard helps in clarifying the understanding between the two parties. Miscommunication can happen very easily when two people discuss something. A community member may tell you something that you understand in quite a different way from the way he/she meant it. To prevent miscommunication when listening to a community member’s problem or when sharing information with a community member, it is useful to summarize or paraphrase what has been said. It is important for change agents to use words that motivate and ensure a community member of approval. Praise and encouragement help build a community members sense of confidence and reinforces desired behaviour. Praise elicits feelings of self-worth, which in turn empowers them to better meet their health care needs. A kind, encouraging word from someone like a change agent, goes a long way in helping make change and reinforce positive behaviour. Information should be given clearly and in simple language so that the community member understands. Using visual aids and other IEC materials effectively- People understand more from what they see than they hear. There is a saying that a “picture is worth a thousand words”. So, when talking with community members use visual aids (example, the flipbook, posters, flyers etc) and other IEC materials whenever possible.

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Benefits of using visual aids/IEC materials • Helps to remember • Makes complex information or tasks easier for the provider to explain and for the community

members to comprehend • Makes small things big enough to be seen • Captures interest and attention • Helps to point out similarities and differences • Can make discussion of sensitive terms and issues easier • Generates discussion • Re-enforces key points and health messages • Prompts and reminds change agents of important information points • Take home materials helps to disseminate accurate information when materials are shared with

others. • Reduces information overload, by allowing community members to learn at their own pace and

leisure. Types of visual aids and IEC materials available

• Posters • Flipbook • Pamphlets • Samples and models • Videos • Flyers

When to use visual aids /IEC materials

• Community events • Home visits

Using a variety of visual aids and IEC materials enhances the effectiveness of interpersonal communication.

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Appendix 6.3

Checklist for assessing IPC SKILLS of change agents

Name of change agent: ________________ Household number---------------------- Date :________

TASK/ ACTIVITY

FU

1 Greets and introduces self if not known 2 Makes eye contact, smiles and appears relaxed and confident 3 Tone of voice is maintained 4 Asks following types of questions:

1. Both open ended 2. Close ended 3. Probing questions

5 Encourages the individual to talk 6 Listens actively i.e; pays attention to both verbal as well as non-verbal communication 7 Remains non-judgemental 8 Shares the knowledge and skills (relevant) correctly 9 Observes the emotions and reflects back to him/her 10 Summarizes and paraphrases i.e; repeats back to community member what you heard

him/her say in a short form to clarify understanding

11 Appropriately uses visual and IEC materials 12 Focuses on call to action 13 Provides flyers, booklets, safewat etc 14 Shares the referral information Total Scores obtained (Maximum 14 Point) % SCORED PTS – YES/NO

CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible score is 14. For example if a trainee has performed satisfactorily on 11 tasks, she/he will score 11points. To calculate the percentage, the formula will be (11/14) * 100 = 79%. A person performed to standards (PTS) if she/he scores 80% or above.

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Appenidx 6.4 MANAGEMENT OF A ROLE-PLAY

CHECKLIST Name of person being assessed:________________________________________________ Name of observer:_________________________________________ Date:___________________________________________________ Each question is worth up to 3 points. For questions with a yes or no answer, the number of points given is either 3 (if the action has been taken) or 0 (if the action has not been taken). Other questions – such as number 4 or 5 (below), can be scored by gradation: 3 if the action was done very well 2 if it was done satisfactorily 1 if an attempt was made but much improvement needed 0 if it was not done Question Points 1 Does the trainer explain the situation to be role-played to

one of the participants?

2 Does the trainer make sure the role-play is seen and heard by every one?

3 Does the trainer provide the relevant checklist to the participants to use while observing the role-play?

4 At the end of the role-play, does the trainer lead a discussion in the group, to elicit the main points learned in the role-play (with a view to achieving the learning objectives)?

5 Did the trainer provide, or did the trainer facilitate others to provide supportive feedback?

6 Was the trainer able to manage the players and audience during the role-play if they were diverting from the issue?

7 Did the trainer elicit from the participants a summary of the key points arising from the role-play and discussion?

Total Points Scoring: Total points possible 21 (7 questions x 3 points each) Divide total points achieved by 21 and multiply by 100. SCORE %_________

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Day two Session number : 7 Topic : Synthesis Duration : 15 minutes Objectives: At the end of the session, the participants will be able to: 1. List the key learning points for the day

Content: • Learning points for the day Training Materials: • Flip chart, pens Steps, duration and method:

Steps Duration Method 1. Key learning points for the day 15 minutes Interactive discussion

Learning Process


1.3 Facilitator to ask the participants to come up with the key learning points for the day. Listen to the responses of the participants and add, clarify wherever required.

1.4 Also share with the participants that tomorrow we will begin the day with recapitulation of the key

learnings so they need to come prepared for it. Share that they can use any creative method to present the learnings for the day. Ask for volunteers who will present the key learnings for the day. Ensure at least four volunteers are there in the group. Share that the role of these volunteers would be to interact with all the other participants after the day one training is over and to take feedback from them regarding the key learning points and also identify those points where more clarity is required.

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Day three

Session number : 1 Topic : Recap Duration : 15 minutes Objectives : At the end of the session, the participants will be able to: 1. List the learning points from the previous day and clarify their understanding.

