COMMUNITY HEALTH STRATEGY

Abbreviations

AIDS- Acquired immune deficiencysyndrome

ANC- Antenatal care

AOP- Annual operational plan

ART- Anti-retroviral therapy

ARVs- Anti-retroviral drugs

BCC- Behaviour change communication

CBCC- Community-based child care centre

CB-KEPH- Community-Based Kenya EssentialPackage for Health

CBHIS- Community-based health informationsystem

CBOs- Community-based organization

CBR- Community-based rehabilitation

CHC- Community health committee

CHW-Community health worker

CHEW- Community health extension worker

CU- Community unit

DTC- Diagnostic testing and counselling

DHMB- District Health Management Board

EEDL- Essential elements of dignified life

FANC -Focused Antenatal Care

FBO- Faith-based organization

FGD- Focus group discussion

FP- Family planning

GMP- Growth monitoring and promotion

HBC- Home-based care

HH- Household

HIV- Human immune-deficiency virus

HMIS- Health management informationsystem

HR -Human resource

IBP- Individual birth plan

IEC- Information, education andcommunication

ID- Identification/identity card

IMCI- Integrated management of childhoodillness

IHI- Institute for Health Improvement

ITN- Insecticide treated nets

IUCD -Intra-uterine contraceptive device

KEPH- Kenya Essential Package for Health

MCH- Maternal and child health

M&E- Monitoring and evaluation

NGO- Non-government organization

NHSSP II- Second National Health SectorStrategic Plan 2005–2010

PCR- Polymerase chain reaction test

PLWHA- Person living with HIV and AIDS

PMO- Provincial Medical Officer

PMTCT- Prevention of mother to childtransmission (of HIV)

STD- Sexually transmitted disease

STI- Sexually transmitted infection

TB- T tuberculosis

TBA- Traditional birth attendant

VCT- Voluntary counseling and testing

INTRODUCTION

1. Definitions

Development is a process through which there is positive change in a population’s attitudes,

knowledge and skills, thus raising the health, economic and political status of the people
involved.

According to the World Health Organization, health is defined as a state of complete physical,
mental and social wellbeing, and not merely the absence of disease or infirmity. There are
various factors affecting health and development in the communities where we live. These can
be broadly divided into two: those that hinder health and development and those that promote
health and development.

2. Factors Hindering Health and Development

a). Poverty and lack of resources

b).Lack of individuals’ voice in decisions affecting them

c). Poor infrastructure

Political environment

d). Policies

e). Unemployment

f). Disasters

g). Diseases, especially chronic illness

h).Lack of availability and poor quality of land

i). Cultural beliefs, traditions and attitudes

j). Illiteracy w Lack of knowledge and skills

k). Dependency w Insecurity

m).Poor leadership
n).Lack of self-initiative

o). Corruption/lack of transparency and accountability

3. Factors That Promote Development

Infrastructure

Opportunities

Human capital (essential elements of dignified life)

Democratic space and leadership

Respect for the basic human rights of all people

Creation of employment

Resource generation

Community capacity building to improve knowledge and skills

Community participation and involvement in development activities

Disaster preparedness

4. Relationship between Health and Development

Health and development are interdependent:

To develop, people must be healthy and to be healthy people require access to the necessary
resources.

Both depend on education.

Both call for a change in attitude.

Health is a component and indicator of development.

Community Participation/Partnership

1. Definitions

Community participation is a process by which the communities are actively involved in all
stages of project or programme implementation.

2. Importance of Community Participation

Helps the community members as a group to identify and prioritize their felt needs

Enhances sense of ownership

Promotes sustainability of projects

Empowers the community to manage their own projects

Promotes intra- and inter-sector collaboration

Helps to change peoples attitudes

Reduces project costs

Promotes development

Enhances and promotes utilization of resources

3. Factors Hindering Community Participation

Inadequate awareness creation

Poor leadership

Dependency syndrome – people expect handouts for participating

Political influence interference

False promises from implementing agencies

Lack of prioritization of community needs

Gender biases

Application of inappropriate technology

Poor timing of activities/Seasonal priorities

Lack of transparency

Lack of decentralization in decision making

Use of unskilled change agents

Poor extension policies and methodologies

4. Promoting Community Participation through Partnership

Conduct dialogue based on evidence

Conduct regular meetings to give feedback at all stages of implementation

Build on strengths, not needs

Strengthen existing structures rather than form new ones

Create awareness at all levels of implementation process

Involve community at all stages of planning and action

Enhance joint investment in activities benefiting all parties involved

Apply appropriate but effective technology

Apply demand driven approaches, being responsive to the local context

Involve everybody (women, men and children)

Build the capacity of the community

5. What Community Participation/ Partnership Involves

Community decision making

Cost sharing

Labor concept (use of locally available resources)

Contractual obligation (sense of responsibility)

Leadership

1. Definition of Leadership

Leadership is the ability to influence the behavior and actions of others in a given situation to
work towards achieving a common goal.

2. Functions of a Leader

Convey vision and the ability to achieve goals

Ensure that tasks are carried out

Motivate the team

Build team work

Plan, organize and clarify tasks and responsibilities

Arbitrate disagreements on issues

3. Leadership Styles

a. Democratic

Makes decisions on the basis of majority input; this type of leader appreciates the opinion of
others

Accepts criticism and values feedback

Delegates’ authority and responsibility

Tends to be communicative and participatory

b. Authoritative

Decides unilaterally

Uses top-down approach w Insists on being the final decision maker

Communicates commands

Tends to be domineering, bossy, oppressive and suppressive

c. Laissez-Faire

Provides little direction

Allows everybody to make decisions

Fosters very little accountability

Tends to be indecisive, “on the fence”

4. Qualities of a Good Leader

Flexible

Good listener

Knowledge, wise, seeks knowledge

Innovative, creative

Time conscious

Honest, exemplary

Confident enough to delegate

Accepts criticism

Seeks new knowledge

 Participatory Methods

Participatory methods of assessment are many and varied. They range from notations about daily
routines and seasonal calendars, to interviews and discussions.

1. Daily Routine Schedule

This method records workload by gender and age. Women and men are recorded separately,
according to current activities or by seasons, and compared. The community brainstorms on
activities by gender and age, and the ideas are given to groups to develop daily schedules.

12 Taking KEPH to the Community

Groups present and discuss their schedules. The facilitator summarizes for the record. The
community reflects on what they have discovered that may need action based on available
resources as support for the participatory planning session.

2. Seasonal Calendar

This method plots happenings, activities, diseases, food availability, etc. It also reflects gender
and age. Brainstorm first by months or seasons, and then calendar the events in groups. The
groups present and discuss the calendars and generate a common calendar for the record. The
group may discuss what they have discovered needs action and what action is needed.

3. Time Trends

These are graphs to show how things have changed over time (crop yields, area under
cultivation, livestock population, prices, births and deaths, rainfall, etc.).

4. Direct Observation: Look, Listen and Learn (the 3 L’s)

This means systematically observing objects, events, relationships or people’s behaviour,

listening to what people talk about in an emotional way (excitement, anger, fear and concern),
and learning and recording these observations in an organized manner. This is a good way to
check people’s responses (triangulation). A checklist is necessary to ensure completeness of
observation, based on the indicators that can be assessed through this method. Information-rich
sites may include: marketplaces, shops, bars, worship sites, water points, festivals, buses, etc.
The quality of observation can be improved by participating with the community in their
activities. This then becomes participant observation, which requires more time than normally
available for a rapid assessment exercise.
5. Transect Walk

These are constructed by walking from point A to B across the community or study area often
with a key informant (a knowledgeable community member). One uses direct observation as
described above, but one can also talk to people one meets on the way.

6. Venn Diagram

This is used to plot the institutions and individuals in a community, their relationship and
importance in decision making. They are indicated by circles. The radius of the circle indicates
the importance in decision making, while overlap indicates the extent of relationship or
collaboration and information sharing.

7. Key Informant Interviews of Individuals from the Community

According to the type of information required, it may be necessary to discuss with

knowledgeable informants using a semi-structured questionnaire or interview guide. This is
particularly useful in collecting information about the history of the community and other factual
information such as population size, composition and structures; mortality and morbidity
experience; history of projects in the community; and what information and communication
systems are already in place. The questionnaire is used as a guide, as not all questions need be
asked. Care must be taken in the way questions are constructed and asked so that answers are not
suggested to the interviewee.

8. Focus Group Discussions

A focus group is an interview or discussion with a target group of uniform composition to ensure
freedom to express views frankly. It allows for gathering information from several people at a go
and permits cross–checking of information from others in the group. Groups should have
between 6 and 12 members to allow adequate participation by all. Facilitation skills are very
important with focus groups. Facilitators should work in pairs to allow one person to guide the
discussion while the other takes notes. The facilitator should encourage all members to
participate, but gently and sensitively so as not to embarrass anyone. The discussion should be
held in a comfortable place without interruption. The atmosphere should be informal, to promote
equality and relative trust. The method of recording the conversation should be agreed upon with
the group members.
Community–Health Facility Governing Structures in Support of Community Based KEPH

Definitions

There are several notions to decentralized governance as outlined below:

Devolution: Transfer of the authority and responsibility from the central government to local
government agencies in political and administrative areas (province-district).

DE concentration: Transfer of the functions from higher to lower levels within the administrative
structure of the country.

Delegation: Transfer of responsibility and functions from central government units to other more
autonomous and/or specialized types of government agencies.

Taking KEPH to the Community

2. Advantages of Decentralized Governance

Enhances accountability

Enhances efficiency

Promotes decision making by the people directly affected

Brings services closer to the people

3. Community Governing Structures

Household

Village

Community health committee (CHC)

Health facility management committee

Divisional dialogue day (divisional stakeholder forum)

4. Functions of the Structures

Plan level 1, 2 or 3 activities according to level of structure

Explain/interpret what health policy says about legal requirements or ownership

Promote linkages and networking

Raise funds /mobilize resources

Identify the community health workers (CHWs)

Organize and support the CHWs in their work

Organize and facilitate the registration of households

Facilitate household visits for the purposes of dialogue for behaviour change

Carry out dialogue on household issues based on information

Disseminate household information at the CHC

Discuss the health issues and enter them on the chalk board

Prepare reports to level 2 management

Facilitate the linkage with other health and development partners

Lead community organizing activities

Initiating Community-Based KEPH

1. KEPH Service Delivery Matrix by Cohort and Level

Services to each KEPH cohort are summarized in the table on the next page. To recap, the six
cohorts are: 1. Pregnancy and newborn 2. Early childhood 3. Late childhood 4. Adolescence and
youth 5. Adulthood 6. The elderly

2. Service Provision by Household Caregivers

Households have important responsibilities for addressing members’ health needs at all stages in
the life cycle. Among these are health promotion, disease prevention, contributions to the
governance and management of health services, and knowing and claiming their rights to quality
health services.

