Curriculum and Trainers Guide for Training

Shopkeepers and other community players on use of ORS

and Zinc for Management of Diarrhea in under five year
old children within the Community

October, 2013

1
Authors

Anastasiah Kimeu1, Josephat Nyagero2, Bob Akach3, Elijah Mbiti 4, Josphat Mutua5,
Esther Chula 6
1
Programme Manager - Training, Amref Health Africa Directorate of Capacity Building
2
Research Lead, Health Programmes Development Directorate, Amref Health Africa Headquarters
3
Programme Manager, Amref Health Africa Kenya Country Office
4
Senior Program Officer, Micronutrient Initiative, Kenya
5
Programme Officer, Ministry of Health, Neonatal, Child and Adolescent Health Unit
6
Narok South Sub-County District Medical Officer

2
Foreword
Pneumonia, diarrheal disease, malaria and malnutrition are the top 4 causes of illnesses and
deaths of children under five years of age. In Kenya diarrhea contributes to over 20% of
under five year old child mortality and severe childhood diarrhea (admitted cases) has a case
fatality of 21% or more annually. The young children may suffer as many as 6 to 10 episodes
of diarrhea per year in communities with poor hygiene and sanitation practices. This situation
persists despite the deliberate efforts from both government and development partners that
target the children with prevention and early management through breastfeeding, good
hygiene practices and use of low osmolarity Oral Rehydration Salts (ORS solution) and Zinc
supplementation to avoid severe illness and death. It is well documented that ORS can
prevent up to 93% of diarrhea deaths and Zinc can prevent 23% of diarrhea deaths. Evidence-
based innovative strategies to rapidly scale up the delivery of high impact child survival
interventions are highly desired.

This trainers’ guide carries both the curriculum and facilitators’ manual intends to strengthen
the management of diarrhea in under five year old children within the community level by
ensuring that mothers and caregivers have access to ORS and Zinc. It targets training
Shopkeepers/ kiosk owners, Faith Based Organisations representatives, Early Child
Development Education and Primary school teachers so that they can make ORS and Zinc
accessible to mothers and caregivers in support of diarrhea management at community level.
Such training takes cognizance of the need to involve the community more in managing their
own health and reinforces and to what the health sector and development partners are already
doing in order to reduce child mortality especially that of the under five year old children.

The development of this curriculum has been informed by the baseline survey report of 2013
conducted in Narok South Sub-County, Narok County. The baseline survey specifically
reported on the mother’s/ caregiver’s knowledge, attitudes and practices on diarrhea
treatment, the readiness of the health facilities as sources of ORS and Zinc, the proportion of
mothers/ caregivers who obtain ORS and Zinc from any source when their child had diarrhea,
and the preferred alternative (non-traditional/formal) sources of accessing ORS and Zinc to
mothers and caregivers in the community. The ORS and Zinc baseline survey confirmed the
prevalence of diarrhea of 20.4% in Narok South which was above the national level of 17%.

We wish to appreciate this partnership of the Ministry of Health, Amref Health Africa and
Micronutrient Initiative in developing and successfully piloting this curriculum in Narok
South Sub-County. It is through such partnerships that evidence based models can be
developed and tested for informed policy and programming in the health sector in the
country.

_____________________ ____________________ ___________________

Dr Nicholas Muraguri Dr Githingi Gitahi Dr Christopher Wanyoike
Director of Medical Services CEO, Amref Health Africa Country Director, MI Kenya
Ministry of Health

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Acknowledgement

Several organizations and individuals have been involved in the process of developing this curriculum
and trainers guide for training on accessing ORS and Zinc for management of Diarrheadiarrhea in
under five year old children within the community. As it is not possible to mention everybody by
name, we would like to express our appreciation to each of them for their invaluable contributions.

We appreciate the Ministry of Health Team lead by Dr Rachel Nyamai Igoki and Dr Stewart Kabaka,
Neonatal, Child and Adolescent Health Unit for reviewing, providing general policy guidelines and
reference materials used in the development of the curriculum. Special thanks to the Sub-County
Public Health Nurse, James Yiaile and David Rotich for their intensive participation in the curriculum
development meeting to review and adapt the content to the local context.