Content: Participants responses Training Materials:

• Flip chart, pens Steps, duration and methods:

Steps Duration Method 1. Recapitulation 15 minutes Creative (upto the participants)

Learning Process

Step-1 Recapitulation 15 minutes

1.1 Ask the volunteers to present the key learning points from the previous day. Facilitator to add clarify any points that were not understood properly. Also ask participants regarding any suggestions they have from the previous day to make the training more useful for them. For example; were the facilitators going too fast or too slow, any suggestion for improvement. etc.

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Day three

Session number : 2 Topic : Introduction to home visit -purpose, key activities to

be done during each visit. Duration : 2 hours Objectives : At the end of the session, the participants will be able to:

2. Explain the purpose of home visits and the key activities that needs to be done during each visit. 3. Demonstrate a home visit

Content:

Home visits and key activities to be done during the visits Training Materials:

• Flip chart, pens, copies of form to be filled during home visit, flipbook, flyers hand washing, Safewat, POP material like poster, sticker etc., pencil, eraser.


Steps Duration Method 1. Home visit and the key activities to be done during the visits.


2. Demonstration of home visit by facilitator 20 minutes Role-play

3. Practicum 1 hour Role-play

Learning Process

Step-1 Home visit and Planning for a home visit 40 minutes

1.1 Ask participants what do they perceive is their role as a change agent during home visit. Listen to the responses and then share the following.

As health educator – to inform, educate and communicate the community how to have access to safe drinking water by household treatment and prevent and manage diarrheal diseases.

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As agents of change – to help educate the community members, widen their knowledge and change attitudes and practice so that they are able to adopt positive hygiene and sanitation behaviours to lead healthier and happier lives.

1.2 Now ask participants why a home visit is required?. Listen to their responses and then share the

following.

Key message

Home visit is required to - • To disseminate hygiene and sanitation messages related to safe handling of water, handwashing, food hygiene and prevention and management of diarrhea in the community.

• Filling up forms of each household visited.

• To demonstrate usage of Safewat during household visits.

• To inform about dates for Visibility, Acceptability and Taste (VAT) activities in the area and meetings with community leaders, women, men etc. for promoting and generating demand of Safewat and ORS.

• To demonstrate the quality of water to the households and community by using water quality testing kits.

• To inform the community members about the “Saadhan Network Counsellers” who are available for counselling on MCH issues.

1.3 Now ask what are the necessary preparations that you should do before going for a home visit. Listen

to their responses and then share the following.

Key message:

What you should do before making a home visit : Review any procedures to be carried out, specific advice to be given, or demonstrations to be given. Check your kit to see that it contains the required equipment and supplies needed for the day including IEC materials. Make a note of any resources, including information about available services, which may be required by the families that you plan to visit.

1.4. Now ask the participants what are the things they would keep in mind while conducting the home visit. Listen to responses and then share the following.

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Conducting a home visit: The following points should be considered whenever you make a home visit :

Key message:

Essential points for conducting a home visit

1. Greet the individual or family and introduce yourself.

2. Comment positively on something you note about the individual or her environment.

3. Assess whether your visit is at the time which is convenient for the individual and whether the planned content of your visit is suitable for the present situation.

4. Encourage the individual to talk about her condition or problem by framing your questions so that ‘yes’ or ‘no’ answers are avoided.

5. Avoid asking any intimate questions when other members, especially older members of the family are present.

6. Give credit and support for positive actions taken. This can be an incentive for further action by the family.

7. Pay attention to vocabulary and use simple language and words, which are familiar to those you are trying to reach.

8. Be alert to ‘teachable moments’ and use them whenever they arise. E.g. a mother whose child has diarrhea is more ready to learn how to prepare and give ORS to her child.

9. Avoid any inclination to impart or communicate and educate everything in one visit because too much information or too many messages may confuse the person.

10. Use a variety of teaching /communication tools e.g. demonstrating, talking, models, flipcharts etc, as this can help the person to understand better what they are explaining.

11. Choose your words carefully when commenting on a poor habit or custom because sharp criticism or ridicule can result in hostility and loss of rapport.

12. Summarise the important points discussed or demonstrated and plan with the individual or family for the next home visit.

13. During your visit make a note in your diary/register of important details pertaining to the visit. Do this directly as possible so as not to cause suspicion or alarm. This information should later be recorded on the household record.

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14. At the end of the day, spend some time to assess what was achieved or not achieved in your work

with families in your area and think of possible reasons for either result. Make a note of those cases, which should be discussed with your supervisor .

Most important message for home visit: MAKE YOUR SELF-AVAILABLE TO A FAMILY AT A TIME AND PLACE WHEN THEY ARE

FREE. THIS SHOWS YOUR INTEREST IN THEIR WELFARE

1.4 Now ask the participants what are the essential things that they need to carry while going for a home

visit. Listen to responses and then share the following list.

Key message:

Essential things to carry while going for a home visit - 1. Household inspection form 2. Safewat demonstration bottle 3. Oral Rehydration salts packet 4. Flipbook 5. Safewat Flyer 6. Handwash Flyer 7. Water Testing Kits (As and when required to be obtained from Team Leader)

1.5 Now hand over a copy of the relevant form to be filled during home visit to each participant. ( refer to

appendix 2.1 for details) Facilitator to enable the participants to go through the forms and let them understand how they need to fill it. Let the participants practice how to use the form. Facilitator to help clarify.