Health promotion

Ensuring a healthy diet for people at all stages in life in order to meet nutritional needs.

Building social capital to ensure mutual support in meeting daily needs as well as coping with
shocks in life.

Demanding health and social entitlements as citizens.

Monitoring health status for early detection of problems for timely action.

Exercising regularly.

Ensuring gender equity.

Using available services to monitor nutrition, chronic conditions and other causes of disability.

Disease prevention

Practicing good personal hygiene in terms of washing hands, using latrines, etc.

Treating drinking water.

Ensuring adequate shelter, and protection against vectors of disease.

Preventing accidents and abuse, and taking appropriate action when they occur.

Promoting dialogue on sexual behavior to prevent transmission of sexually transmitted diseases.

Care seeking and compliance with treatment and advice

Providing appropriate home care for sick household members.

Completing scheduled immunizations of infants before first birthday.

Recognizing and acting on the need for referral or seeking care outside the home.

Complying with recommendations given by health workers in relation to treatment, follow-up

and referral.

Ensuring that every pregnant woman receives antenatal and maternity care services.

Governance and management of health services

Attending and taking an active part in meetings to discuss trends in coverage, morbidity,
resources and client satisfaction.

Giving feedback to the service system either directly or through representation.

Claiming rights

Knowing what rights communities have in health.

Building capacity to claim these rights progressively.

3. Service Provision by CHWs

CHWs have an important role in health promotion, disease control, respect for human rights, and
the governance and management of health services. They also have additional responsibilities in
such areas as expanding family planning (FP), maternal, child and youth services, promoting
good hygiene and environmental sanitation, and monitoring care seeking and compliance with
treatment and advice.

Health promotion

Demonstrating a healthy diet for people at all stages in life in order to meet nutritional needs.
Providing guidance on social capital to ensure mutual support in meeting daily needs as well as
coping with shocks in life.

Encouraging demand for health care and social entitlements as citizens.

Observing health status to ensure early detection of problems for timely action.

Providing guidance on gender equity.

Encouraging emergency preparedness.

Disease prevention and control to reduce morbidity, disability and mortality

Controlling communicable disease through behaviour change, modification and formation of
healthy practices (HIV/AIDS, STI, TB, malaria).

Providing first aid and emergency preparedness services, treating injuries and common ailments.
Demonstrating good personal hygiene in terms of washing hands, using latrines, etc.

Ensuring access to water treatment for safe drinking water.

Demonstrating and encouraging integrated vector control measures.

Enhancing prevention of accidents and abuse, and taking appropriate action when they occur.

Family health services to expand FP, maternal, child and youth services w Promoting MCH/FP,
maternal care, use of trained obstetric care, immunization, nutrition, community-based IMCI.

Promoting improved adolescent reproductive health through household and community based
dialogue targeting behavior formation, modification and change.

Facilitating the organization of community based day-care centers.

Maintaining a community-based referral system, particularly for emergencies.

Encouraging payment for first-contact health services provided by CHWs.

Hygiene and environmental sanitation w Providing IEC for water, hygiene, sanitation and school
health.

Demonstrating and promoting safe, effective disposal of excreta/solid waste.

Improving water sources to ensure access to safe drinking water.

Demonstrating and practising good food hygiene.

Demonstrating good personal hygiene.

Developing kitchen gardens. Organizing community dialogue and health days.

Care seeking and compliance with treatment and advice

Training and supporting home caregivers.

Facilitating availability of and access to vaccines.

Training caregivers to recognize signs of illness and on the need for referral or seeking care
outside the home.

Encouraging compliance with recommendations given by health workers in relation to treatment,

follow-up and referral.
Ensuring every pregnant woman receives antenatal and maternity care services.

Governance and management of health services

Attending and taking an active part in meetings to discuss trends in coverage, morbidity,
resources and client satisfaction.

Giving feedback to the service system either directly or through representation.

Claiming rights

Promoting community rights have in health care.

Building capacity to claim these rights progressively.

Ensuring that health care providers in the community are accountable for effective health service
delivery and resource use, and above all are functioning in line with the Citizen’s Health charter.

1. Definition of Partnership

Partnership is individuals/institutions working together to share resources, ideas and experiences

to support and enrich each other’s work so as to achieve a higher quality outcome of value to all
parties involved.

2. Principles of Partnership

Begin to build a partnership by cooperating on something that the partners are already engaged
in, given their existing capacities, assets and experience. Starting with the familiar increases
confidence among the partners and generates

more energy and commitment to the partnership. This in turn suggests possibilities for additional
areas of cooperation and increases the enthusiasm for joint action. Partners should clearly define
and agree on objectives for the partnership that are beneficial to all partners. Partners should also
identify and agree on roles and tasks of each partner, according to abilities of the partners.
Partners must recognize that the skills and contributions of all parties are valuable to the success
of the partnership. Partnership requires mutual trust and confidence that must be nurtured.
Partners should engage in joint action focusing on areas of their own influence not on needs.
Receiving from the partnership more than one contributes weakens the role and voice of the one
receiving. It reinforces dependence and vulnerability to external factors and undermines
partnership relationships. Fear replaces cooperation and those affected become threatened and
defensive.

3.Community Entry Process

In order to build partnership with the community, it is necessary to gain entry through a
structured, step-by-step approach that involves creating awareness, conducting situation
analyses, forming linkage structures, training teams, and establishing monitoring and evaluation
mechanisms. Effective community entry must be based on a process of engagement that
recognizes the need for the health system to negotiate its way into the community agenda and
care system as a way of addressing their health and development issues. The entry process
involves a number of specific steps as described below.

STEP 1: Creating awareness

Create awareness among locational and sublocational leaders, and other existing structures such
as churches/mosques, schools and social welfare organizations. You should ensure adequate
knowledge of the local situation as part of this first step. This can be undertaken in a one-day
workshop that ends in the formation of the community health committee. This committee could
also be a subcommittee of the sub-locational development committee, if one already exists.
During this workshop the Community Strategy is introduced, focusing on the linkage structures,
their formation, composition and functions. In addition, the workshop would outline the
community unit implementation plan and identify officials to join the CHEW and the CHWs to
spearhead it.

STEP 2: Situation analysis and household registration

The participatory assessment and household registration provide information for planning. The
situation analysis will include:

Exploration: This sub-step entails a relatively low-key fact finding to enable the CHEW to gain
an understanding of life as it is lived in the community. The findings should be written up and
shared with the community highlighting the facts that community people speak about with
emotions such as fear, frustration, anger, joy, hope and anticipation.

Participatory assessment: This process starts with discussions with the key individuals at every
level and control point down to the household. This ensures that the introduction of the
Community Strategy takes full cognizance of what is going on in the community. The idea has to
be negotiated through the gatekeepers at every level, down to the level of individuals concerned.
In this process the community is also asked to define the issues to be included in the assessment,
and thus set objectives for it. Under each objective the assessment and planning task group
defines indicators/key questions and identifies the sources of reliable information and the most
appropriate methods of gathering the information. They then develop information gathering tools
(checklists, interview guides, etc.). The scope of the assessment should include:

The population size and structure

Community structures
Any existing community information systems

Resource availability, access and management (money, manpower, material)

Service delivery and the package of care and support

Communication strategy, networking, collaboration and linkages

Coping mechanisms, innovations and best practices

The status of health and wellbeing, based on agreed indicators

The status of food security and nutrition based on agreed indicators

Care seeking behaviour

The environment (water, sanitation, shelter, soils, vegetation, infrastructure)

Identified dialogue centres and groups (religious institutions, schools, civic leaders, youth
groups and other sectors), their roles and responsibilities

The assessment methods may include transect walks, direct observation, mapping of the
availability and access to resources, and a seasonal calendar of events, activities, diseases, food
availability, etc., and daily activities by gender. Other tools might be Venn diagrams to
understand stakeholders, key informant

Receiving from a partnership more than one contributes undermines the partnership because it
weakens the role and voice of the one receiving by reinforcing dependence and vulnerability.

Interviews of individuals from the community and focus group discussions. During this process
the task group may also carry out household registration and mapping to create village registers
to be kept by frontline health providers, the CHWs. Specific activities may include:

Activity 1: Review the history of the community over ten years: events, achievements and
challenges.

Activity 2: Carry out household registration and mapping, creating the village register.

Activity 3: Review community resources, assets, manpower, networks, etc.

Activity 4: Map the community health situation and the causes, thus summarizing the
community profile, based on the household register (population structure, environment,
immunization, place of delivery, ITNs, use of family planning, diseases, births and deaths by age
and sex, education, food, income).

STEP 3: Planning actions to improve health status once obtained and processed, the
findings are used for dialogue in the established structures to prioritize issues and decide
on action. The community participants reflect on the future they want (their vision/dream of the
way things ought to be) and agree on the main action points. The same task group as well as
additional working groups, identified according to priority issues, are assigned to prepare plans
that are collated and presented to the whole group for consideration and adoption. The process
allows for all partners to explore what relevant actions are already in place in order to add doable

options that are lacking. Planned actions must be based on available resources for action. The
activities may include:

Activity 5: Facilitate dialogue on the community health situation (why, what has been done,
what more can be done).

Activity 6: Identify action options, select doable options.

Activity 7: Outline actions by time frame for various groups and individuals.

The plans from the different interest groups should be harmonized into one community unit plan.
The CHEW, local non-government and community-based organizations, and other extension
staff within the community unit provide technical assistance throughout this process of
assessment and planning, with the CHEW as the responsible technical person. The integrated
community unit plans are submitted to the health facility committees where they are discussed
and approved by the committees, based on resource implications. Finally, the community unit
plans are consolidated into one integrated divisional health plan for level 1 activities and
submitted to the DHMT.

STEP 4: Establishing information systems to monitor change

Activity 8: Analyse the information gathered by the CHWs and supporting task groups.

Activity 9: Facilitate regular evidence based dialogue and community days.

Activity 10: Disseminate analysed. information for dialogue, advocacy and social mobilization.