We would also like to thank the Micronutrient Initiative (MI) for providing the financial support of
this cluster randomized implementation research study. We in particular thank Christopher Wanyoike,
the Country Director of Micronutrient Initiative for his valuable input in reviewing the curriculum.

We acknowledge the support and contribution of Amref Health Africa’s Intervention Research
Assistants (IRA); Eunice Moturi (Field Coordinator and IRA for Melelo, Enelerai, Ereteti and
Olchoro oloiruwa clusters), Colleta Kiilu (IRA for Rongena, Mara Rianta and Olkinyei clusters),
Nancy Morogo (IRA for Entasekera and Oloiruwua clusters), Moses Lengewa (IRA for Naikara and
Esoit clusters), and Eric Njiru (IRA for Co-pack supply chain across all clusters). This Amref Health
Africa team specifically participated in the critical analysis of baseline survey results and findings
leading to the identification of community gaps in the management of diarrhea using ORS and Zinc.
They also participated in pre-testing the curriculum.

Finally, we acknowledge the mothers and caregivers of the under five year old children of Rongena
cluster for accepting the invitation to the curriculum pretesting meeting. The exercise was indeed
pivotal in the finalization of the curriculum and the guide.

Dr John Nduba
Director, Health Programmes Development
Amref Health Africa Headquarters

4
TABLE OF CONTENTS
Authors2

Foreword 5

Acknowledgement 6

Acronyms and Abbreviations 7

CURRICULUM 8

Introduction 8

Background 8

Justification 9

Target Groups 10

Competencies of Trained Participants 10

Course Duration 11

Course Objectives 11

Course Structure: Mothers and caregivers 12

Teaching Approach and Methods for Mothers and Caregivers 13

Teaching/learning resources 13

Course Structure: Shopkeepers, FBO representatives, ECDE and Primary School Teachers14

Teaching approach and methods for Shopkeepers, FBO representatives, ECDE and primary
school teachers15

Teaching & Learning Resources 15

Certification 15

Monitoring and Evaluation 16

FACILITATORS GUIDE 17

Purpose 17

Step by Step Approach 17

SESSION 1 18

SESSION 2 20

SESSION 3 23

SESSION 4 29

SESSION 5 33

5
6
Acronyms and Abbreviations
CHEWs Community Health Extension Workers
CHVs Community Health Volunteers
ECDE Early Childhood Development Education
FBO Faith Based Organisation
HCWs Health Care Workers
IEC Information Education and Communication
IRA Intervention Research Assistant
KDHS Kenya Demographic Health Survey
MI Micronutrient Initiative
MOH Ministry of Health
NLM National Library of Medicine
ORS Oral Rehydration Salts
ORT Oral Rehydration Therapy
UNICEF United Nations Child Education Fund
WHO World Health Organisation

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 CURRICULUM

Introduction

Pneumonia, diarrheal disease and malaria account for more than 50% of deaths of children under five
years of age in the developing world. Africa and Asia account for more than 90% of child deaths due
to Pneumonia and diarrhea, and diarrhea alone causes about 11% of all child deaths 1. In Kenya
diarrhea contributes to over 20% of under five year old child mortality and severe childhood diarrhea
(admitted cases) has a case fatality of 21%. In communities with poor hygiene and sanitation
practices, young children may suffer over 6 to 10 episodes of diarrhea per year. This is in spite of the
fact that Childhood diarrhea is amenable to prevention by early management through breastfeeding,
good hygiene practices and use of low osmolarity Oral Rehydration Salts (ORS solution) and Zinc
supplementation to avoid severe illness and death. ORS can prevent up to 93% of diarrhea deaths and
Zinc can prevent 23% of diarrhea deaths 2. Kenya is unlikely to achieve the millennium development
goal 4 that calls for a reduction of child deaths by two thirds by 2015 unless strategies to rapidly scale
up the delivery of high impact child survival interventions are identified and implemented.

