(WP)ARI/ICP/ ARI/OO I-E Report Series Number: RS/93/GE/03(PHL)
English only
REPORT
TRAINING COURSE FOR TRAINERS ON OUTPATIENT MANAGEMENT OF CHILDREN WITH ACUTE RESPIRATORY INFECTIONS
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 21-25 June 1993
Not for sale Printed and. distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines August 1993 ~ROIWPRO
LmRAR'J
flanila PlIMpp'"
19 NOV 1993
NOTE
The views expressed in this report are those of the participants in the Training Course for Trainers on Outpatient Management of Children with Acute Respiratory Infections and do not necessarily reflect the policies of the Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the governments of Member States in the Region and for the participants in the Training Course for Trainers on Outpatient Management of Children with Acute Respiratory Infections, which was held in Manila, Philippines, from 21 to 25 June 1993.
CONTENTS
SUMMARy ....................................................................................................................................... 1 1. 2. INTRODUCTION ................................................................................................................... 2 PROCEEDINGS OF THE TRAINING COURSE ........................................................... 2 2.1 2.2 2.3 2.4 2.5 2.6 2.1 3. Opening ceremony ........................................................................................................... 2 Objectives .......................................................................................................................... 2 Participants ....................................................................................................................... 3 Methodology ..................................................................................................................... 3 Course content ................................................................................................................. 3 Course evaluation ............................................................................................................ 4 Closing ceremony ............................................................................................................. 5
RESULTS OF THE TRAINING COURSE ....................................................................... 5 3.1 Plans of action .................................................................................................................. 5
ANNEXES: ANNEX 1 • LISTS OF PARTICIPANTS ....................................................................... 1 ANNEX 2 ANNEX 3 PROG RAMME OF WO RK ..................................................................... 11 OPENING SPEECH .................................................................................. 13
ANNEX 4 • POINTS FOR DISCUSSION ON PLANNING FOR TRAINING ................................................................ 15 ANNEX 5 TRAINING WORKPLAN ........................................................................ 11
ANNEX 6 • EVALUATION QUESTIONNAIRE ....................... ,............................. 19
Keywords Respiratory tract infections / Child / Education / Training programmes / PhiJippines
SUMMARY
The World Health Organization Regional Office for the Western Pacific organized a training of trainers course on the "Outpatient Management of Young Children with ARl" for 16 participants from Member States, in Manila, from 21 to 25 June 1993. The objectives of the course were to develop a core of national trainers who were familiar with the new WHO training materials and methods and to prepare a draft plan for national training courses for trainers in the use of the training package. Given the special emphasis of this course, a training course for trainers, great emphasis was given to participants practising the various teaching methods as if they were the course instructors in different sessions. Methods included a combination of techniques appropriate for classroom sessions, such as group discussions, exercises with individual feed-back, drills, audio-visual aids, presentations, and for clinical sessions, such hands-on practice and case studies. Clinical practice, which was carried out at San Lazaro Hospital, Manila, was particularly appreciated by all participants, who recognized its importance as a key training tool in this kind of courses. An important part of the training course was that of communication, since mothers of children with ARI are in most cases those charged with the responsibility of carrying out the prescribed treatment at home. Individual plans for planning, conducting and following up training activities in their own countries were prepared by the participants, after going through a problem-solving exercise on difficulties they anticipated might be encountered when implementing standard ARI case management practices in their facilities. The course evaluation indicated that the course had achieved its objectives. The participants, who were responsible for training staff on ARI, felt they had learnt and practised the necessary training skills adequately. The combination of various teaching methods and especially the clinical sessions with hands-on practice on cases and on advising mothers, were highly valued by the participants. The plans of action realistically reflected what participants could implement in their own capacity. Follow-up of the implementation of participants' plans of action will provide a valuable feed-back on the impact of this training course.
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1. INTRODUcnON
The WHO and national programmes for the control of acute respiratory infections (ARI) have been placing major emphasis on the promotion of standard case management of ARI cases to reduce the severity of and mortality from ARI in young children. A priority component of the programmes has therefore been training of health workers in using the WHO standard protocol to assess, classify and treat ARI cases. To support such training the WHO ARI programme has recently developed the instructor's training guide "Outpatient management of young children with ARI". The purpose of this training course was to introduce this new training package to the national ARI programmes in the Western Pacific Region.