Step-2 Role –play regarding home visit by facilitator 20 minutes

2.1 Facilitator to role-play an ideal home visit situation. After the role-play invite questions form the

participants and clarify. Facilitator should ensure that they use all the relevant communication material during the role-play.

Step-3 Practicum 60 minutes

2.1 Now ask for few volunteers from the group and let them role-play few typical community situation in

which a change agent is approaching one of the house for the very first time. Ensure that she has a copy of the relevant household visit form/s. (refer to appendix 2.1 for details) One of the volunteer

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can play the role of community member the second person can be the change agent and the third person can be the team leader. Facilitator to ensure that the participants need to role-play a situation from the following few: Situation 1- diarrhea management through ORS. Situation 2- Water quality assurance through usage of safewat Situation 3- Importance of handwashing

2.2 Now let the participants prepare for the role-play for 15 minutes. Conduct the role-play for 7

minutes and after the role-play thank the volunteers for their active participation. Now ask all those who were observing them regarding their feedback.

2.3 De-brief the role-play on the following lines. Do they think the interaction was good? Was the

community member happy after the interaction? Will the community member be happy to meet the change agent again in future? Did the change agent do a good job while filling up the household visit form? How was the flipbook used? Was the change agent confident during the interaction? Facilitator to add, clarify the points and help the participants experience an actual field situation.

Pre-training preparation: - Read the scheme of the session thoroughly. - Ensure that copies of all communication materials alongwith relevant forms are made available for

all the participants alongwith pencil and eraser for practice. - Prepare flipcharts for all the relevant points that needs to be shared during training.

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Appendix 2.1 Household Information Format

Name of Change Agent : __________________________________________________ CA Code : _ _ _ Household Code : _ _ _ _ Information of Household : Name of Head of Household : _____________________________________________ No. of family members : _____________ No. of Children (0-5 Years) : __________

Determinants Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Household Visited Using Safewat Knows correct Dosing of Safewat

Knows correct Use of ORS

Using ORS Handwashing with soap after defecating and before eating

Y : Yes N : No Report of Residual Chlorine Testing ( If using Safewat) Details/Month June September December Residual Free Chlorine levels > 0.2 mg/litre. Y : Yes N : No

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SCORING INSTRUCTIONS

A. Knowledge questions on hygiene, sanitation, prevention and management of Diarrhea Evaluate every right answer with +1 and every wrong answer with –1, the maximum score being 32 for 8 questions. Use the correct answers given below to score each question. Complete the following scoring table to score each question and to derive the total score and percentage. A trainee has retained the Required Level of Knowledge (RLK) if he/she scores 80% or above. I.e; a score of 26/32 and above. TO BE FILLED BY THE FACILITATOR Qn. No. 1 2 3 4 5 6 7 8 Total %

Score

Correct Answers for scoring

1. a,b,c,d,e,f,g 2. a,b,c,d,e,f,g,h,i 3. c,e 4 d 5 d 6 a,b,d,f,h,i 7 a, b 8 a,b,c,d

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Hand washing checklist

Name of trainee :________________ Dates of Training ___________________ Pre –test score (%):------------- Post –test score (%):--------------

No TASK/ ACTIVITY Score 1 Share that it is essential to wash hands during the following situations:

1. Before you start to cook, 2. Before you start feeding children, 3. Before you eat food, 4. After defecation, 5. After washing your child after defecation, 6. After touching dirty objects, 7. After playing with animals etc.

2 Demonstrates hand washing by wetting hands /forearms thoroughly with running water.

3 Holds hands up above the level of the elbow, soaps the hands and lathers well, covering all surfaces.

4 Weaves fingers and thumbs together and slides them back and forth. Highlights that should not forget the area under the fingernails and between the fingers.

5 Washes the hands for at least 15-30 seconds and rinses hands under a stream of clean, running or poured water until all the soap has been removed.

6 Air dries hands completely or dries them with a clean dry towel/cloth.



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No TASK/ ACTIVITY FU 1 Explored local perceptions about ORS and clarified misconceptions

-Shares that if the doctor advises your child ORS he is a good doctor and doing the right thing

2 Explains to the mother and family the importance of ORS to prevent diarrhea -Highlights the important role ORS plays in controlling dehydration.


you poured ORS 4. stir until all the powder in the container has been mixed with water and none

is remaining at the bottom of the container 5. ensures re-demonstration of the above

4 Advises the mother on the following points to be remembered while administering ORS:

1.Prepare fresh ORS every day. 2. Ensure that small children are given ORS with the help of spoon and cup rather than bottle. 3.The mother should give 1 teaspoon of the solution to the child. This should be repeated every 1-2 minutes ( an older child can drink it in sips should be given one sip every 1-2 minutes) 4. If the child vomits the ORS tell the mother to wait for 10 Minutes and resume giving the ORS but this time more slowly than before 5.Breastfed babies should continue to be given breast milk in between ORS 6.Any ORS which is left over after 24 hours should be thrown away 7.After about 4 hours of giving ORS, reassess the child for dehydration. If the child is better, tells the mother to give fluids that are available at home the same way she gave ORS and continue to give ORS after every motion.

8.Begin feeding the child even if dehydration persists, continue ORS. If the child’s condition deteriorates, take the child to the district hospital. On the way to the hospital, the mother should continue to give ORS to the child.