Background

Amref Health Africa in collaboration with the Ministry of Health and Micronutrient Initiative has
conducted a baseline survey in Narok South Sub-County in the Rift Valley region to assess expanded
delivery mechanisms of distributing ORS and Zinc beyond the public health system, and
strengthening the capacity of mothers and caregivers in diarrhea management of under five year old
children as an additional means to scale up uptake of ORS and Zinc.

The proportion of children in Narok South Sub-County with diarrhea in the two weeks preceding the
baseline survey for this intervention was 20.4% and 43.9% had diarrhea for 3 to 4 days. The use of
ORS in the group that had diarrhea was 43.6% while that of Zinc was only 7.8% and 38.8% of
caregivers had sought care from a health facility. Herbs, fat, milk and other home-made fluids also
featured. Several myths and misconceptions were found to exist in this community regarding the
causes and treatment of childhood diarrhea. In this community, 40.4% of the community left child’s
last stool in the open while 18.2% disposed of the stool in the toilet.
1
Pneumonia and diarrheadiarrhea - Tackling the deadliest diseases for the world’s poorest children: UNICEF,
June 2012;ISBN: 978-92-806-4643-6
2
DiarrheaDiarrhea: Why children are still dying and what can be done about it: WHO and UNICEF 2010: ISBN :
978-92-806-4462-3 (UNICEF) and ISBN: 978-92-4-159841-5 (NLM classification: WS 312 (WHO)
http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.7.pdf accessed on 20/6/2012

8
Access to correct information on home management of childhood diarrhea and to ORS and Zinc at
community level remains one of the bottlenecks to effective implementation of this life saving
intervention. This problem has its highest impact in hard to reach communities. This fact prompts
management of diarrhea using ORS and Zinc which is a simple, cheap and highly effective method.
It is in this background that this curriculum has been designed to address maternal and caregivers`
knowledge and practice in the management of diarrhea in the child below five years. It will also be
used to enhance their knowledge of the diverse sources of ORS and Zinc such as local shops and
kiosks, local schools, traditional healers and faith based institutions among others. Evidence
accumulated from the 70s till now suggests that use of social marketing approaches could also play a
key role in increasing supplies of ORS and Zinc at community level and ultimately increasing access
of ORS and Zinc to mothers and caregivers and enable them manage diarrhea in the sick under five
year old children.

Justification

In hard to reach communities, action time to treatment and access to correct information on home
management of childhood diarrhea and to ORS and Zinc at community level remains one of the
bottlenecks to effective implementation of this life saving intervention. According to the Kenya
demographic health survey of 2008-9, only 39% of the children with diarrhea received ORS
treatment. Approximately, 80% of the mothers knew about ORS. There is erratic supply of ORS and
Zinc in the health facilities and not all children with diarrhea seek treatment at the health facilities.
The use of ORT corners in health facilities has also declined confirming other KDHS findings on
declining use of ORS.
Although Zinc was introduced for treatment of diarrhea in Kenya in 2007, less than 1% of children
were receiving Zinc supplements as part of the treatment for diarrhea. This is because Zinc was not
introduced in health facilities uniformly, and the health personnel have not been adequately updated
on use of Zinc in diarrhea case management. Community Health Volunteers (CHVs) similarly have
not been trained on use of Zinc in the management of diarrhea. In addition, Masai and Kipsigis
mothers and caregivers of under five years in Narok South district often do not receive the requisite
information to manage diarrhea or expected commodities that are available at clinics and the
community; hence the tendency to use traditionally and culturally accepted practices among the
Maasai and Kipsigis such as fluids especially blood, animal fat and herbal concoctions. Evidently
there is therefore a gap between maternal knowledge of ORS (high) and its use which is low and of
Zinc which is even lower.
To achieve millennium goal number 4, it is imperative that expanded delivery mechanisms beyond the
public health system for management of diarrheal diseases are implemented.
The curriculum and training guide for training mothers and caregivers and retailers of ORS and Zinc
has been developed to strengthen their capacity to effectively expand timely use of ORS and Zinc in

9
the management of diarrhea in children under five years old in the community.