2. PROCEEDINGS OF THE TRAINING COURSE
2.1
Opening ceremony
The training course was opened by Dr S. T. Han, Regional Director, who noted that ARIs, in particular pneumonia, were one of the most important health problems in the Western Pacific Region and a major cause of mortality in young children, accounting for about one-third of outpatient visits and hospitalizations. Dr Han emphasized that improving access to the ARI standard case management through training of health workers had been the cornerstone of most national ARI control programmes. Dr Han mentioned that the training course had the major objective of enhancing the participants' training and communication skills in order to plan and conduct similar training courses in their respective countries in the future. In concluding his remarks, Dr Han thanked the Department of Health of the Philippines for making the San Lazaro Hospital facilities available for the course. 2.2 Objectives The objectives of the training course were: (1) to develop a core of national trainers who are familiar with the new training materials and methods; and (2) to prepare a draft plan for national training courses for trainers in the use of the training package.
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2.3
Participants
There were 16 participants from 7 countries and an observer from UNICEF. They were all doctors: most were physicians or paediatricians working in hospitals and therefore responsible for managing ARl cases; there were also few ARl programme managers. The careful selection of participants by countries was a good premise for the proper conduct of the course and the preparation of relevant training plans. 2.4 Methodology
The course proper was preceded by a three-day training session for the course instructors, to review the materials and methods and rehearse clinical and classroom sessions. The methodology of the course included a combination of various methods, aiming at reinforcing learning and practicing the newly learnt skills in various ways. Presentations were kept to a minimum to give way to other more active and participatory learning methods, such as group discussions, reading with exercises with individual feedback, drills, hands-on clinical practice, audio-visual aids, case studies, monitoring of clinical work and mid-course progress check. Clinical practice was held at the outpatient department and paediatric respiratory department of San Lazaro hospital in Manila and represented one of the most important aspects of this training course. Given the special nature of this course, a training of trainers, great emphasis was given to participants practicing the various teaching methods as if they were the instructors, thus alternately shifting from the participant's role to the instructor's. This allowed them to become familiar with the training guidelines contained in the module "Outpatient management of young children with ARI" in addition to the participant's manual content. 2.5 2.5.1 Course content Presentations
The two presentations of the course, on the epidemiology and etiology of ARl and on the standard case management of ARI, besides furnishing technical background information, provided also an opportunity to review some technical aspects of the WHO recommended clinical protocol. Since the major focus of the course was on the training methodology and the methods used for the teaching of different types of ARl are the same, sessions dealt with acute lower respiratory infections (e.g., pneumonia) and excluded upper ones (e.g., "ear problems" and "sore throat"). 2.5.2
Video-filin
The revised WHO video "Assessment of the child with cough or difficult breathing" presenting cases with different signs of ARl, was welcomed by the participants, who found it very useful and an improvement over the previous version. 2.5.3 Training module
The WHO module "Management of the young child with an acute respiratory infection" provided the technical information necessary to manage children with a cough or difficult breathing, through reading, individual feedback and group discussions. Participants were divided into four groups, each having on average four persons and a facilitator.
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2.5.4
Clinical practice
Hands-on practice for clinical sessions consisted of assessing, classifying and treating ARI cases seen at the outpatient department or admitted to the ward. Participants, working in teams of two persons each, appreciated the importance of identifying clinical signs and the difficulties that without sufficient practice may be found in correctly recognizing some of these signs such as chest indrawing. On average, four participants were assigned to one facilitator as in the classroom sessions. Participants' clinical work was individually supervised by the facilitator and recorded in a monitoring form. It was in this way evident to the participants that for practice to be effective and properly followed up there was a need to rationalize the number of participants in these training courses, by considering both the number of facilitators available for close monitoring of clinical practice and the patient load. In this course participants had the opportunity to manage several ARI cases with various degrees of severity. Cases were discussed by the group of four participants with their facilitator. Drills were then used to further strengthen the skills learnt and as another training method for the participants to practice. 2.5.5 Interpersonal communication