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6 Shares the following additional information regarding ORS -

1.Keep ORS covered, if not using it 2.Till diarrhea stops keep giving additional home available useful fluids, it can take 3-5 days for it to stop 3.Without consulting a doctor, please do not provide the person suffering from diarrhea any medicine, only give ORS 4.Also remember that ORS is used only for replenishing vital fluids and nutrients in the body. 5.Do not mix ORS in milk, Sharbat, soft drink etc. 6.Keep giving ORS till diarrhea stops.


CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible scores are 5. For example if a trainee has performed satisfactorily on 4 tasks, she/he will score 4 points. To calculate the percentage, the formula will be (4/5)*100 = 80%. A trainee performed to standards (PTS) if she scores 80% or above.

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Checklist for demonstration of Safewat (the water disinfectant)



dosage




5 Clearly specifies the steps of purifying water using disinfectant-( Safewat): 14. Clean the jar/ container in which you will fill the water. 15. From a clean source fill the water in the jar/container 16. Open the Safewat bottle carefully.

Add 1 drop of liquid from Safewat bottle for every 1 litre of water 17. Shake the water jar/ container well, in which you have added safewat. 18. Use water after 30 minutes. 19. Use a ladle with long stem to take the water from the jar




9 Highlights the following precautions with the community- -Always use safewat in water in recommended dosage -Keep safewat in a cool and dry place -Do not keep safewat under direct sunlight -Keep safewat away from reach of children

10 Shares that by using safewat, there will be some difference in taste and smell of water but this is a positive indication that water is pure for drinking

11 Also shares that other ways of disinfecting water are by either using a filter or by boiling water for 20 minutes.

% SCORED

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PTS – YES/NO CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible scores are 11. For example if a trainee has performed satisfactorily on 9 tasks, she/he will score 9 points. To calculate the percentage, the formula will be (9/11)*100 = >80%. A trainee performed to standards (PTS) if she/he scores 80% or above.

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Day three Session number : 3 Topic : Practicum Duration : 1 hour and 45 minutes Objectives: At the end of the session, the participants will be able to:

2. Practice different simulated situations with respect to their role as change agents in the community.

Content: • Practice sessions on simulated situations, samples of ORS, safewat.

Training Materials:

• Flip chart, pens, all communication materials


Steps Duration Method 1. Practice sessions on simulated situations 1 hour and 45

minutes Role-play, large group discussion

Learning Process

Step-1 Practice sessions on simulated situations 1 hour and 45 minutes

1.1 Share with the participants that we are going to have practice sessions on simulated situations. The situations on which the role-plays will be conducted are as follows:

Situation one: mother being convinced for using ORS for diarrhea management. The mother is not ready to even listen to what the change agent wants to share. She is busy doing her household chores and does not have time to listen. Situation two: household members being convinced on the need to test water and use water disinfectant. Mother-in-law shares that the water they use is safe and she is not interested to listen to the change agent. Situation three: household members being convinced of the importance of hand washing and how and when to do it. Head of the household feels agitated that you young girls will teach us how to wash hands. Situation four: Sharing the importance of hygiene and sanitation in and around the house with household members and how to secure food and water. Members of the house welcome the change agent and are happy to listen. They also offer tea. Situation five: explaining to the household members what is diarrhea, its causes and how to prevent it. A child in the household is suffering form diarrhea and the mother-in-law also started getting loose motions.

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The child was taken to the nearby doctor who gave injection and some pills. But the child is still continuing to get loose stools and is not being given anything to eat. 1.2 Let the team of two participants present one situation. Facilitator to let the participants select the situations from the above list. Let them role-play the situation. After role-play, invite feedback and highlight points that were done well and points that could be improved. (Use the relevant checklists wherever applicable. For example: ORS, Hand- washing checklist and IPC skills). Facilitator to keep the role-play checklist in hand and conduct the role-plays accordingly. Pre-training preparation:

- Prepare flipcharts for all the relevant points that needs to be shared during training.

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Day three Session number : 4 Topic : Follow –up mechanism Duration : 60 minutes Objectives: At the end of the session, the participants will be able to: 1. Explain the follow-up mechanism as visualized for the project. 2. Demonstrate a follow-up situation

Content: • Follow up plan, tools Training Materials: • Flip chart, pens, handouts on follow-up plan and relevant checklists that will be used. Steps, duration and methods:

Steps Duration Method 1. Follow-up mechanism 20 minutes Interactive discussion 2. Role-play a follow up situation 40 minutes Role-play

Learning Process

Step-1 Follow-up mechanism 20 minutes

1.2 Facilitator to share with the participants the follow-up mechanism as planned in the project. Share the objective of follow-up and the specific activities as planned for follow-up. (refer to appendix 4.1 for details) Clarify any doubts the participants may have. Share handouts on each of them.

1.2 Now share the follow –up tools that would be used to assess their knowledge and skills. (refer to

appendix 4.1 for details) Familiarise the participants to the tool and clarify that these are the same tools which are being used during the training too. Also give them a handout on it. Share that they can use this tool to practice and improve their knowledge and skills.