Aim

The curriculum aims to strengthen capacity of:

 mothers and caregivers to manage diarrhea in children under five years
 distributors and retailers (shopkeepers, FBO representatives, ECDE and primary school
teacher) to dispense ORS and Zinc to mothers and caregivers of sick under five year old
children

Target Groups

The target groups are mothers, caregivers with children under five years, ECDE and primary school
teachers, leaders of religious groups and retailers of ORS and Zinc in the study clusters.

Competencies of Trained Participants

Mothers and caregivers

The participants, upon completion of training, should be able to demonstrate abilities to:
1. Promote health for their under five year old children and prevent diarrhea
2. Correctly treat diarrhea using ORS and Zinc
3. Correctly treat diarrhea using recommended home fluids
4. Correct feeding practices for children with diarrhea
5. Positively change their health seeking behaviour and practices which will lead to disruption of
the diarrhea disease transmission cycle and use of the correct diarrhea management practices
Shopkeepers, FBO representatives, ECDE and primary school teachers
The participants, upon completion of training, should be able to demonstrate abilities to:
1. Provide accurate information to mothers and caregivers on importance of using ORS and Zinc
to treat children with diarrhea
2. Dispense/sell ORS and Zinc (co-pack) to mothers and caregivers of under five year old
children with diarrhea
3. Promote the health of children under five years
4. Participate in positively influencing positive health seeking behaviour leading to disruption of
the diarrhea disease transmission cycle and use of the correct diarrhea management practices

Course Duration

The course for mothers and caregivers will cover four hours while that of shopkeepers, FBO
representatives, ECDE and primary school teachers will cover five hours.

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Course Objectives

For mothers and caregivers

At the end of the course, the participants should be able to demonstrate:
1. An understanding of diarrhea with regard to:
a. what it is
b. how it shows/manifests
c. its causes
d. transmission
e. severity/ seriousness
f. complications
2. Ability to prevent diarrhea
3. Ability to assess and identify danger signs of a child with diarrhea
4. An understanding of importance of ORS and Zinc in the treatment of diarrhea
5. Ability to identify diverse sources of ORS and Zinc
6. Ability to carry out home management of diarrhea
7. Ability to develop an action plan for prevention and management of diarrhea at household
level
For shopkeepers, FBO representatives, ECDE and primary school teachers
1. An understanding of diarrhea with regard to:
a. What it is
b. how it manifests
c. causes
d. transmission
e. severity/seriousness,
f. complications
2. Ability to prevent diarrhea
3. Ability to advice mothers and caregivers on home management of diarrhea
4. Ability to assess and identify danger signs of a child with diarrhea
5. An understanding of importance of ORS and Zinc in the treatment of diarrhea
6. Ability to procure, safe storage and distribute ORS and Zinc co-packs to mothers and
caregivers
7. Ability to maintain records of ORS and Zinc co-packs flow
8. Ability to develop an action plan for prevention and management diarrhea at the community
Course Structure: Mothers and caregivers

SESSIONS TOPICS DURATION

SESSION ONE:  Definition 30 mins

11
Overview on diarrhea
SESSION TWO:
Severity of diarrhea and
recognizing danger signs
SESSION THREE:
Home management of diarrhea
SESSION FOUR:
Prevention of diarrhea
 Signs and symptoms
 Causes
 Transmission
 Concept of dehydration 30 mins
 Home assessments
 Severity of diarrhea to include danger
signs
 Use of homemade fluids 2 hrs
 Use of ORS and Zinc tablets
 Preparation, administration and storage
of ORS and Zinc
 Sources and cost of ORS and Zinc
 Dosage of ORS and Zinc and duration of
administration
 Continued feeding during diarrhea
 Early and exclusive breastfeeding 1 hr
 Immunization and Vitamine A
supplementation
 Improved sanitation including proper
faecal disposal
 Proper hand washing
 Proper personal and food hygiene
(handling, preparation and storage)
 Proper water treatment and storage
 Drying of utensils
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Teaching Approach and Methods for Mothers and Caregivers