Participatory Planning

Planning actions to improve health status

 Facilitate dialogue on the community health situation (why, what has been done, what more can
be done).

Identify action options, select doable options.

Outline actions by time frame for various groups and individuals.

Community Organization, Household Registration and Mapping

1. Code/Starter

Organize the presentation of a role play in which two CHWs are discussing the fact that there are
many child deaths in the sub-location. One of them asks about what might be the cause of deaths.
The second thinks it is measles. The first one asks whether the children in the sub-location have
been immunized against measles and the second one says, “I don’t know”. “Don’t you have a
record of child immunization in the sublocation?” the first one asks. “No,” the second answers
with a sigh. What a pity! Using the code, inform the participants about the problem, its
occurrence, local experience and consequences (part analysis of the CODE using SHOWeD
questions: what did you see, what did you hear, does it happen, what do we do, what can be
done?). The intention is to:

Identify the problem of lack of information: Because information was lacking the problem was
identified only after many deaths had occurred. The participants identify the problem as lack of a
regularized information system to alert them and the system in time before the disaster strikes. w
Document its occurrence and how they have experienced it (testimonies).

Determine the causes and consequences of missing information: In buzz groups the

Code refers to a role play, story, poster or other means of prompting discussion. SHOWeD =
questions to ask after the code has been presented: What did you SEE? What was HAPPENING?
Does it happen in OUR community? WHY does it happen? What can we DO about it?

Taking KEPH to the Community

participants identify the importance of establishing a functional information flow linking various
levels to trigger appropriate health action. The participants identify reasons such as: Planning
Implementation of projects in order to monitor progress and measure achievement For reference.
Draw up possible solutions/responses (group work to design mechanisms to fill the information
gap): This should include the essential elements of a community-based health information
system (CBHIS).

2. Approach to Home Visiting

Create rapport by greeting the household head and other members according to the local custom,
including general questions, recognition of effort and progress relevant to the stage of
relationship development.

Accept seating offered.

Outline the purposes of the visit, and seek consent to proceed, agreeing on roughly how long the
visit might take.

At first visit, introduce the register as a checklist guiding the work of a CHW. Explain that the
information is not linked to specific individual households but is being gathered to enable
targeted service delivery according to the situation of each household. It is also an education
tool, reminding the CHWs and households on how to sustain good health.

Start with their areas of interest and concern.

Use the register as checklist to note what is covered and to ensure that all the important elements
are discussed or observed and noted.

Record the relevant information in the household register, ensuring transparency but with
confidentiality.

Give relevant information according to what has been discussed or observed.

Provide any necessary and possible service.

Ask for questions and reactions.

Thank the household members and agree on the date for next visit.

3. Key Information to Consider during Home Visits

Morbidity (malaria, diarrhoeal diseases, acute respiratory infections, measles, scabies, AIDS,
malnutrition) and action taken

Household profile (members by age and sex)

Presence of any pregnant women w Immunization status

Use of MCH, VCT and PMTCT services w Sanitation (toilets) and water (household storage and
treatment)

Use of ITNs (under-fives)

Education (children aged 6–16 in school by sex)

Food availability
4. Structure of the Register

Identification page

District

Community unit (CU)

CHW name

Village name

Household and individual code: CU/hh / individual (xxx/xxx/xx)

5. Variables

Unique Identification at top left corner of the page (XXX/XXX)

Individual (household member) ID on first column (XX)

Name of HH members (not family name)

Age in completed years (months for<1 yr, but indicate unit)

Sex (M - male, F - Female) w Small box for Under-5 deaths, date of birth, date of death w
Relationship to householf head (HHH) (1 – HHH; 2 – Spouse; 3 - Child(B); 4 - Child(R); 5 –
Other B = Child by birth R = Child by relation w Completed education of spouse and household
head (X - None, Primary, Secondary) w Housing type (X - Temporary, Semipermanent,
Permanent)

Under-5 child death in the last 1 year or since last update. ([Tick] Yes / X No)

Chronic (>4 weeks) Illness ([Tick] Yes / X No)

Date of death

Explain that the information is not linked to specific individual households but is being gathered
to enable targeted service delivery according to the situation of each household.

6. Mapping Procedure

1. Identify villages within specified community units.

2. Identify CHWs within the village.

3. Write on charts the placement of infrastructure in the village (hospitals, schools,

churches/mosques, markets).
4. Identify the location authorities (village elders, chiefs and their assistants).

5. Locate each village per sub-location on flip charts.

6. Determine the number of households to be covered by each CHW/enumerator.

7. Determine the unit of registration (HH).

8. Plot on the chart the households supported by each CHW by ID No. (XXX/XXX).

9. Compile the maps of all the villages in the sub-locations to form a sub-location map.

10. Compile all sub-location maps to form a district map.

11. Collect data and ensure data quality (checking 10% randomly selected of households by a
validation team).

7. How to Collect Information

Discussion and dialogue

Observation

Recording the necessary information in the household register

8. Tasks of CHW in Home Visiting

Communicating for behavior change

Giving information

Recognizing health problems and issues

Treating identified conditions

Referring for further action

Gathering relevant information

Recording data in register

Giving feedback, educating based on information gathered

Bringing the information in the register to the collation point

Participating in the analysis of the information

Providing feedback to own village (VHC, other leaders, structures and concerned households)
9. The Significance of Household Registration

The purpose of collecting household specific information is to generate data that can support
evidence-based decision making by government, research institutions, non-government
organizations, local communities and others. Such data may be used to influence behavior
change at household or community level, and to improve health facility and health system
operations.

10.Frequency of Household Registration and Updates

This will be done twice a year (every six months, in June and December).

Lesson Planning

1. Steps in Lesson Planning

The actions agreed upon to be undertaken by the CHWs will determine the abilities needed to
carry out the activities in terms of knowledge, attitudes and skills. Thus the first step is to
identify what knowledge, attitudes and skills are needed for the CHWs to carry out their
assignment successfully.

The next step is tooutline the objectives of the lesson, to ensure it will enable the CHWs to carry
out their tasks. If well stated, the objectives also imply what content should be covered to
produce the required ability in the CHWs. The content determines the methodology to be used
and how the learning is assessed.

2. Outline of a Lesson Plan

Take note of the structure of these sessions as a model for lesson planning.
 Adult Learning

1. Characteristics of an Adult Learner

Are sensitive, anxious to protect self-esteem.

Have strong views and expect to be listened to.

Are knowledgeable and experienced in their field.

May be preoccupied with many life issues.

Learn selectively.

Possess strong verbal ability, but not necessarily physical capacity. That is, the older people
become, the less they are able

Facilitating Adult Learning

1. Definition of Session Plan

A session plan is a written description of what will happen in the process of facilitating learning:
Topic, time, venue, participants, content, activities, learning aids, methodology, summery and
evaluation.

2. Definition of Learning Material

These are pamphlets, handouts, posters, pictures, films, slides, puzzles and other materials that
stimulate learning. A multi-sensory approach – that is the use of a variety of different types of
materials – helps to making learning effective. The materials may be projected or non-projected,
and the different types have both good and bad qualities.

Projected aids (transparencies with an overhead projector, computer aided slides if available)
Different materials can be projected. Easy tracing and drawing of diagram. Easy development of
the idea and structure. O May be costly and require access to an electrical power supply.

Non-projected materials (chalkboard, pictures, flipcharts, etc.) Generally available. Generally

low cost. O Not terribly exciting or flexible.

3. Factors to Consider when Choosing the Materials

Availability of the material

Its relevance and usability

Simplicity of operating the material

Cost of the material

Its effectiveness in facilitation

Maintenance and repair

Continuity and duration of use

Storage facilities

Substitute and replacement

Availability of power

4. Facilitating

Set the climate for learning Prayer Introduction Expectations/objectives

Call participants by name (or appropriately)

Be sensitive to cultural issues

Maintain eye contact with participants

Reinforce responses positively

5. Who Is a Facilitator?

A facilitator is a person who helps the participants learn the skills presented in the course. The
facilitator spends much of the time in discussion with participants, either individually or in small
groups. For facilitators to give enough attention to each participant, a ratio of one facilitator to 3
to 6 participants is desired. In your assignment to train CHWs, YOU are a facilitator. As a
facilitator, you need to be very familiar with the material being taught. It is your job to give the
explanations, do the demonstrations, answer the questions, talk with participants about their
answers to exercises You will conduct role plays, lead group discussions, organize and supervise
clinical practice in

outpatient clinics and in the community, and generally give participants any help they need to
successfully complete the course. You are not expected to teach the content of the course through
formal lectures.

6. What Does a Facilitator Do?

A facilitator has three basic tasks: instruction, motivation and management.

A facilitator instructs:
 Make sure that each participant understands how to work through the materials and what they
are expected to do.

Answer the participants’ questions as they occur.

Explain any information that the participants find confusing, and help them understand the main
purpose of each exercise.

Lead group activities, such as group discussions, oral drills and role plays, to ensure that
learning objectives are met.

Promptly assess each participant’s work and give correct answers.

Discuss with each participant how they obtained answers in order to identify any weaknesses in
their skills or understanding.

Provide additional explanations or practice to improve their skills and understanding.

Help each participant to understand in real life how to use the skills taught in the course.
Explain to each participant what to do in each clinical practice session.

Model good skills, including communication skills, during practice sessions.

Give guidance and feedback as needed during practice sessions.

A facilitator motivates:

Compliment the participants on their correct answers, improvements or progress.

Make sure that there are no major obstacles to learning (such as too much noise or not enough
light).

A facilitator manages:

Plan ahead and obtain all supplies needed each day, so that they are in the classroom when
needed.

Also plan for field exercises to ensure that they go smoothly without wasting time.

Make sure that movements from classroom to community and back are efficient.

Monitor the progress of each participant.

7. How to Facilitate

Show enthusiasm for the topics covered in the course and for the work that the participants are
doing.
Be attentive to each participant’s questions and needs.

Encourage the participants to come to you at any time with questions or comments, and be
available during scheduled times.

Promote a friendly, cooperative relationship. Respond positively to questions (by saying, for
example, “Yes, I see what you mean,” or “That is a good question.”). Listen to the questions and
try to address the participant’s concerns, rather than rapidly giving the “correct” answer. Often
you could bounce the question back to the rest of the participants before you summarize the
response needed.

Always take enough time with each participant to answer their questions completely (that is, so
that both you and the participant are satisfied).