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Step-2 Role-play a follow-up situation 40 minutes

2.1 Share with the participants what is meant by feedback. Clarify that during follow-up the supervisors and peers

will provide feedback to you on your performance with a view to enhance your performance. 2.2 Now provide information on feedback. Clarify that feedback is a communication technique in which the facilitator provides information to participants about their progress in mastering a skill or activity. Feedback is most effective when it is timely (provided immediately), positive and descriptive. Guidelines for receiving feedback are:

• Ask for it. If you need information to answer a question or pursue a learning objective, ask for it. • Direct it. Find facilitators/peers who will direct you. Ask them to be specific and descriptive. • Accept it. Do not defend or justify your behavior. Listen to what people have to say and thank

them. Use what is helpful, quietly discard the rest.

Share that now we will conduct role-play to see a situation where follow-up is happening. 2.2 Now conduct two role-plays: Situation one- (Peer feedback is given) Shyama and Rema are change agents. They have been trained to provide information on diarrhea management, sanitation and hygiene with specific emphasis on handwashing. Before going for a home visit during which Shyama is going to share the information on Diarrhea Management, She requests Rema to observe her and provide feedback using the IPC skills checklist. Rema accompanies Shyama and when they come out of the house after sharing the key message on diarrhea management, Shyama uses the checklist to give feedback. The role-play situation should depict how Shyama gives feedback to Rema. Situation two- (supervisor gives the feedback). Rajesh is the supervisor of change agents. On a routine field visit he accompanies, Leela the change agent. He observes her while she conducts the home visit. Leela shares the message on using Safewat, water disinfectant with the household members. After the home visit, Rajesh gives feedback to Leela using the relevant checklist. Facilitator to ensure that after each role-play, feedback is given on how the follow -up was done. Adequate focus should be given on the way feedback was given by the peer/supervisor to the change agent and how the change agent accepted feedback. 2.3 After the role-play is over share that in the field also similar situations will happen. Participants hence need to be prepared for the same. Pre-training preparation: - Prepare flipcharts for all the relevant points that needs to be shared during training.

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Appendix 4.1 FOLLOW-UP PLAN

Objective of the follow-up:

1. To reinforce knowledge and skills that help change agents transfer the same to the communities 2. Identify problems faced by them during field visit and help solve these problems 3. Gather information on the performance of change agents and the conditions that influence

performance

How it would be done. (Method)

When would it be done? (Time)

Who would do it and where

What essential knowledge and skills would be assessed

What tools would be used to assess knowledge and skills during follow-up

During home visit observation

Weekly Fortnightly

Team Leaders Project Supervisors

IPC skills, Message delivery on Water handling, storage, safewat usage, handwashing skills, food hygiene, sanitary habits, knowledge regarding diarrhea prevention and management

Knowledge and skills assessment checklists

By interviewing During fortnightly and monthly meetings etc.

Project Supervisor/ Project Officer

Knowledge regarding Safe wat usage and dosing, ORS preparation, diarrhea prevention and management.

Knowledge and skills assessment checklists

Observing through mocks/role-plays

During monthly meetings

Project Supervisor/ Project Officer

IPC skills Knowledge and skills assessment checklists

Peer assessment Weekly fortnightly

Peers during home visit

IPC skills, Message delivery on Water handling, storage, safewat usage, handwashing skills, food hygiene, sanitary habits, knowledge regarding diarrhea prevention and management

Using checklists

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FOLLOW – UP TOOL TO ASSESS RETENSION OF KNOWLEDGE

Questionnaire for hygiene, sanitation, prevention and management of Diarrhea

Name of change agent :________________ Name of person conducting follow-up:_____________ Date of follow-up:__________ Score (%):------------ Share the questionnaire with the change agent and inform her that this the same one they used in training for pre-post knowledge ‘quiz’ that comprises of questions with multiple answers. Inform her/him that this is to assess the retention level of knowledge that he gained during the training. Ask her/him to tick "3" all correct response/s for each question in 15 minutes. 7) Hand washing is important during the following instances:

a) Before cooking food b) Before eating food c) Before feeding children d) After touching animals e) After defecation f) After cleaning the child’s defecation g) After touching dirty objects

8) Possible ways of ensuring hygiene and sanitation in and around the house are a follows: a) Hand washing with soap and water b) Keeping the food covered c) Raw food should be stored at proper place away from rats d) Ensuring that drinking water is disinfected before use e) Keeping the drinking water and food covered f) Cut and cooked food should always be covered and not left out in the open g) Defecation should be in a toilet or latrine h) Before feeding children or touching food always wash hands i) Ensure that animal faeces are kept away form the house, paths, well and children’s play areas.

9) Breastfeeding: a) Should be started one week after birth. b) Should be started one day after birth. c) Should be started soon after birth. d) Should be stopped when child has fever. e) Should be continued when child has diarrhea.