Approach
The teaching approach will include preferably identifying a participant’s home that will be used as a
teaching and learning environment to enable participants to learn in their own setting. Criteria for
selection of the home shall be existence of an under five year old child, centrality of the home and
accessibility by participants within the study clusters. Initial consent on the selected home shall be
obtained from household heads and the local administrator. This home will then be used as a model
for training in home-based management of diarrhea.
The training will be facilitated by trained CHEWs and research assistants who will use experiential
learning cycle and adult learning approaches for community based education. The teaching
approaches will mainly focus in ensuring that participants are engaged in problem identification in
order to become problem solvers rather than receivers of information.
Methods
The teaching methods will include use of starters e.g. role plays, songs, pictorials brainstorming,
question and answers, demonstrations and return demonstrations, case examples, group activity, song
and dance among others.

Teaching/learning resources

The course will be facilitated using the following resources among others:
 Home facility with mother and under five year old child
 ORS and Zinc co-packs
 Plastic bottles and containers for water treatment
 Utensils
 IEC materials
 Local food items
 Water, soap/ash
 Pieces of wood for making a rack for drying utensils

13
Course Structure: Shopkeepers, FBO representatives, ECDE and Primary School T eachers

SESSIONS TOPICS DURATION

SESSION ONE:  Definition 30mins
Overview of diarrhea  Signs and symptoms
 Causes
 Transmission
SESSION TWO:  Concept of dehydration 30mins
Severity of diarrhea and  Home assessments
recognizing danger signs  Severity of diarrhea to include danger
signs
SESSION THREE:  Use of homemade fluids 2 hrs
Home management of  Use of ORS and Zinc tablets
diarrhea  Preparation, administration and storage of
Co-Pack (ORS and+ Zinc)
 Sources and cost of ORS and Zinc
 Dosage of ORS and Zinc and duration of
administration
 Continued feeding during diarrhea
SESSION FOUR:  Early and exclusive breastfeeding 1 hr
Prevention of diarrhea  Immunization and Vitamine A
supplementation
 Improved sanitation including proper faecal
disposal
 Proper hand washing
 Proper personal and food hygiene
(handling, preparation and storage)
 Proper water treatment and storage
 Drying of utensils
SESSION FIVE:  Packaging ORS and Zinc 1 hr
Guidelines for dispensers/  Transportation of ORS and Zinc co-pack
retailers  Purchase of the ORS and Zinc co-
packs
 Re-order levels and resupply
 Storage, security and forecasting drug
needs

14
  Data collection tools (book keeping)
 Use of ORS and Zinc Register
 Use of ORS and Zinc Invoice
Teaching approach and methods for Shopkeepers, FBO representatives, ECDE and primary
school teachers

Approach
The course will be facilitated in a central place, such as schools, churches, community meeting sites
among others within the study clusters.
Trained CHEWs and research assistants will facilitate the course by using experiential learning cycle
(action, reflection, analysis and application) and adult learning approaches for community based
education. The teaching approaches will mainly focus on ensuring that participants are involved in the
learning process as problem solvers rather than receivers of information
Methods
The teaching methods will include starters, e.g. role plays, songs, pictorials brainstorming, question
and answers, demonstrations and return demonstrations, case examples, group activity, exercises and
among others.

Teaching & Learning Resources

The course will be facilitated using the following resources, among others:
 ORS and Zinc co-packs
 Plastic bottles for water treatment
 Utensils
 Water storage bottle
 Soap/ash
 Record keeping booklet
 Flip chart, markers
 Note books
 Pens
 IEC materials

Certification

The shopkeepers, FBO representatives, ECDE and primary school teachers will be awarded a
certificate of completion of the course on use of ORS and Zinc co-pack to mothers and caregivers of
sick under five year old children and shopkeepers. The certificate will be jointly awarded by MOH
and supporting partners for recognition, reward and motivation (see appendix).