An important aspect of the training course was that of communication, since mothers of children with ARI are in most cases those charged with the responsibility of carrying out the prescribed treatment at home. First, participants read some background information in the participant's manual included in the instructor's training guide, doing some exercises individually or in group discussions or role-plays. Then, they practised the skills learnt to communicate effectively with mothers of children with ARI that they assessed at San Lazaro hospital. Checking for mothers' understanding of the advice given was a key aspect of the two-way communication process that participants practised in addition to providing information, using cards and giving support. Drills were used afterwards to reinforce the practice. 2.5.6 Progress check
A mid-course progress check was carried out to monitor participants' learning and identify areas requiring more practice. The results showed that the course was progressing smoothly and there were no particular areas of difficulty. 2.5.7 Standard case management at your facility
The session ·Standard case management at your facility" was designed for participants to be better prepared for using standard ARI case management procedures in their own facilities, anticipating difficulties they might face later on and discussing possible causes and solutions to overcome them. Careful planning for training to ensure good quality results was also discussed thoroughly and emphasis was placed on the importance of the various steps before, during and after the training course, from planning to the conduct of the course and monitoring of those trained. This work, carried out in small groups like most activities in the course, was followed by the preparation of plans of actions by the participants, according to their specific responsibilities and the feasibility of implementing such plans in the near future. Monitoring of the implementation of these plans would provide a valuable feedback on the impact of this training. 2.6 Course evaluation
A simple questionnaire to provide a rapid feedback on the training course was ftlled in by each participant at the end of the course. The questionnaire confirmed that participants had been properly selected, since they were responsible for treating patients
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with ARI and training staff and were involved in ARI activities in their own countries. Clinical sessions with hands-on practice on cases and on advising mothers, the video on ARI assessment and the module "Management of the young child with an acute respiratory infection" were highly valued by the participants, who at the end of the course felt confident using the standard ARI case management procedures. They felt that the more the cases available for assessment, the better, thus reiterating the importance of clinical practice in this kind of training. The duration of the course and the time spent on each activity were considered adequate. 2.7 Closinl: ceremony
In closing the training course Dr Han said that the course had been a good opportunity to review various aspects of the WHO ARI standard case management protocol. He noted that results from health facility surveys conducted in the region had pointed out the existence of specific weaknesses in the practice of health workers already trained, especially in identifying chest indrawing and danger signs and in communicating effectively with mothers. Dr Han also referred to the plans of action prepared by the participants during the course and how important it was that such plans be prepared in any future training course, to consider not only training of staff but also monitoring of case management practices after training and availability of essential ARI drugs. Dr Han concluded thanking the Department of Health of the Philippines and the director and staff of San Lazaro hospital for making the hospital facilities available for the clinical sessions and providing all necessary support.
3. RESULTS OF THE TRAINING COURSE
3.1
Plans ofaction
The preparation of plans of action by each participant was a major aspect of this course. Now that they were trained and had acquired new skills, they were to plan these activities necessary to transfer this technology, so as to improve practice of and training on standard ARI case management procedures in their own facilities or in health facilities under their responsibility. The plans included: translation and reproduction of training materials; training of staff in the same facility; planning for and conduct of training of trainers courses at a central level to develop teams of trainers at provincialleveJs; training of nursing schools tutors; and monitoring the quality of training and its effects on the practices of trained health workers. Follow-up of the implementation of these plans will provide valuable feed-back on the impact of this training course.
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ANNEXt
LISf OF PARTICIPANTS TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT
J. PARTICIPANTS
CAMBODIA
Dr Chan Sary Vice Director of Technical Bureau (Mother and Child Health Center) Ministry of Health Phnom Penh DrSeng Teng Medecin Traitant Funcinpee Health Department c/o Ministry of Health Phnom Penh
CHINA
Dr Dai Yaohua Chairman, Associate Professor Department of Child Health Care Capital Institute of Pediatrics Beijing Dr Li Chaoyang Lecturer and Deputy Dean Department of Maternal and Child Health Tongji Medical University Wuhan Dr Liu Xicheng Vice-Director of Pulmonary Function Laboratory Beijing Children's Hospital
Beijing Dr Xiao Xiaming Professor of Pediatrics West China University of Medical Sciences Sichuan
FUI
Dr Lisi Vesikula Tikoduadua Chief Medical Officer Department of Paediatrics Colonial War Memorial Hospital
SlIYI
- 8Annex 1
LAO PEOPLE'S DEMOCRATIC REPUBLIC