8. When Leading a Group Discussion

Always begin the group discussion by telling the participants its purpose. Often there is no single
correct answer that needs to be agreed on in a discussion. Just be sure the conclusions of the
group are reasonable and that all participants understand how the conclusions were reached. Try
to get most of the group members involved in the discussion. Record key ideas on newsprint as
they are offered. Keep your participation to a minimum, but ask questions to keep the discussion
active and on track. Always summarize, or ask a participant to summarize, what was discussed.
Reinforce the participants for their good work by (for example):

Praising them for the list they compiled.

Commenting on their understanding of the exercise.

Commenting on their creative or useful suggestions.

Praising them for the ability to work together as a group.

1. Key Messages in Pregnancy and Childbirth

Ensure that every pregnant woman has adequate antenatal care and seeks care at the time of
delivery and afterwards.

2. What is PMTCT?

A baby born to a woman who is infected with HIV can also be infected by the virus. The greatest
risk of transmission is during labour and delivery, but HIV can also be transmitted during
pregnancy or through breast milk. To prevent transmission of thevirus, pregnant women should
receive counselling and testing for HIV. If they are HIV infected, they should receive anti-
retroviral treatment. At level 1, prevention of mother to child transmission of HIV(PMTCT)
targets building awareness among community members of the importance of PMTCT treatment
for preventing HIV in newborns and of the availability of PMTC services in health facilities.
Thus community level PMTCT encourages women to deliver in health facilities, rather than at
home, so that they can access PMTCT services.

3. Importance and Benefits of PMTCT

Helps reduce stigma through counselling, testing and community sensitization.

Taking KEPH to the Community -roles of a CHEW

Promotes use of dual method family planning.

Improves antenatal care through clinic attendance (four or more times).

Promotes preparation and implementation of individual birth plans (IBPs).

Promotes access to early medical care such as ART, STD treatment, malaria treatment, TB
therapy, obstetric care, etc.
Gives time to plan for the future, e.g., infant feeding support systems.

Decreases numbers of HIV infected children.

Increases child health and survival.

Promotes behaviour change.

Helps prevent unintended pregnancies in HIV infected women.

Provides an entry point for care and support to HIV infected women, their infants and families.
Decreases the load on the health system.

Gives an opportunity to improve/expand health services and strengthen the health infrastructure.
4. Why CHWs and CHEWs Should Be Involved in PMTCT Scale Up

Significant progress has been made in the scaling up of PMTCT services across the country by
expanding the number of facilities, training health staff, and increasing the availability of testing
reagents and drugs. Despite notable progress, however, the number of women visiting health care
facilities for PMTCT services is low. Similarly, the number of women delivering in health
facilities is fundamentally low (40%). The high rate of women receiving ANC (92%) provides a
big opportunity for scaling up the use of PMTCT services. ANC visits are good times to raise the
level of awareness and knowledge about PMTCT among community members so that they can
make informed choices to utilize PMTCT services. Because HIV can be transmitted via breast
milk, ANC visits are also appropriate occasions to educate HIV-positive women on safe
breastfeeding for infants and proper nutrition. An expected outcome of enhanced community
sensitization will be reduction of stigma associated with exclusive breastfeeding and an increase
in the number of women visiting health facilities for HIV counselling and testing.

Strategy Both CHEWs and CWHs can use their influence to encourage pregnant women to
continue to be faithful to the ANC schedule, and to make arrangements to deliver in a health
facility. Delivery in health care facilities will help reduce

the chance that the infant will be exposed to HIV if the mother is HIV positive. The process The
Ministry of Health target is to increase the number of HIV-positive women who deliver in health
facilities from 40% to 80% so as to reduce the proportion of HIV-positive infants from the
current 20% to 50% . The PMTCT process is confidential. It involves: w Women to be tested in
early pregnancy and again when they come to maternity to deliver. This will minimize any
chance of misreporting. w Women who come to maternity with no information about their sero
status will have HIV test regardless of claimed previous testing. w Women in established labour
will be tested after delivery. Babies born to HIV+ women will be given ART post-exposure
prophylaxis. w At six weeks, polymarase chain reaction (PCR) tests will be done for infants
whose mothers are positive. If positive the babies will be started on cotrimoxazole prophylaxis.
w For mothers whose sero status is not known, the infant and the mother will undergo antibody
testing at six weeks post delivery. w Preventive counselling and testing will be available to all
women as part of routine perinatal care.

Objective The aim of involving CHEWS and CHWs in the PMTCT strategy is to facilitate
effective community mobilization and to enhance referral of clients to health facilities. Testing of
women and infants in the clinic set up is still a challenge because not all women choose to be
tested to determine their status. This is where the CHWs and CHEWS come in: to identify
pregnant women and prepare them to demand PMTCT. 5. Family Planning

There is a major emphasis on promoting the use of condoms among the most sexually active
groups and the vulnerable to prevention transmission of HIV. Used correctly and consistently,
condoms also help prevent unwanted pregnancies. There are a number of other family planning
methods, but none of these prevent the spread of HIV. The main family planning methods are: w
Injectables, pills, Norplant w Condoms (male and female) w Spermicides, diaphragm w Tubal
ligation w Vasectomy w Intra-uterine contraceptive device (IUCD) w Natural family planning
 Community Child Care

1. Growth Promotion and Development

Breastfeed babies exclusively for 6 months.

Introduce appropriate complementary foods from 6 months whilst continuing breastfeeding for
up to 24 months.

Ensure that children receive adequate micronutrients (vitamin A, iron and zinc) through diet or
supplement.

Promote mental and psychosocial development by responding to child’s needs for care and by
playing and talking with the child and providing a stimulating environment.

Ensure that your child’s birth is registered and that you receive a birth certificate.

Monitor the child’s growth regularly for the first two years.

2. Home Management of the Sick Child

Continue to feed and offer more food and fluids when child is sick.

Give child appropriate home treatment for infections.

Reduce fever by appropriate dressing and sponging with cool water, but don’t allow the child to
get chilled.

Follow instructions regarding treatment and advice.

Recognize when sick children need treatment outside the home and seek care from appropriate
health worker.

3. Disease Prevention
 Dispose of faeces safely, wash hands after defecating, after cleaning a baby’s bottom, before
preparing meals and before feeding children.

Improve ventilation in the home (household air pollution).

Protect children from malaria by ensuring that they sleep under insecticide treated bed nets.

Provide appropriate care for children with HIV/AIDS.

Treat drinking water at the point of use.

Prevent child abuse and neglect and take action when it does occur.

Take child to complete the full course of immunization before 1st birthday.

Involve fathers in the care of their children.

Take appropriate action to prevent and manage child injuries and accidents.

1. Assessing a Sick Child

1.) Take the child’s history from the mother: age, reason for the visit, current problems

2.) Ask about the three main symptoms: Cough or difficulty in breathing Diarrhoea Fever
(malaria, measles, meningitis)

3.) Check child for general danger signs: Child not able to drink or breastfeed Child vomits
everything Child has had convulsions Child is lethargic or unconscious

4.) Check the child for specific danger signs: Cough, difficult breathing or fast breathing (>50
per minute, chest indrawing) Dehydration (skin pinch going back slowly), blood in stools Fever

5.) Check the child also for: Malnutrition and anaemia Immunization status Other problems the
mother has mentioned

2. The Role of Mothers and Caregivers

Mothers/caregivers have a very important role in preventing deaths due to illness. Mothers/
caregivers here refers to the persons who look after the child and bring a sick child for treatment
or a healthy young child for advice to a CHW.

“Check for general danger signs” and “Does the child have cough or difficult breathing?” If
demonstration is possible then the framework below can be used to help participants practice
assessment and classification of a sick child. Participants can be drilled on assessing and
classifying these children to decide on action to be taken. Participants record their findings;
discuss the cases after all participants have finished assessing the 5 cases.
3. Case Histories for Practising Assessment, Classification and Action

Case History No. 1 Pauline is six months old. Her mother brought her to you because Pauline is
not able to drink. She is conscious. She has cough and her breathing rate is 65 per minute. She
does not have diarrhoea and she does not have fever.

Case History No. 2 Jack is two years old, and has diarrhoea. On assessing Jack, you find he is
conscious and can drink well. He has a cough but does not have chest in-drawing and his
breathing rate is 36 per minute. He has had diarrhoea for the last two days. There is no blood in
the stool.

Fever, difficulty in breathing and diarrhoea are the Big 3 dangers to child health. They cause 7
out of 10 deaths in children below 5 years of age.

Framework for Assessment, Classification and Action

For each of the children seen, answer the question:

Does the skin pinch go back? Does the child have Is the child lethargic chest in-drawing? or
unconscious? Very slowly? Slowly? Immediately? Yes No Yes No Child 1 Child 2 Child 3 Child
4 Child 5

Participants can be drilled on assessing and classifying these children to decide on action to be
taken.

Case History No. 3 Carol is six months old. Her mother brought her to you because Carol is not
breathing well. She is conscious. She has a cough and her breathing rate is 75 per minute. She
does not have diarrhoea and she does not have fever.

Case History No. 4 Nelly is a 16-month-old child. She was brought to the CHW by her mother
because of diarrhoea. On assessment, the CHW found that the child was conscious. The CHW
also observed that the diarrhoea was of 16 days’ duration. Nelly was eager to drink and drank
the fluid when offered. The skin pinch was slow. The CHW asked the mother whether Nelly has
had a cough or difficulty breathing and the mother said Nelly did not have either one. On further
assessment, the CHW discovers that Nelly has fever.

Case History No. 5 Ken is 14 months old. His mother brought him to the CHW because he was
not eating well. On assessment, the CHW found that Ken was conscious and when offered a
drink, he drank well. The CHW asked the mother whether Ken has had a cough or difficulty
breathing, diarrhoea or fever and the mother said none. On further assessment, the CHW found
that the child was

hot to touch, had red eyes, runny nose, and generalized body rash.
Summarize the process of assessment, classification and action. Clarify where necessary and ask
participants to practise with more case studies.

5. Available Home Fluids

This refers to fluids that are generally at hand in the home or that can be prepared at home
relatively quickly and easily. Water should be treated or boiled and allowed to cool. Milk should
be boiled and allowed to cool. Fruits should be washed thoroughly and dried before pressing the
juice out. The fluids should not be diluted. All containers should be kept clean and covered.
Spend money on fruits rather than sodas.