15
Monitoring and Evaluation

Monitoring
The training of participants will occur concurrently in four zones. The training shall be routinely
monitored at one month of training, fourth month, eighth month and twelfth month to identify and
document challenges and successes.
Evaluation
The impact of the training will be evaluated after the twelfth month of the training intervention. This
will be done through the end of Project evaluation whose findings will be compared to the study
baseline results.

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 FACILITATORS GUIDE

Purpose

The purpose of this guide is to help you (instructor/facilitator) to train the target groups in each of the
study clusters intervention to enable participants to learn the five sessions outlined in the curriculum.
It is important to keep in mind that ALL the information given to mothers and caregivers is also
relevant to shopkeepers in addition to the specific roles as shopkeepers.

Step by Step Approach

It is important that you are aware that your participants are adult learners. It is essential that you
conduct each session using experiential learning cycle which involves use of experience, reflection,
generalization, and application.
 The experience is a participatory exercise or presentation in which information is presented
for discussion and learning. A starter of 2-3 minutes is helpful in posing a problem that the
participants have experience with. Participants are asked what they saw; how they felt about
it, whether it is happening to them, what is causing it, what they can do about it. This
approach is abbreviated as SHOWeD (See Hear Our Why Do). This helps them connect with
new information as you present it.
 Reflection helps participants think about and analyze new information and develop their own
ideas about a topic.
 Generalization allows participants to draw broad conclusions and lessons learned about the
new information.
 Application enables them to visualize how they may apply their new knowledge and skills in
the future.
It is important to start the sessions with appropriate starters, which depicts a common problem in
their area that allows participants to use the experiential learning cycle.

In this guide, each session has a serial number, title, duration, objectives, overview,
materials/preparation in case you require to do so before teaching and key messages in points to
remember section.

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 SESSION 1
SESSION TITLE: DURATION: 30 minutes
Overview of diarrhea

SESSION OBJECTIVES:
By the end of session, participants should be able to:
1. Explain what diarrhea is
2. Explain the signs and symptoms of diarrhea
3. Identify diarrhea in a child less than 5 years
4. Name predisposing factors and the possible causes of diarrhea.
5. Explain how diarrhea is transmitted

SESSION OVERVIEW:
During this session you will give instruction to participants on the definition and identification of
diarrhea in children below 5 years and determine the local terms for the different kinds of diarrhea and
terms for diarrhea in the local language or dialect that mothers use. You will also help the participants
identify the predisposing factors and causes of diarrhea as well as understand how diarrhea is
transmitted.
Define diarrhea: help the participants to have a good grasp of what constitutes diarrhea. They should
be able to identify a child with diarrhea.

Try to help participants

 Learn of any other concepts or beliefs about diarrhea that could be important to adherence to
ORS and Zinc intake.
 Why is the knowledge of diarrhea and correct identification of a child with diarrhea so
important?

POINTS TO REMEMBER:
 What is diarrhea?
Definition: Diarrhea is the passage of 3 or more loose or liquid stools per day, or more frequently
than is normal for the individual.
 What causes diarrhea?
Diarrhea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms,
most of which are spread through the faecal-oral route mostly by contaminated water and food.
Infection is more common when there is a shortage of clean water for drinking, cooking and
cleaning. Rotavirus and Escherichia coli are the two most common causes of diarrhea in
developing countries.

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 Transmission
Emphasize that diarrhea is transmitted through 5Fs: Fingers, Flies, Faeces, Food, Fluids.
 Predisposing factors
 Contaminated water and food
 Open defecation
 Flooding of mothers and babies with swarms of flies
 Inadequate hand washing facilities
 Bottle feeding
 Improper food handling
 Some cultural practices

MATERIALS/PREPARATION:
 MCH booklet (all children below age five years need to have one)
 Flip chart
 Markers
 Notebooks
 Pens
 IEC materials
 Demonstration equipment

TIPS/NOTES FOR THE TRAINER

Use the information sheet found in the ORS and Zinc co-pack to demonstrate diarrhea sequence in a
child. You also need to use culturally appropriate health learning and IEC materials.