Dr Lee Soua kou Lee Nkia vue Deputy of National ARi Programme Mother and Child Health Institute Ministry of Public Health Vientiane Dr Kbampe Phongsavath Chef de service de Pediatrie Vice Directeur de I'Hopital Hopital Sethathilath Vientiane
PAPUA NEW GUINEA
Dr Langas Garap Specialist Medical Officer (paediatrics) Angau Memorial Hospital P.O. Box 457
l& Dr Hilda H. Polume Senior Specialist Medical Officer Port Moresby General Hospital Free Mail Bag Boroko PHILIPPINES Dr Casiana C. Malantic Medical Specialist III San Lazaro Hospital Qu iricada Street Sta. Cruz, Manila Dr Feliciano Yamas Medical Specialist II Davao Regional Hospital Davao del Norte VIETNAM Professor Nguyen Tan Vien Chief of Paediatrics Department Hue Central Hospital and Hue Medical College Hue City Dr Nguyen Tien Dung Chief of Emergency Ward Paediatrics Department Bach Mai Hospital
Han2i. Dr (Mrs) Vu Thi Thuy Deputy of Respiratory Department Hai phong Children's Hospital Hai phong City
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Annex 1
2. TEMPORARY ADVISERS
Dr Emmalita Maiialac Medical Specialist III Maternal and Child Health Services Department of Health San Lazaro Compound Sta. Cruz Manila Philippines Dr Dolores Saucelo Chairman Department of Paed iatrics Tacloban City Medical Center Taclohan, Leyte Philippines
3. OBSERVER
UNICEF
Dr Pham Ngoc Len National Officer ARI, COD, Malaria and Trachoma Projects Hanoi Office Hanoi Socialist Republic of Viet Nam
4. SECRETARIAT
Dr A. Cattaneo Medical Officer ARI Programme Division of Diarrhoeal and Acute Respiratory Diseases Control (CDR) World Health Organization Geneva Switzerland DrN.Okabe Regional Adviser in Communicable Diseases WHO Regional Office for the Western Pacific Manila Philippines
- 10Annex 1
Dr Sergio Pieche Medical Officer Acute Respiratory Infectionsl Diarrhoeal Disease Control - Philippines WHO Regional Office for the Western Pacific Manila Philippines
- 11 ANNEX 2
DRAFT PROGRAMME OF ACTIVITIES DAY I (Monday. 21 June 1993) 08.()().{)9 .00 09.()().{)9 .45 09.45-10.00 10.00-11.00 11.00-12.00 12.00-13.00 13.00-13.30 13.30-14.30 14.30-14.45 14.45-15.30 p.m. a.m. Registration Opening ceremony COFFEE BREAK Module: Supervisory skills Assess: Video LUNCH BREAK Module: Classification of illness of child 2 months-5 years Presentation: Standard case management of ARt COFFEE BREAK Slide presentation: Epidemiology and etiology Cocktails
1600
DAY 2 ITuesday. 22 June 1993) 08.()().{)9.30 09.30-12.00 12.00-13.00 a.m. Clinical session I: Recognizing clinical signs Clinical session 2: Assess and classify LUNCH BREAK
DAY 2 ITuesclay. 22 June 1993> 13.00-14.00 14.00-14.45 14.45-15.00 15.00-15.30 15.30-16.00 p.m. Module: Classification of illness of young infant Module: Treatment instructions COFFEE BREAK Treatment instructions (continued) Course progress check
- 12 Annex 2
DAY 3 /Wednesday. 23 June 1993>
OS.OO-W.OO 09.00-12.00 12.00-13.00 13.00-14.45 14.45-15.00 15.00-16.00
a.m.
Treatment instructions (continued) Clinical session 3: Assess, classify, and treat young infants and children LUNCH BREAK
p.m.
Exercise: Talking to mothers COFFEE BREAK Case studies
DAY 4 Cfhursday. 24 June 1993) 08.00-11.00 11.00-12.00 12.00-13.00 13.00-14.00 14.00-14.20 14.20-14.45 14.45-15.00 15.00-16.00 DAY 5 (friday. 25 June 1993) 08.00-11.00 11.00-11.45 11.45-12.00 a.m. Exercise: Standard case management in your area (continued) Evaluation questionnaire Closing ceremony with awarding of certificates p.m. a.m. Clinical session 4: Assess, classify and treat with emphasis on talking to mothers Discussion: Talking to mothers LUNCH BREAK Discussion: Talking to mothers (continued) Referring a child to the hospital When referral is not possible COFFEE BREAK Exercise: Standard case management in your area.
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ANNEX 3
OPENING REMARKS OF THE REGIONAL DIRECfOR AT THE TRAINING COURSE FOR TRAINERS ON OUTPATIENT MANAGEMENT OF CHILDREN WITH ACUTE RESPIRATORY INFECTIONS, Manila, 21-25 June 1993
LADIES AND GENTLEMEN, It is a great pleasure to welcome aU of you to this training course for trainers on outpatient management of children with acute respiratory infections.
Acute respiratory tract infections, in particular pneumonia, is one of the most important health problems in the Western Pacific Region, and a major cause of mortality in infants and young children. On average, a child will suffer from three to five episodes of ARI every year. About one-third of outpatient visits and of hospitalizations are due to ARI. This places a heavy burden on the families concerned and on the health care services. The WHO ARI programme was established with the objective of reducing mortality and morbidity from acute respiratory infections in children under five years of age. Since its inception, improving access to the standard case management has been the cornerstone of most national ARI control programmes. During this training course, you will become familiar with our recently developed package of teaching materials, designed particularly for conducting clinical training in small hospitals and health centres. They should, therefore, be well suited to the needs in your countries. Apart from refreshing your knowledge and skills on ARI case management, the main purpose of the course is to enhance your training and communication skills. By the end of the course, you should be equipped to plan and conduct case management training courses in your own countries. I have no doubt that this training course will be very valuable for all of you. I should like to take this opportunity to thank the Department of Health, Philippines, for making the San Lazaro Hospital facilities available for this course. I wish you every success in this endeavour.