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10) Most cases of diarrhea in children can be prevented by: a) Taking appropriate antibiotics b) Stopping all food and water c) Stopping breastfeeding d) Using clean water for drinking, washing hands after toilet and before eating food e) None of the above f) All of the above


a) Appropriate antibiotics b) Stopping all food and water and giving antibiotics c) Stopping all food and water, giving antibiotics and ORS. d) Treating with ORS, providing home care and advising mother when to return immediately e) All of the above f) None of the above


a) Milk b) Yoghurt c) Fruit juices (sweetened) d) Lemon drink e) Soft drinks f) Dal and vegetable soup g) Coffee h) Fruit juice (Unsweetened) i) Plain clean water

13) Water is safe to drink if it is:

a) Boiled b) Treated with water disinfectant c) From government water supply system d) All of the above


a) Eating food that is dirty or stale b) Drinking dirty water c) Eating with dirty hands d) Using dirty vessels, utensils and equipments

END

TO BE FILLED BY THE PERSON WHO CONDUCTS FOLLOW-UPS Qn. No. 1 2 3 4 5 6 7 8 Total %

Score

RLK: YES/NO

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SCORING INSTRUCTIONS TO THE PERSON WHO CONDUCTS FOLLOW -UPS A. Knowledge questions on hygiene, sanitation, prevention and management of Diarrhea Evaluate every right answer with +1 and every wrong answer with –1, the maximum score being 27 for 8 questions. Use the correct answers given below to score each question. Complete the following scoring table to score each question and to derive the total score and percentage. A trainee has retained the Required Level of Knowledge (RLK) if he/she scores 80% or above. TO BE FILLED BY THE PERSON WHO CONDUCTS FOLLOW-UPS Qn. No. 1 2 3 4 5 6 7 8 Total %

Score


1. a,b,c,d,e,f,g 2. a,b,c,d,e,f,g,h,i 3. c,e 4 d 5 d 6 a,b,d,f,h,i 7 a, b 8 a,b,c,d

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FOLLOW – UP TOOL TO ASSESS INTERPERSONAL COUNSELING (IPC) SKILLS

Checklist for assessing IPC SKILLS of change agents

Name of change agent: ________________ Household number---------------------- Name of person conducting follow-up:_______________ Date of follow-up:________ Score (%):------------------

TASK/ ACTIVITY

FU

1 Greets and introduces self if not known 2 Makes eye contact, smiles and appears relaxed and confident 3 Tone of voice is maintained 4 Asks following types of questions:

4. Both open ended 5. Close ended 6. Probing questions

5 Encourages the individual to talk 6 Listens actively i.e; pays attention to both verbal as well as non-verbal communication 7 Remains non-judgemental 8 Shares the knowledge and skills ( relevant) correctly 9 Observes the emotions and reflects back to him/her 10 Summarizes and paraphrases i.e; repeats back to community member what you heard

him/her say in a short form to clarify understanding

11 Appropriately uses visual and IEC materials 12 Focuses on call to action 13 Provides flyers, booklets, safewat etc 14 Shares the referral information Total Scores obtained (Maximum 14 Point) % SCORED PTS – YES/NO

CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible score is 14. For example if a trainee has performed satisfactorily on 11 tasks, she/he will score 11points. To calculate the percentage, the formula will be (11/14) * 100 = 79%. A person performed to standards (PTS) if she/he scores 80% or above.

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Day three

Session number : 5 Topic : Sharing Action plan Duration : 30 minutes Objectives : At the end of the session, the participants will be able to: 1. Explain the plan of action to be implemented at the community after the training. Content: • Action plan Training Materials: • Flip chart, pens Steps, duration and method:

Steps Duration Method 1. Action plan 30 minutes Interactive presentation

Learning Process

Step-1 Action-plan 30 minutes

1.6 Inform participants that after this training each of them will be expected to fulfill a list of activities in the community.

1.7 Facilitator to familiarize the participants to the plan of action as planned in the project. For example, a

change agent is supposed to visit 100-150household. Facilitator need to clarify how it will be done and what messages will they deliver during the first few weeks. Give participants an opportunity to ask questions. Clarify wherever required. Refer to the handout on action plan provided by project coordinator.

Pre-training preparation: - Read the scheme of the session thoroughly and prepare a chart on the plan of action as planned under the project.

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Day three Session number : 6 Topic : Post-test Duration : 2 hours Objectives: At the end of the session, the participants will be able to: 1. Assess their knowledge regarding diarrhea, hygiene and sanitation, hand washing and compare with

their pre-test knowledge. 2. Assess their skills on hand washing and ORS preparation and safewat. Content: • Post-test questionnaire Training Materials: • Flip chart, pens, questionnaire Steps, duration and method:

Steps Duration Method 1. Post-test 30 minutes Questionnaire 2. Skills test on hand washing and ORS preparation 1 and ½ hour Demonstration

Learning Process

Step-1 Post-test 30 minutes

1.8 Inform participants that they will be given a copy of the same form, which was used during pre-test. (refer to the appendix 6.1 for details)

1.9 Distribute the form and after the participants have completed filling it, collect the same back and do the

scoring. Facilitators need to share with the participants the maximum and minimum scores obtained. They should also highlight those points where participants may have made mistakes in order to reinforce the correct answer.

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Step-2 Hand washing and ORS preparation skills test 1 hour and 30 minutes

2.1 Facilitator to divide the large group into two small groups of 10 each. Using the relevant checklists for

hand washing and ORS preparation (Refer to appendix 6.1 for details) assess each participants present level of skills. Provide actual samples of ORS and other material as required.

2.2 Facilitator to ensure that the pre and post test assessment form for all the participants is tabulated and

kept for records. The details of what percentage had good skills and what percentage had poor skills should be shared with the participants by the end of the session.

2.3 Highlight that it is essential for all change agents to improve their skills on both hand washing and ORS

preparation and safewat before they start going to the field. Hence they need to use the relevant checklists and keep preparing self till they improve and get more than 80% score on the checklist. Highlight that these checklists are tools to aid them to prepare self as effective change agents. Share that confidence will come only if you are comfortable in the relevant knowledge and skills. So you need to put extra efforts to master the knowledge and skills through repeated efforts.