19
 SESSION 2
SESSION TITLE: DURATION: 30 minutes
Understanding severity of diarrhea and recognizing danger signs in a Child with Diarrhea

SESSION OBJECTIVES:
By the end of session, participants should be able to:
1. Recognize that diarrhea is a serious illness
2. Recognize the danger signs of diarrhea in a child under 5 years

SESSION OVERVIEW:
During this session you will instruct participants on the concept of dehydration, relate the level of
dehydration to any danger sign if present and choose the appropriate course of action.

POINTS TO REMEMBER:
 Diarrhea is a serious condition

Figure 1: A child with diarrhea

 To enable participants understand the SEVERITY of diarrhea, you need to change their
perception that diarrhea is not a serious condition.
Ask them: Do you know diarrhea is one of the leading causes of death in children under five
years in Kenya as well as in Narok? Find out why they think or don’t think so.
Explain to them that:
 Out of every 5 children who die, 1 death is due to diarrhea
 Every child below five years in Kenya is likely to have at least 4 episodes of diarrhea in a
year. That puts your child in danger.
 During a diarrheal episode a lot of fluids are lost through stools, and sometimes vomiting.
This fluid loss leaves the body without the water and salts that are necessary for survival
leading to dehydration. It is this dehydration that kills children
 We can save our children from dying of diarrhea by:

• Preventing diarrhea from occurring

20
 • Beginning rehydration at home immediately diarrhea starts

• Seeking care from a health provider promptly

• Following up on the instructions given by the HCWs

 What is dehydration?
 Dehydration is a condition that occurs with excess loss of water and other body fluids.
Children are particularly susceptible to dehydration from illnesses that
cause vomiting, diarrhea and fever. Dehydration occurs when the amount of water leaving the
body is greater than the amount taken in.
 Dehydration is caused by a loss of body fluids, which are made up of water and salts. When
sick children have diarrhea or are vomiting, they can lose large amounts of salts and water
from their bodies and can become dehydrated very quickly.
 Dehydration is very dangerous, and children can die if they are not treated quickly.

Figure 2: A child with severe dehydration

 What are the danger signs for a child with diarrhea?
If there are any of these signs, the child should be taken to the nearest facility as soon as possible:
 Diarrhea in child less than 6 months of age
 Passes blood in the faeces
 Vomits frequently
 Has a fever
 Not able to drink/breastfeed
 Refuses to eat
 Looks weak
 Has had diarrhea for more than one week
 A child who generally looks more sick

Figure 3: A child with signs of dehydration (you can use this graphic as a starter)

21
MATERIALS/PREPARATION:
 Flip chart
 Markers
 Notebooks
 Pens
 IEC materials
 A child under five years

TIPS/NOTES FOR THE TRAINER

You need to help the participants to appreciate that diarrhea is a serious condition and also help them
know when to seek care from a health care provider. Do not dwell on signs of dehydration as any
child with diarrhea requires treatment.

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 SESSION 3
SESSION TITLE: DURATION: 2 hours
Home management of diarrhea

SESSION OBJECTIVES:
By the end of session, participants should:
1. Be informed on prompt start of rehydration at home using appropriate homemade fluids
2. Have their capacity built (of mothers and caregivers) to initiate management of diarrhea using
ORS and Zinc
3. Have their knowledge enhanced on healthy feeding practices during episodes of diarrhea in
children under five years
4. Be sensitized and aware of local sources/channels and cost of ORS and Zinc

SESSION OVERVIEW:
 Establish the various treatments currently associated with the different kinds of diarrhea
including medicines, herbals, and ORT or Zinc and challenge the participants on any myths or
misconceptions
 Discuss the various homemade fluids available
 Demonstrate the correct preparation and administration of ORS and Zinc and proper storage.
 Stress the duration of treatment and the need to seek care in a health care facility or refer
 Ask the participants to tell you about their feeding practices during diarrhea. Probe for giving
of breast-milk, other milk supplements, fluids, and solid foods