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ANNEX 4
POINTS FOR DISCUSSION ON PLANNING FOR TRAINING
1.
BEFORE THE COURSE
Selection of panicipams (category, facility, position, number) Selection of trainers (previous training in case management and as trainers, training experience and skills, availability) Ratio trainers/panicipams (minimum requirement) Selection of training facilities (quality of case management, number of staff trained, availability of antibiotics, adequate records, staff availability) Ratio cases/panicipams (minimum requirement) TIming (pneumonia season) Duration (minimum requirement) Materials (nationally adapted from WHO standard materials) 2. 3. THE COURSE AFTER THE COURSE
Monitoring of training (collection of quantitative and qualitative information) Follow-up/supervision (responsibility, frequency, problem solving, logistics support, checklist)
Evaluation ofpeifonnance (indicators, rapid assessment of case management, health facility survey).
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ANNEX 5
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- 19 ANNEX 6
EVALUA TION QUESTIONNAIRE ARI CLINICAL TRAINING COURSE
To enable us to improve the training for others in the future. please fill out this questionnaire. I. Briefly describe your responsibilities in the area of ARI case management:
Basically all panicipants were responsible for training. In what type of setting(s) do you work (e.g .• private practice. health centre. hospital)?
All but one worked in a healthfacUity, mostly hospital. 2. For each activity listed in the left column. tick (I) the box which you think best describes the value of the session to you.
Very
Useful
Somewhal
Useless
No answer
useful "Management of the Young Child with an Acute Respiratory Infection" Module Video 00 assessment Presentation: Epidemiology and Etiology of ARI Presentation: Standard case management of ARI Clinical session I: Recognizing clinical signs Clinical session 2: Assess and classiry Course progress check Clinical sessioo 3: Assess. classify and treat Exercise: Talking to mothers Case studies Clinical session 4: Assess. classiry, treat. with empbaais on talking to mothers Drills Discussion of referral (Annexes A and B) Exercise: Standard Case Management at Your Facility
useful 2 2 10
13 14
I
5 9 14 14
I
7 2 2
9 12 12
6 4 4
I
8 13
8
3 8 I I
7
8 1
7 9
- 20Annex 6
3.
During your clinical sessions, did you have the opportunity to *assess children age 2 months up to 5 years? *classify children age 2 months up to 5 years? *assess and classify young infants? *treat children with pneumonia? *treat children with cough or cold including teaching mothers about home care? YES: YES: YES: YES: YES: 16 16 11 16 16
Do you feel confident using standard ARI case management procedures with each of these types of cases? If not, YES: please tell which type of case concerns you and why. 4.
16
Did you find any aspeL1S of your training at this facility especially difficult? Why? NO: 7 YES: 9
-Need for more cases (3) -Identification of chest indrawing (2) -Need for demonstration of danger signs in severe cases (I) -Counting RR in young infants (I) -Drills (I) -Language problem (I)
5.
For each activity listed below, check one box to indicate whether you thought the time spent on that activity was too short, adequate or too long.
Time Spent Was: Too Short "Management of the Young Child with an Acute Respiratory Infection" Module Video: Assessment
Adequate
Too Lolli
I I I I I I
IS IS IS
Presentations Clinical -.ions
14 14 13
I I
Drills c-st\Idies Exercise: Talkin. to mothers Di8CUS8ioo of referral - Annexes A and B Exercise: Standard Case Management at Your PI<:i1ity Eatire trainia. course
2
3
13 16 16
I
IS
- 21 Annex 6
6.
What additional support, if any, do you think you may need after this training to enable you to improve ARI case management in your own facility?
-Training materials, including modules, videos and treatment cham (6) and updates (1) -TImers (3) -Funds for training (3) and drugs (I)
-Materials on health education (I) and media support (I) -Support for planning and conduct of surveys (1) 7. How could the content and/or management of this training course be improved for future participants?
-More cases for clinical sel·sions (3) -Reassess the same patient to check the progress of the disease (I) -Have clinical sessions since the first day (I)
-Include briefpresentation on rationale for recommending certain drugs in ARl case management (1) -Provide separate room for practice on advising mothers withfew persons present (1) -Select participants who have already been trained in ARI (/)