Pre-training preparation: - Read the scheme of the session thoroughly. - Prepare enough photocopies of the post-test questionnaire for all the participants.

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Appendix 6.1 Post-test Knowledge assessment questionnaire

Name of change agent: ________________ Post test score (%):--------------- Share the questionnaire with the change agent and inform her/him that this is to assess the level of knowledge that they will gain during the course of the training. Ask her/him to tick "3" all correct response/s for each question in 15 minutes. 1) Hand washing is important during the following instances:

j) Before cooking food k) Before eating food l) Before feeding children m) After touching animals n) After defecation o) After cleaning the child’s defecation p) After touching dirty objects

2) Possible ways of ensuring hygiene and sanitation in and around the house are as follows: q) Hand washing with soap and water r) Keeping the food covered s) Raw food should be stored at proper place away from rats t) Ensuring that drinking water is disinfected before use u) Keeping the drinking water and food covered v) Cut and cooked food should always be covered and not left out in the open w) Defecation should be in a toilet or latrine x) Before feeding children or touching food always wash hands y) Ensure that animal faeces are kept away form the house, paths, well and children’s play areas.

3) Breastfeeding: z) Should be started one week after birth. aa) Should be started one day after birth. bb) Should be started soon after birth. cc) Should be stopped when child has fever. dd) Should be continued when child has diarrhea.

4) Most cases of diarrhea in children can be prevented by:

a) Taking appropriate antibiotics b) Stopping all food and water c) Stopping breastfeeding d) Using clean water for drinking, washing hands after toilet and before eating food e) None of the above f) All of the above

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g) Appropriate antibiotics h) Stopping all food and water and giving antibiotics i) Stopping all food and water, giving antibiotics and ORS. j) Treating with ORS, providing home care and advising mother when to return immediately k) All of the above l) None of the above


m) Milk n) Yoghurt o) Fruit juices (sweetened) p) Lemon drink q) Soft drinks r) Dal and vegetable soup s) Coffee t) Fruit juice (Unsweetened) u) Plain clean water

7) Water is safe to drink if it is: e) Boiled f) Treated with water disinfectant g) From government water supply system h) All of the above


e) Eating food that is dirty or stale f) Drinking dirty water g) Eating with dirty hands h) Using dirty vessels, utensils and equipments

END TO BE FILLED BY THE FACILITATOR Qn. No. 1 2 3 4 5 6 7 8 Total %

Score

RLK: YES/NO

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SCORING INSTRUCTIONS

A. Knowledge questions on hygiene, sanitation, prevention and management of Diarrhea

Evaluate every right answer with +1 and every wrong answer with –1, the maximum score being 27 for 8 questions. Use the correct answers given below to score each question. Complete the following scoring table to score each question and to derive the total score and percentage. A trainee has retained the Required Level of Knowledge (RLK) if he/she scores 80% or above.

TO BE FILLED BY THE FACILITATOR Qn. No. 1 2 3 4 5 6 7 8 Total %

Score


1.a,b,c,d,e,f,g 2.a,b,c,d,e,f,g,h,i 3.c,e 4 d 5 d 6 a,b,d,f,h,i 7 a, b 8 a,b,c,d

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Hand washing checklist


No TASK/ ACTIVITY Score 1 Share that it is essential to wash hands during the following situations:

1. Before you start to cook, 2. Before you start feeding children, 3. Before you eat food, 4. After defecation, 5. After washing your child after defecation, 6. After touching dirty objects, 7. After playing with animals etc.

2 Demonstrates hand washing by wetting hands /forearms thoroughly with running water.

3 Holds hands up above the level of the elbow, soaps the hands and lathers well, covering all surfaces.

4 Weaves fingers and thumbs together and slides them back and forth. Highlights that should not forget the area under the fingernails and between the fingers.

5 Washes the hands for at least 15-30 seconds and rinses hands under a stream of clean, running or poured water until all the soap has been removed.

6 Air dries hands completely or dries them with a clean dry towel/cloth.



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No TASK/ ACTIVITY Score 1 Explored local perceptions about ORS and clarified misconceptions

- Shares that if the doctor advises your child ORS he is a good doctor and doing the right thing

2 Explains to the mother and family the importance of ORS to prevent diarrhea - Highlights the important role ORS plays in controlling dehydration.


you poured ORS 4. stir until all the powder in the container has been mixed with water and none is

remaining at the bottom of the container 5. ensures re-demonstration of the above

4 Advises the mother on the following points to be remembered while administering ORS: 1. Prepare fresh ORS every day. 2. Ensure that small children are given ORS with the help of spoon and cup rather

than bottle. 3. The mother should give 1 teaspoon of the solution to the child. This should be

repeated every 1-2 minutes ( an older child can drink it in sips should be given one sip every 1-2 minutes)

4. If the child vomits the ORS tell the mother to wait for 10 minutes and resume giving the ORS but this time more slowly than before

5. Breastfed babies should continue to be given breast milk in between ORS 6. Any ORS which is left over after 24 hours should be thrown away 7. After about 4 hours of giving ORS, reassess the child for dehydration. If the child is better, tells the mother to give fluids that are available at home the same

way she gave ORS and continue to give ORS after every motion. 8. Begin feeding the child even if dehydration persists, continue ORS. If the child’s

condition deteriorates, take the child to the district hospital. On the way to the hospital, the mother should continue to give ORS to the child.