Summary of key points Home available fluids are important to prevent dehydration during
diarrhoea. The presence of food in such fluids, like soups, helps in its absorption. Counsel the
mother:

To give readily available fluids that she can afford.

Not to give fluids liked carbonated drinks (sodas), sweetened fruit juices, spicy drinks, coffee,
etc. These can worsen the diarrhoea.

To NEVER DILUTE A FLUID. If she feels that a fluid is too strong, then after giving it, offer
the child clean water to drink.

To give the fluids by a cup or a spoon.

To give small quantities at frequent intervals.

To continue to feed the child with solid foods as well.

To give a variety of fluids as far as possible. This helps to balance the salt and sugar intake.

Examples of available home fluids

Fluids not to be given are water Carbonated drinks (sodas – Vegetable soup Coke, Fanta, etc.)

Fluids to be given, -Soups of chicken, Sweetened fruit drinks/ fish, meat juices Water Coffee
Lemon juice in clean water (lemon juice is the only fruit juice that should be diluted) Milk Weak
chai Fresh fruit juice (not sweetened)

6. Counsel the Mother

The most important part of the CHW’s job is to counsel the mother or caregiver. The principles
of talking to the mothers must be learnt early. Conduct a demonstration role play to stress the
basic steps of talking to the mother, so that participants have a role model of counselling and
communication with the mother. An example here is a topic such as “Referring the Sick Child”.
Role play The topic of the role play is explaining to a mother that her child needs to be taken
urgently to the health facility. The characters in the role play are the mother and the CHW. Select
someone to play the role of the CHW and someone to play the role of Mumo’s mother.

Description for the mother: Mumo is the two-year-old child of Mary, who has brought him to the
CHW for treatment of a cough he has had for the last six days. Mumo is sleeping all the time and
would not wake even if Mary tried. Mumo is not drinking anything. The CHW examined Mumo
and told the mother the child has severe disease and must be taken to the hospital immediately.
The mother is reluctant to take Mumo to the hospital. She is scared. She must get permission
from her husband. She does not have money to take Mumo to the hospital. Her husband can be
contacted at the near-by shopping centre.

Tips for the CHW: 1. Praise the mother for bringing Mumo and tell her that Mumo is quite sick
and should be taken to the hospital. The child would need special care, including medicines by
injections, that you can not provide.

. Give one or two examples of children who have been sent from her village who got better and
support her to get rid of her fears about the hospital. 3. Ask the mother to contact her husband at
the shopping centre and offer to talk to him to explain the illness. 4. Explain to the mother how
to get to the hospital quickly. Tell her about costs and stay arrangements. Prepare her for the
hospital by explaining the procedures that are likely to be carried out in the hospital for the
treatment of Mumo’s illness. 5. Prepare a referral card explaining the illness, treatment given and
why the child is being referred. 6. Give any treatment that should be given, but tell the mother
that this treatment is not a substitute for the hospital treatment. 7. Advise the mother what to do
while taking Mumo to the hospital.

Observers The observers of the role play should check the following while watching the role
play:

Is the mother convinced that Mumo has a serious illness?

Is she convinced about the need for urgent referral?

Has the CHW resolved the mother’s concerns about the quality of care in the referral hospital?

Were the problems of the mother regarding utilizing the referral facility addressed?

Does the mother know what to do while taking Mumo to hospital?

Were the questions raised by the mother answered?

Did the CHW prepare the referral card correctly?

Summarize the role play

Immediate referral to a hospital is necessary for a child who has a serious illness.

CHWs must provide all the necessary information about the referral and be able to convince the
mother to go to the referral facility.

Family support is essential in successful referral.

The referral card given to the mother should have the condition and all treatment that has been
given written on it.

Advice should be given to provide the necessary care to the child while transporting the child.
All treatment that is required before referral must be provided.

Ask the participants to review common problems in referral of the sick and possible solutions.
 The Chronically Ill

1. Definition

Home-based care (HBC) is the care given to the sick and affected in their own homes. It is
extended from the hospital or health facility to the home through family participation and
community involvement supported by the CHEW. It is a collaborative effort by the health
facility, the family and the community.

2. Importance of Home-Based Care

The sick person learns self-care skills, positive living.

Family/caregivers learn new skills, how to cope more effectively.

Community health worker links the person and family to other services.

Health system is less stressed, offers better overall care.

3. Objectives of Home-Based Care Programmes

To facilitate the continuity of care from the health facility to the home and community.

To promote family and community awareness of HIV/AIDS prevention and care.

To empower the family and the community with the knowledge needed to ensure longterm care
and support.

To raise the acceptability levels of persons living with HIV and AIDS (PLWHAs) by the
family/community in order to reduce the stigma associated with AIDS.

To streamline the patient/client referral from the institutions into the community and from the
community to appropriate health and social facilities.
To facilitate quality community care for the infected and affected.

4. Key Players in Home-Based Care

The health facility - Making the initial diagnosis and delivering clinical care.

Recruiting the sick into the programme, identifying needs at various levels, preparing the sick
person for discharge home.

Preparing the family caregiver for the caring responsibility at home.

Supplying simple drugs and basic home nursing supplies.

Facilitating training and supervision of community health workers in home care, caring for
terminally ill depending on their wish, the use of simple drugs and supplies.

The family - Caring for the sick at home, collaborating with other care providers, e.g., religious
institutions, support groups, and health and social institutions.

Consulting and involving the sick on matters concerning them.

Taking KEPH to the Community (role of CHEWs)

Helping them accept the reality of the situation.

Helping the sick to prepare for death.

The sick- Identifying the primary or alternative caregiver of choice.

Participating in the care process.

Participating in planning for the future by writing a will. Identifying own spiritual/pastoral
needs.

Resolving to take personal responsibility to stop the further transmission of HIV.

Advocating for behaviour change and informing the partner of one’s HIV status.

The community -Accepting the situation of the sick and accepting the family without
stigmatizing them. w Collaborating with existing agencies to meet the needs of those infected. w
Forming support groups, advocating for the rights of the sick. w Supporting the family of the
sick.

The government -Creating a supportive policy environment, developing policies and guidelines.

Developing/maintaining home-based care standards.

Providing/coordinating training.
Providing essential drugs and commodities.

5. Care Needs of the Chronically Ill

Assistance with general household chores.

Psychological support: Stress and anxiety reduction, promoting positive living, and helping
individuals make informed decisions on HIV testing, planning for the future and behaviour
change, and involving sexual partner(s) in such decisions.

Nursing care including personal hygiene: Care given to promote and maintain good health,
hygiene, good nutrition and comfort to ensure a cheerful life despite the illness.

Clinical care, including palliative care: Early diagnosis, rational treatment and planning for
follow-up care of HIV-related illness.

Food and nutrition.

Environmental cleanliness.

Social support: Information and referral to support groups, welfare services, and legal advice for
individuals and families, including surviving family members, and where feasible the provision
of material assistance.

Referral.

6. Caregivers Course Content

Home-based counselling

Introduction to VCT and diagnostic testing and counselling (DTC)

Dealing with stigma and discrimination

Feeding/nutrition care for the chronically ill

Community tuberculosis case finding

Community TB treatment and care w Support mechanisms to TB clients in the community

Medical care of the chronically ill (antiretroviral therapy, treating opportunistic infections,
prophylactic drugs, palliative therapy)

7. Anti-Retroviral Therapy (ART)

The person infected with HIV gets sick easily, leading to persistent illness and ultimately death.
These infections include pneumonia, diarrhoea, skin infections, meningitis, tuberculosis and
others. At the early stages of HIV infection, the body’s immunity can still fight infections. It is
only as the HIV infection progresses and the immunity can no longer fight these infections, that
anti-retroviral drugs should be taken. Antiretroviral drugs (ARVs) work by helping to stop the
virus from multiplying in the body and subsequently destroying the cells of the immune system.
The immune system is thus still able to stop infections from causing disease among those
affected by HIV. For these drugs to work well, the treatment should be administered carefully
bearing in mind that proper drugs are used. These drugs should not be bought directly in a
chemist without a prescription from a doctor. A person who is infected should go to the nearest
comprehensive care centre/HIV clinic. There a team of specialists will talk to them about the
infection and assess them to establish if they are at a stage that requires the drugs. Those who do
not yet require ART will be put on a drug called Cotrimoxazole (Septrin). This drug will protect
them against common infections that HIV-positive people are predisposed to, like pneumonia
and diarrhoea, as well as malaria and other infections. The person should take the drugs every
day as recommended by the clinician. Once treatment is started, it should be taken for life. It is
important to understand that for the

ART is not a cure for AIDS. A person on ART can still be re-infected by HIV and can infect
others.

drugs to work well, they must be taken every day at the same time without skipping some days.
The people started on ART are also given Cotrimoxazole as the benefits outlined above apply
even to them. Along with these drugs, HIV infected individuals should remember to eat a well
balanced and nutritious diet, drink clean water to avoid water borne illnesses, and practise safer
sex through abstinence or use condoms so that they do not get re-infected by HIV, a different
strain of HIV or other sexually transmitted illnesses. All those infected, whether on treatment on
not, should attend clinic regularly so that the clinicians can monitor their progress and detect any
problems early enough, and in the case of those not on ART, so that treatment can be started in
good time.

8. General Care and Nutritional Care and Support of PLWHAs

A key objective of nutritional care and support for PLWHAs is to prevent weight loss and to
maintain normal nutritional status. Another important objective is to restore the nutritional status
of severely malnourished PLWHAs to optimize their health and reduce stigma against them.
Nutritional support will also assist those who are overweight to reduce their weight and its
associated health risks. In summary, the critical nutrition interventions for PLWHAs are:

Advise the client to have periodic nutritional status assessments, especially of their weight, every
two months.

Educate and counsel PLWHAs of the increasedenergy needs for their disease stage and the need
to consume a balanced diet. Clients with severe malnutrition should be supported with
therapeutic supplementary foods.
 Educate and support clients to maintain high levels of sanitation, food hygiene and water safety
at all times. They should be dewormed biannually with an appropriate broad-spectrum anti-
helminthic drug, like Albendazole or Mebendazole.

Encourage PLWHAs to practice positive living behaviours, including safer sex.

Counsel PLWHAs to seek prompt treatment for all opportunistic infections.

Advise clients to do physical activity or exercises to strengthen or build muscles, increase

appetite and improve general health.

Inform those on medicine, including ARVs, about drug/food interactions and sideeffects that
can be managed by food and nutrition interventions.

Recommend multivitamin supplements for children on replacement feeds, and vitamin A (50,000
IU) for non–breastfed infants.

Refer also to the Ministry of Health’s Home Care Handbook for detailed guidelines on nutrition,
nursing care, management of opportunistic infections and other aspects of home care for
PLWHAs (Home Care Handbook: A Reference Manual for Home-Based Care for People Living
with HIV/AIDS in Kenya, second edition, National AIDS/STD Control Programme, Ministry of
Health, 2006).
 Tuberculosis

1. What Is Tuberculosis?

Tuberculosis is an infectious disease caused by bacteria that usually enter the body through the
lungs. TB can affect any part of the body except the hair and the nails. With proper treatment TB
is curable. Without treatment, it is often a fatal illness.

2. Predisposing Factors

Exposure and the extent of contact with an infectious person who is not on treatment

Poorly lit and poorly ventilated environment

HIV infection

Extremes of age (very young or very old)

Tobacco smoking

3. Mode of Spread

Like the common cold, TB is spread through the air by inhaling droplets after infected people
cough, sneeze or even speak. People nearby, if exposed long enough, may breathe in bacteria in
the droplets and get infected. People with TB of the lungs are most likely to spread the bacteria
to those with whom they spend time every day – including family members, friends and
colleagues.

4. Signs and Symptoms

Cough that lasts for two or more weeks

Weight loss and loss of appetite w Fever, night sweats

Coughing up blood or blood-stained sputum

Remind patient to come for sputum smear examination follow-ups at two, five and eight
months.
 Avail the patient’s clinic card to the CHEW or health facilities for data entry into the TB
treatment register every month.

If you will be away from the area for some time, inform the patient and the CHEW so that
substitute can be arranged during that period.

Participate in the seminars organized by TB control programme.

Liase with the HIV/AIDS home-based care workers to assist in creating awareness on TB among
PLWHAs and refer any patient with signs and symptoms of TB to the nearest health facility for
sputum examination.

Participate in campaigns to create awareness on TB in the community.

Disease Control

1. Voluntary Counseling and Testing

The extent of the HIV/AIDS epidemic in the country makes it is important for everyone to make
an effort to know their HIV status. This is particularly the case for any healthy person or anyone
planning to get married or start a sexual relationship. It is also important for women who are
thinking about getting pregnant. Knowing their status will enable people to make the right choice
concerning their health and to plan ahead as well explore their sexual behaviour and the risks
involved in being infected with HIV. Voluntary counselling and testing - VCT – is the process of
providing appropriate information, guidance and testing to people who wish to know their HIV
status. VCT is an a HIV prevention intervention that clients initiate. It is extended from the VCT
facility to the hospital facility through to the community. At government facilities the service is
free of charge.

What it involves The voluntary part means that VCT clients are tested by their own choice. The
counselling takes place both before and after the test. Pre-test counselling serves to inform the
client about HIV/ AIDS, the test procedure and the possible results, and helps the client to
prepare for possible bad news. This stage of the process helps counter stigma and the myths
about HIV/AIDS. The test itself requires collecting a few drops of blood from a finger prick on
test strips. Processing takes no more than about a half hour. Post-test counselling explains the
results of the test. Post-test counselling helps clients who test negative to plan their life so as to
continue to avoid infection. Clients who test positive are counselled to make appropriate choices
about living positively, protecting their partners and families, and maintaining a healthy lifestyle.
It is important to note that: w The client makes the decision to be counselled and tested. w The
client must give consent for testing by signing a form. w Testing is confidential. w Any
necessary referrals are confidential. w The counsellor does not give written test results to any
client.

Who benefits from VCT

 Any one aged 18 years and above is eligible to be tested in any VCT centre in the country. The
benefits of knowing one’s status may be

important for any teenager from the age of 15 years, for partners wishing to get married or start a
sexual relationship, and those in multiple relationships. In fact, almost anyone can benefit from
VCT services: any foreigner in the country, those already married who do not know their HIV
status, commercial sex workers, leaders in the community or in the religious sector.

Benefits of VCT VCT is an important mechanism for primary prevention of the spread of HIV. It
is an entry point to care and support for those who are infected. And it has proven benefits in
influencing behaviour change. If people know their HIV status they will be able to plan their
lives more effectively. If negative, they will learn how to protect themselves from being infected.
And if positive they will get accurate information about HIV works in the body, how to practise
safer sex and how to access anti-retroviral therapy (ART), HIV-positive women who are
pregnant or thinking about starting a baby will be advised on prevention of mother-to-child
transmission of HIV.

Who is to offer VCT services?

A VCT counsellor can be a health worker, teacher, a religious leader. Any person with
secondary school education and a score above C- is able to offer VCT services after undergoing
counselling and a VCT training course.

Responsibilities for the CHEWS and CHWs

Create awareness in the community about the importance of knowing one’s HIV status.

Create awareness about VCT services and how they work.

Promote and distribute HIV/VCT-related information, education and communication (IEC)

materials

Promote and distribute condoms

Ensure quality of the service delivered to the community.

Ensure the referral systems are working well at the community level.

Mobilize resource on VCT issues.

2. Messages for Promoting Abstinence and Condom Use in a Community

The two most important ways to avoid spreading HIV are abstinence – not having sex at all –
and using condoms correctly and consistently for every sexual act. The use of condoms is of
particular importance for people who are sexually active or vulnerable to infection, and for
Discordant couples (one partner is HIV positive and the other is HIV negative). But discussing
HIV and AIDS can be extremely difficult in many settings because it is not possible to talk about
the disease without talking about issues of sexuality. Such issues are often regarded as taboo
topics; they can’t be mentioned openly and many vernacular languages do not even contain
“respectable” vocabulary for such topics. Messages related to sexual issues must therefore be
viewed and handled within the community’s social norms as some messages may be considered
offensive. Consultation with the community’s “gatekeepers” or opinion leaders before
introducing such issues can make the process of community mobilization much smoother and
more effective. These are the people who regulate and guide the decision making process and
they are extremely influential. The important thing is to try to move people from awareness to
action. Studies show that the vast majority of Kenyans actually do know about HIV and AIDS
and how HIV is spread. But they do not always practise what they know. This is where the
gatekeepers come in handy, because they have potential to work with the health care team to
help convince people to act on their knowledge. Before being allowed for general consumption,
messages should be pre-tested and given due consideration by carefully selected teams
constituted from the community. Messages can be in different formats: large strategically placed
billboards, mass media like newsletters, radio, TV programmes, and community level plays,
dances and folk songs.

3. Basic Facts about HIV/AIDS

Definition HIV stands for human immuno-deficiency virus. This is a virus of a type known as
retrovirus that attacks the white blood cells, which are the body’s main defence against illness.
AIDS stands for acquired immune deficiency syndrome. This is the condition that results from
infection with HIV.

Progression of HIV/AIDS

As HIV destroys the white blood cells the body’s immune system becomes weaker and weaker
until it cannot resist other types of infection (known as opportunistic infections). The virus also
directly affects other body cells, e.g., nerve cells and some of the gut cells. For as long as 12
weeks after the initial infection HIV tests will not be able to detect the presence of the virus in
the body. This time is called the window period. The HIV blood tests will

give negative results even though the person is infected with the virus and can easily transmit
HIV. The incubation period of HIV – that is, the time between infection and the appearance of
signs and symptoms of AIDS – varies from individual to individual. In some people it may be as
long as 10 years. This is called the asymptomatic period (which means there are no symptoms).
During this period the infected person can infect others but AIDS does not show.

Modes of transmission
 Sexual: Unprotected sexual intercourse with an infected person (this is the most common means
of transmission in Kenya).

Contact with contaminated blood or other body fluids: e.g., through blood transfusion, sharing
syringes and needles, using contaminated tools and instruments like razors and other sharp
objects such as those used in traditional tattooing and circumcision.

From an infected mother to a child in the womb during pregnancy, labour and delivery or via
breastfeeding.

Prevention and control measures

Abstain from sexual intercourse.

Learn about AIDS.

Use condoms correctly and consistently.

Be faithful to your partner.

Modify labour and delivery approaches and breastfeeding to PMCT.

Avoid risky behaviour.

Learn to handle peer/social pressures.

Prevention strategies

Providing accurate information on transmission and prevention of HIV/AIDS through advocacy

and the use of IEC materials.

Promoting abstinence for young people, including schoolchildren, and delaying sex.
Mainstreaming sex and family education into the education system and socio-religious
institutions.

Establishing and promoting the use of VCT.

Promoting blood screening.

Strengthening home-based care and support for PLWHAs.

Providing and supporting PMTCT services.

Supporting the development of consistent healthy nutrition programmes.

You can’t tell by looking at someone that they have HIV.

Care for people with HIV/AIDS

Counseling

Positive living, including Taking care of oneself Avoiding pregnancy Eating a well balanced
diet

Supportive care from family and friends

Treatment of signs and symptoms

Home care and spiritual support

 Disability

1. Definition

Disability is defined as any degree of physical or mental impairment that substantially limits a
person’s ability to achieve their full potential in major life activities such as walking, seeing,
hearing, speaking, breathing, learning, working orself-care. The degree of handicap depends on
corrective and compensating measures including medical or surgical treatment. It is estimated
that there are 650 million disabled people in the world today and more than 35 million in Africa.
In many societies disabled people are locked away, shunned, abused, denied education and other
basic rights, and otherwise discriminated against.

The text of the Convention on the Rights of Persons with Disabilities was agreed by a UN
committee in August 2006 and awaits ratification by member states. The convention outlines in
detail the rights of disabled people. It covers civil and political rights, accessibility, participation
and inclusion, education, health, employment, and social protection. More importantly, the treaty
recognizes the need for attitude change if disabled people are to achieve equality.

2. Types of Disability

The major types of disability are:

Disabilities that one is born with.

Disabilities due to physical impairment.

Disabilities due to illness or accident.

3. Common Approaches and Interventions to Reduce Disability

Disability is neither inability nor sickness. Most persons with disabilities are just as healthy as
people who don’t have disabilities. For a variety of reasons, however, persons with disabilities
may be at greater risk for illness. Most people with disabilities can, and do, work, play, learn and
enjoy full healthy lives in their communities. In some communities, however, beliefs and
customs cause people to look down on disabled people. Some people believe that children are
born disabled or deformed because their parents did something bad or displeased the gods.
Therefore, the community needs to be made aware of the real causes of disability in order for

them to appreciate how they can contribute to reducing disability. In order to reduce disability in
our communities, adherence to preventive measures is very important. Among other things, this
includes:

Ensuring that mothers and children receive all the necessary vaccinations.