5 Shares the following additional information regarding ORS - 1. Keep ORS covered, if not using it

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2. Till diarrhea stops keep giving additional home available useful fluids, it can take 3-5 days for it to stop 4. Without consulting a doctor, please do not provide the person suffering from

diarrhea any medicine, only give ORS, 5. Also remember that ORS is used only for replenishing vital fluids and nutrients in

the body. 6. Do not mix ORS in milk, Sharbat, soft drink etc, 7. Keep giving ORS till diarrhea stops.



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Checklist for demonstration of Safewat (the water disinfectant)

Name of trainee: ________________ Dates of Training ___________________ Pre –test score (%): ------------- Post –test score (%): --------------


dosage




5 Clearly specifies the steps of purifying water using disinfectant- (Safewat) 1. Clean the jar/ container in which you will fill the water. 2. From a clean source fill the water in the jar/container. 3. Open the Safewat bottle carefully. 4. Add 1 drop of liquid from Safewat bottle for every 1 litre of water. 5. Shake the water jar/ container well, in which you have added safewat. 6. Use water after 30 minutes. 7. Use a ladle with long stem to take the water from the jar




9 Highlights the following precautions with the community- - Always use safewat in water in recommended dosage - Keep safewat in a cool and dry place - Do not keep safewat under direct sunlight - Keep safewat away from reach of children

10 Shares that by using safewat, there will be some difference in taste and smell of water but this is a positive indication that water is pure for drinking

11 Also shares that other ways of disinfecting water are by either using a filter or by

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boiling water for 20 minutes. % SCORED PTS – YES/NO

CALCULATION OF SCORES AND PERCENTAGES Each correct task in the checklist receives 1 point. The possible scores are 1 or 0. For the question, which has sub-bullets, all sub-bullets need to be covered to score 1 point for that question. Total eligible scores are 11. For example if a trainee has performed satisfactorily on 9 tasks, she/he will score 9 points. To calculate the percentage, the formula will be (9/11)*100 = >80%. A trainee performed to standards (PTS) if she/he scores 80% or above.

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Day three Session number : 7 Topic : Evaluation Duration : 15 minutes Objectives : At the end of the session, the participants will be able to:

• Evaluate the training programme and synthesize the key learnings from the training. Content:

• Evaluation form Training Materials:

• Flip chart, pens, evaluation form Steps, duration and method:

Steps Duration Method 1. Evaluation and synthesis 15 minutes Question-answer

and interactive discussion

Learning Process

Step-1 Evaluation and synthesis 15 minutes

1.1 Inform participants that they will be given a copy of the evaluation form, (refer to appendix 7.1 for

details) which they need to fill and return back to the facilitators in order to enable them to evaluate the training programme. Facilitators can take the feedback from the evaluation to improve the future training programmes.

1.2 Now the facilitators need to ask the participants to share the key learning points from the training. Listen to the responses and add, clarify as required.

Pre-training preparation: - Read the scheme of the session thoroughly. - Prepare enough photocopies of the evaluation form for all the participants.

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Appendix 7.1 Evaluation form

Strongly agree Strongly disagree

The facilitator was well prepared 1 2 3 4 5

The facilitator spoke in a clear voice and was easily understood

1 2 3 4 5

The facilitator was knowledgeable about the topic and helped you to understand your role clearly

1 2 3 4 5

The facilitator clearly expressed ideas and information

1 2 3 4 5

The facilitator gave the group a chance to ask questions

1 2 3 4 5

The facilitator understood the questions asked, and answered them satisfactorily

1 2 3 4 5

The facilitator was interesting and engaging 1 2 3 4 5

The activities the facilitator used were enjoyable

1 2 3 4 5

The facilitator provided information that will be helpful to you when you go back to work

1 2 3 4 5

What did you most like about this training session? What did you like least about this training session? What suggestions do you have for improving this training session? Thanks for taking your time to fill this form.

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Day three Session number : 8 Topic : Synthesis and Closure Duration : 15 minutes Objectives: At the end of the session, the participants will be able to: 1. List the key learning points for the day

Content:

• Learning points for the day Training Materials:

• Flip chart, pens Steps, duration and method:

Steps Duration Method 1. Key learning points for the day 15 minutes Interactive

discussion

Learning Process


1.1 Facilitator to ask the participants to come up with the key learning points from the training. Listen to the

responses of the participants and add, clarify wherever required. Ask the participants regarding are they clear about what they are expected to do in the field. Remind them that any problems they face in the field, they should share it with the team leader and project supervisor.

Thank the participants for their active participation and conclude the training.

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References:

• Proposal on Safe Water Systems (SWS) project- A pilot intervention in urban slums of Dehradun and Haridwar, funded by US-AID/AIDSMARK.

• Enhancing Interpersonal Communications Skills (IPC) curriculum for delivery of improved health

services II project (DISH)- Republic of Uganda, MOH.

• Training module for health workers developed by Voluntary Health Association of India (VHAI).

• Training module on diarrhea management developed for SMS-MCH Saadhan Project by Rural Development Institute (RDI) and IntraHealth International Inc. New Delhi

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