Providing maternity care and good nutrition for women during pregnancy and after delivery.
When mothers do not get enough to eat during pregnancy their babies are often born early or
underweight. These babies are much more likely to develop cerebral palsy, a disease that causes
severe handicaps.

Taking care to prevent accidents at home, schools, workplaces and on the roads.

Safely storing all chemicals at home away from the reach of children.

4. Interventions

People with disability can be assisted in different ways, depending on the type of disability:
Provision of training and equipment for mobility – crutches, wheelchairs.

Physiotherapy to help them make the best use of the mobility they have.

Speech training for those with speech problems.

Surgical correction of sight problems and provision of spectacles.

Training in sign language.

Referral for specialist care for conditions like spina bifida.

 Rehabilitation

1. Definition of Rehabilitation

Rehabilitation is a process that assists people with disabilities to develop or strengthen their
physical, mental and social skills to meet their individual/collective specific skills. In the past
disabled people were assisted while in special institutions. Today rehabilitation is carried out
with the active participation of people with disabilities, their families and the community. This is
now known as community-based rehabilitation (CBR). CBR aims at bringing change and
developing systems that are capable of reaching all disabled persons in need. The idea is to
transfer skills and knowledge for basic training to the disabled to the extent of their ability and to
their families and community members. CBR is achieved by improving service delivery, by
providing more equitable opportunities, and by promoting and protecting the human rights of
persons with disability. This requires the full and coordinated involvement of all levels of society
– community, intermediate and national – and an enabling legislative framework. It also requires
integrated efforts by all relevant sectors – the education and health systems, civil society, and
vocational institutions. More importantly, it aims at the full representation and empowerment of
disabled people.

2. The Purpose of Rehabilitation

To make services available and accessible to disabled persons.

To reduce the prevalence of physical, mental and sensory disabilities by focusing on prevention
and intervention.

To develop among the disabled a positive image, a sense of self-reliance and full integration
with the community by helping them: Take care of themselves. Move around with little help by
providing walking aids. Carry out household activities. Obtain gainful employment.
Communicate with others.

To uphold, recognize and respect at all times the dignity of the disabled.

To “level the playing field” in the dispensation of rehabilitation services.

3. The Role of CHWs in Rehabilitation

The role of CHWs and CHEWs in disability and rehabilitation includes the following: w
Educating community members about the causes of disability and what they can and should do
to address the causes.

Locating and identifying the disabled in the community.

Facilitating referral arrangements for people with disabilities to appropriate services.

Making arrangements for disabled people to get help on their disability in the community or
from the nearest centres with trained personnel.

Facilitating the integration of disabled persons into community activities.

Keeping records and tracking the progress of disabled people in the community.
 HEALTH PROMOTION

1. Definitions

Description of communication: Process of interaction involving two or more parties in which

information is passed, received and responded to using variety of channels, verbal and non
verbal.

Elements of communication process: Source, message, medium, receiver, feedback

Qualities of good communicator:

Good listening skills

Provision of feedback

Audibility tone variation

Use of simple language

Confirmation of understanding

2. Simplified Dialogue Model for Effective Communication

Ask the caregiver the problem and what they are doing about it, listen to the responses.

Identify what the caregiver is doing, and praise the efforts.

Give only relevant advice, linking to what is already being done.

Facilitate problem solving.

Taking KEPH to the Community

Ask selected checking questions to ensure that the caregiver has understood what has been
agreed on.

3. Summary of Key Points

Emphasize that participants need not worry so much about the technical aspects of counselling.
They should rather be convinced that talking to mothers is important and they should become
familiar with the steps of communication. Stress that it is important to ask the mother questions.
Listen to her response, to praise her for what she is doing or has done, and then advise her on
important aspects. She may have some problems that must be solved and these need to be
addressed. Finally, it is necessary to ask some checking questions to be sure that she has
understood and is willing to take action.

4. Demonstration Role Play – “When to Return” Using Good Communication Skills

Objective; To demonstrate advising the mother about when to return:

John is eight months old. He has a cough and slight fever, but no general danger signs. He has
no pneumonia, cough or cold and he is not dehydrated.

Have people play the roles of the CHW and the mother

Directions Good communication should involve: Asking, praising, asking for alternative actions,
adding to those actions, summarizing and checking understanding.

Description for the CHW You have assessed John’s feeding and found three feeding problems.
John was not been feeding well during illness; he needs more varied complementary foods; and
he needs one more serving each day. You have counselled the mother to keep feeding him during
illness even though he had lost his appetite. You also have given advice on good complementary
foods for John and advised the mother to feed him five times per day. Now, you give advice on
fluid and when to return.

Observers The participants not playing any roles should observe the use of these skills carefully.

Afterwards When the role play is finished, summarize the role play and ask the observers to
describe what they saw. Use the key points noted on the flip chart to emphasize how the mother
was advised about the signs to observe.

When to Return

CHW: Now we need to talk about when you should bring John back to see me. If his fever
continues for two more days, bring him back. Advise Otherwise, come back in one week so we
can find out how he is feeding.

Mother: In one week?

CHW: Yes, that will be Monday. If you can come in the afternoon at 3:00, there will be a
discussion with mothers on feeding that would be helpful for you. Ask, listen Can you come
then?

Mother: I think so.

CHW: I also want you to bring John back immediately if he is not able to drink or if he becomes
sicker. This is very important. I’m going to show you these pictures on the chart to help you
remember. (Points to chart and describes the pictures for these signs). Can you tell what you
understand by “becomes sicker”?

Mother: I understand. If he does not play or does not take any interest in his toys or the people
around him or he is crying for no reason. Continued

CHW: Good. Now I am going to tell you two more signs to look for so you will know if John
needs to come back. Advise The signs are fast breathing and difficult breathing. If you notice
John breathing fast, or having difficulty breathing, bring him back immediately. These signs
mean he may have developed pneumonia and may need some special medicine. I do not expect
this will happen, but I want you to know what to look for. Here is another picture to help you
remember to look at John’s chest for fast breathing. (Points to the chart.) If John is breathing
faster than usual, or if he seems to have trouble breathing, bring him back. What do you mean by
“trouble breathing”?

Mother: All right. I think that trouble breathing is when there is noise from the chest or if he has
to work hard just to take a breath or if breathing causes pain in the chest.

CHW: I also want to see John again in one month for his measles immunization. I know this is a
lot to remember, but don’t worry, I’m going to write it down for you. Check understanding Can
you remember the important signs to bring John back immediately?

Mother: Yes, fast breathing and difficult breathing (trouble breathing).

CHW: Good. And how will you recognize fast breathing?

Mother: If it’s faster than usual?

CHW: Good. That’s right. And there were two more signs that I told you first. Praise

Mother: Oh yes, if he cannot drink and.. ?

CHW: If he cannot drink and if he becomes sicker. Let’s look again at the chart. Check
understanding (Point to the relevant pictures again and ask the mother to say the signs.)

Mother: Not able to drink, sicker...fast or difficult breathing.

CHW: Excellent. Bring John back even if any one of these signs appear. Praise I’m also writing
down the day to come back for the measles immunization. That is very important to keep John
from getting measles. And remember, if his fever doesn’t stop in two days, you also need to
come back. Do you have any questions?

Mother: No, I think I understand.

CHW: You were right to bring John today. I will see you again on Monday. I hope Praise his
cough is better soon.

Key Messages by Cohort

1. Pregnancy, Delivery and Newborn

Attend antenatal care as soon as possible when pregnant and visit four times before delivery
Develop an individual birth plan

Sleep under insecticide treated bed net (ITN)

Be immunized against tetanus

Deliver at a health facility

2. Early Childhood

Complete all immunizations by first year of birth

Breastfeed infant exclusively for 6 months, and then till until 24 months old

Have your child’s birth registered

3. Late Childhood (up to 12 Years)

Retain child in school

Treat drinking water with chlorine

Introduce adolescent sexuality education

4. Adolescence and Youth (13–24 Years)

Delay sexual engagement till marriage

Seek health care when sick

Follow instructions given at health facility

5. Adults( 25–59 Years)

Engage in physical activity for good health

Talk about sexuality and HIV and AIDS with your children

Practice safer sex – use condoms

6. Elderly Persons (over 60 Years)

Use ITN w Wash your hands before eating or handling food

Go for regular medical check-ups

Exercise and eat a balanced diet

Enhanced service quality is one of the major goals of health care management. And the quality
of available health services plays a big role in whether people will choose to use the service. This
module recognizes the effectiveness of good management in motivating community members to
use health facility services. It covers supportive supervision and the local supply chain for
CHWs. The module also emphasizes monitoring and evaluation based on a community-based
health information system (CBHIS). The need for such an information system is stressed heavily
in the Community Strategy. The module describes how the CBHIS will be set up to track the
daily activities of the CHEWs and CHWs. It further establishes benchmarks for assessing
progress by objectives at the community level so as to support the overall goals of NHSSP II.
Module Goal The goal of the module is to equip CHEWs with knowledge and skills needed for
the effective management of service delivery at level 1. These include data collection and
analysis, and the dissemination of the results for action by the communities. This will strengthen
the management functions of the participants in strengthening the linkage between the
communities and the health facilities Objectives By the end of the module the CHEWs are
expected to be able to: w Outline the steps in evidence-based management (the action cycle) w
Describe the mechanisms of the local supply chain for CHWs w Monitor and evaluate level 1
health activities w Conduct supportive supervision and coaching for the CHWs and CHCs
Content w Session 5.1: Evidence-based management w Session 5.2: Drugs, commodities and
supplies at level 1 w Session 5.3: Monitoring and evaluation w Session 5.4: Supportive
supervision Duration

Total duration 11 hours 30 minutes Materials Needed Newsprint, felt pens/markers, masking
tape, idea cards, question box, M&E tools (checklist, register, files, etc.), pens, pencils and
rubbers and blank A4 sheets
 Management of KEPH at Level 1

1. Definition of Management

Management is getting things done through others (CHWs) to meet the desired objectives using
available resources. Good management involves empowering people to do their jobs efficiently,
effectively and with a positive attitude.

2. Management Tasks of a CHEW

Managing the activities of the Community Health Committee (CHC)

Taking and keeping minutes of the CHC w Supervising, supporting and motivating CHWs
Organizing and managing training workshops for CHWs

Managing the materials, commodities and supplies for the CHWs

Providing oversight for the referral system

Managing the CBHIS, using it to influence continuous improvement in health status at the
community level

3. The Health Action Cycle

Assess the situation (it is usually less than desired).

Dialogue with the community to identify why it is that way and if it can be improved.

Plan a doable action to remedy the situation.

Act on the plan.

Re-assess to see if there is improvement.

Assess - Dialogue - Plan - Act - Re-assess

 Monitoring and Evaluation

1. Rationale

Monitoring and evaluation constitute a powerful management tool that can be used to help policy
makers and decision makers to track the progress and demonstrate the impact of a given project,
programme or policy.

2. Description of Monitoring

Monitoring is a continuous process of following up planned activities to identify any deviations

from the plan and address them immediately for the purpose of attaining targets. It involves: w
Collecting and analysing data to measure the actual performance of programme, process or
activity against expected results.

Taking KEPH to the Community

Routinely tracking information about a programme/project and its intended outputs, outcome
and impacts.

Measuring progress towards programme/ project objectives.

Tracking costs and programme/project functioning

Importance of monitoring

Follow up progress

Analyse relationship between input and output

Ascertain that the methods and strategies used are appropriate

Enable project personnel to plan effectively

Motivate community and staff involved

Indicators for monitoring

Population profile

Births and deaths

Households visited

Disease incidence

Use of services Immunization Pregnant women (ANC)

Availability of latrines Treatment of water at point of use

Use of insecticide treated nets

Number of people reached, trained, etc.

In summary, monitoring seeks to answer questions such as: w Were inputs (e.g., equipment,
commodities, personnel, materials) made available to the programme/project in the quantities
and at the time specified by the programme/project work plan? (input) w Were the scheduled
activities carried out as planned? (process) w How well were they carried out? (process) w Did
the expected changes occur at the programme/project level, in terms of people reached, material
distributed, other? (output)

3. Description of Evaluation

Evaluation is a rigorous, scientifically based analysis of information about programme/project

activities, characteristics and outcomes that intends to determine the merit or worth of the
programme/project. The purpose is to determine whether the intended objectives and goals are
effectively and efficiently achieved. Evaluation is time-bound, meaning that it takes place at
certain points in the life of the project/ programme and is of limited duration; this is incontrast to
monitoring, which is an ongoing exercise.

Evaluation is based on research and analysis. It covers the concept and design of the project/
programme, the success or lack thereof of interventions, and the assessment of programme
utility.

Evaluation permits us to:

Identify successful strategies.

Modify or discontinue interventions that do not yield desired results.

Share findings with other programmes and stakeholders.

Provide donors with evidence of the results of their investment.

Demonstrate accountability.
In other words, evaluation assists project/ programme officers to identify what is working and
what is not working, as well as how to improve the project/programme.

Types of evaluation

Baseline evaluation – before implementation begins

Midterm evaluation – at about the midpoint of the project/programme

Final (summative) evaluation – at the end of the project/programme

Impact evaluation – a few years after the project/programme has ended

Importance of evaluation

Check whether goals and objectives have been achieved.

Check the effectiveness and the efficiency of the technology and methodology applied

Establish a benchmark for determining the achievements and designing appropriate project
interventions.

Assess the sustainability and replicability of a methodology or technology.

Areas to evaluate

Change of the situation

Change in behaviour and practice

Change in household income and social status

4. Monitoring and Evaluation Methods and Tools

Reports , Daily records, registers, checklists, tally sheets , Surveys/interviews , Cross

visits ,Focus group discussions (FGDs) , Observation using the five senses

5. Record Keeping

Definition Record keeping is a process of collecting information about people’s activities and
storing it for planning and future reference:

Household register

Growth monitoring and promotion (GMP)

Child feeding record

HBC registers and plan

Importance of records

It is difficult to keep all the information about a variety of clients and activities in one’s head.
Important information should not be lost, therefore it should be recorded. Once recorded,
information will help us communicate our activities to our supervisors and the village health
management committee for decision making. This will support the identification of priority
problems to be tackled and planning for the next meeting with the committees. Written records
also provide evidence needed for monitoring and evaluating community health activities

In summary, record keeping assists in:

Tracking change

Identifying gaps

Planning for the future

Providing evidence of performance

Providing a reference for research, future planning, etc.

Demonstrating accountability and transparency

Avoiding bad and dead stock w Making decisions

Knowing the fast moving drugs and other commodities

Detecting morbidities

Characteristics of good record keeping

Consistency

Accuracy

Timeliness

Reliability

Cost-effectiveness

Relevance

Types of records needed for level 1

Household (HH) register: Information collected annually from households (head, mother or
guardian) using household register book; information coded according to a predesigned
framework (District name, name of CHW, village name(s), sub-location code/ household
code/individual 8-digit code) w CBHIS forms: Information collected quarterly

so that 50 HHs are visited at least once using a designed tool (20 variables). (HHs under a
community-based child care centre [CBCC] programme to be covered monthly.)

Growth monitoring promotion record:

Involves taking the weight of identified children (monthly using a weighing scale); GMP card
used to monitor the weight.

Child feeding: Document kept at household level to record number of times/types of food a
child is fed.

What information to record In the community where we work and learn from it is
important to have information on:

Population – households

Map – area of coverage w Health problems/needs

Activities planned to address problems

Births and deaths

Community health activities, e.g., hygiene messages disseminated

Common diseases

Use of chlorine and water storage facility with spigot

Number and nature of meetings convened

Latrine coverage and water supply situation

Information gathering process The members of the community will provide most of the
information we need.

Gathering that information requires:

Listening – Listen to what people say about their health and ask all you need to know about their
health Their health problems and needs Their health seeking behaviours

Observation – Observe things that are important for the health of the community; for example,
latrine and wells, are they safe? are they utilized well? do they need improvement?
 Surveillance – Check and count things or events, e.g., how many pit latrines are there? How
may cases of diarrhoea per week? Take note of action taken to manage the diarrhoea and the
outcome. What is the situation at the moment about the problem? For example, about diarrhoea.

How to keep records Records can be kept using various ways and methods (tools). Among these
are registers, notebooks and diaries, and computers. A register is a book in which specific
information that has been gathered is recorded, for example, a water and hygiene promotion
register, a disease register, etc.

Taking KEPH to the Community

Notebooks/diaries are books in which the CHWs write their daily schedules for the month and
what they have accomplished. These activities may include:

Health education and advice given

Home visits – action taken to improve sanitation and cleanliness in the homes w Meetings with
the village health committee

Although costly and not readily available, computers provide a means of storing information so
that it is easily retrievable and analysed. Computers are mostly used in higher levels of service
delivery. It is important to record information as soon as possible after obtaining/collecting it so
that the details are not forgotten. It is also important to write clearly so that others can read the
record.

6. Report Writing

Definition Reports are written or verbal records or accounts of events that have occurred within a
given time frame. From the reports we are able to know: w What we have achieved. w What our
strengths are w Which areas need improvement

Types of reports; There are many different types of reports.

Some of them are:

Status reports

Progress reports

Minutes of meetings

A status report is also referred to as a baseline report. It indicates the current state of

Activities in the community. For health activities, this may include details on:

Number of households/homesteads
Available water sources

Latrine coverage

Number of dish racks constructed w Incidence of common disease

Health seeking behavior

Births and deaths

Progress reports provide an indication of events/occurrences within a given period. These

reports may be prepared at specific intervals , e.g., weekly, monthly, quarterly or annually, or on
demand.

Content of a report

A well prepared report has a definite logical structure that includes the following parts:

1.) Introduction: Overview of health activities in the community.

2.) Body: Planned activities against achievements to date and reasons for deviations if any. In the
case of CHEWs and CHWs these activities may include: w Home visits w Health promotion
activities w Follow ups w Motivation and mobilization w Meetings attended and their nature

3.) Conclusions and recommendations w What the report writer regards as the most significant
aspects of the information, whether positive or negative w Any recommendations for action to
address problems
 Supportive Supervision

1. Supervision

Monitoring of staff activities on the front line.

Tends to be assigned to people with recognized technical expertise.

Supervisors can be, but are not necessarily, leaders or managers.

2. Essential Elements of Supportive Supervision

During supervisory sessions, the CHEW should:

Discuss with CHW the aim of supervision and the content and use of checklists.

Discuss with committees and consumers issues for attention.

Observe performance based on job descriptions; guide, direct and encourage.

Check recording and data systems.

Check stocks of supplies, note gaps.

At end of mission, provide feedback and wind up with an agreed plan of action.

The CHEW should then report to the CHC, HFC and the DHMT, as appropriate, for follow up
and needed action. Such action may include: inservice training, continuing education and
improvements in the supply of materials provided by the health centre or district health office.

3. The Importance of Coaching

The Community Strategy describes CHEWs as “coaches” of the CHWs because the interaction
between the two is essential to maintaining the commitment and motivation of the CHWs, who
are volunteers. CHEWs provide continuing training to CHWs through demonstration and
instruction based on immediate learning needs. They thus train the CHW on the job as they
provide services at level 1. This is the essence of the community system.
References

Ministry of Health March 2007

Reversing the trends The Second NATIONAL HEALTH SECTOR Strategic Plan of Kenya
Republic of Kenya

Linking Communities with the Health System: The Kenya Essential Package for Health at Level
1

A Manual for Training Community Health Extension Workers

Ministry of Health Sector Planning and Monitoring Department Afya House PO Box 3460 -
City Square Nairobi 00200, Kenya Email: secretary@hsrsmoh.go.ke www.hsrs.health.go.ke

Linking Communities with the Health System: The Kenya Essential Package for Health at Level
1 – A Manual for Training Community Health Extension Workers

Communities are the central focus of affordable, equitable and effective health care.
Representing the first level of health care, they are the core of the Kenya Essential Package for
Health defined in Kenya’s second National Health Sector Strategic Plan. Service provision at
level 1 is organized in three tiers starting with household-based caregivers, adult members of the
household who provide the essential elements of care for health in all dimensions and across life-
cycle cohorts. These household-based caregivers are supported by community health extension
workers (CHEWs), a new cadre of health sector personnel, and volunteer community health
workers (CHWs). Both of these cadres require special knowledge and skills to do their job
adequately. This manual presents the training course for the CHEWs, who are the supervisors of
the CHWs and the managers of level 1 service delivery.