POINTS TO REMEMBER:
 The need to promptly start rehydration at home with appropriate home fluids once diarrhea starts.
 All children with diarrhea must be given ORS and Zinc as part of their treatment
 Fluids for children under five years during diarrhea:
Some recommended fluids are The following fluids SHOULD NOT BE given
• Breast milk, • All bottled drinks
• Vegetable soup • Fruit juices which are artificially sweetened
• Clean safe water • Coffee
• Cereal gruel (uji) • Herbs
• Fresh fruit juices (not sweetened) • Salt and sugar solution
• Soups prepared from meat, fish • Animal blood and fat
and chicken
• Coconut water
• Low osmolarity ORS

23
 diarrheaRemember to emphasize the following to participants:
 Continue breastfeeding
 Give home available fluids by a cup
 Give small quantities at frequent intervals
 Continue to feed the child as well
 Give ORS (mixed with clean and safe water) and Zinc tablets
 Zinc tablets should be given once a day for 10 days

Figure 4: Dosage of ORS and Zinc by age of child

 STRESS to the participants that while at home, the mother or caregiver should watch out for the
following signs that indicate that the child is getting worse:
 If there are any of these signs, the child should be taken to the nearest facility as soon as
possible:
 Not able to drink/breastfeed.
 Child becomes more sick (in the opinion of mother/caregiver)
 Develops fever (if child did not initially have fever)
 Passes blood in the faeces
 Vomits frequently
 Drinks poorly
 Preparation of oral rehydration salts (ors) solution
 Explain to the participants that an oral rehydration solution (ORS) is a mixture of water, salts
and sugar in specific amounts. These solutions can be absorbed even when your child is
vomiting or has serious diarrhea.
 What supplies do you need?
Explain to mothers and caregivers that they will need;
• Measuring jar

• ORS packet

• Spoon for mixing the ORS

• Clean boiled water

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 • Soap or ash (if soap not available for hand washing)

• Facilities for hand washing e.g. leaky tin

 What are the steps in preparation?

Demonstrate as you explain the following:
1. Wash your hands with water and soap. If not available use ash and water and dry your hands.

Figure 5: Washing hands with clean water and soap or ash

2. Measure half litre of clean and safe water

Figure 6: Fill a 1/2 litre bottle with boiled clean water

3. Transfer the water in a clean boil.

Figure 7: Transfer the water into a clean bowl

4. Pour all the ORS from one packet into the clean water
5. Mix well with a spoon until the powder is completely dissolved
6. Keep it for not more than 12 hours after preparation. Throw away the unused preparation after
the 12 hours
7. If the child vomits wait for 10 minutes and give again but more slowly.
 How much ORS should a child be given?
Demonstrating using locally available containers, explain:
 If child is less than 2 years, give 50 to 100 mls after each loose stool
 If child is above 2 years, give 100 to 200 mls after each loose stool.
NB: If a child can take more ORS than indicated above, give.
 How much Zinc should a child receive?
Explain to mothers and caregivers that Administration varies with age.

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  Children below six months are given 10mgs, that is one half tablet daily (once a day only) for
ten days.
 Children above six months of age are given the full tablet that is 20mgs daily for ten days.
Emphasize that the child needs to take the Zinc for 10 complete days even if diarrhea stops.
 How are Zinc tablets given?
Ensure mothers and caregivers understand the following:
 For infants less than 6 months:

• Cut the tablet into halves and use one half

• Express some breast milk onto a table spoon

• Add the half tablet and wait till it dissolves completely

• Give the entire amount to the child

• For a child who is not breast-feeded, use clean boiled water instead of milk

 For children 6 months to 5 years

• Give one full tablet of Zinc

• Dissolve the tablet in a small amount of safe water or milk; preferably in a spoon and
give to the child
• In case the child vomits within 30 minutes of taking the tablet, dissolve and administer
another tablet

 Why is Zinc important?

Zinc:
• reduces the duration and severity of a diarrhea episode

• improves appetite

• builds child’s immunity

• helps protect a child against subsequent diarrhea episodes for the next 3 months

Figure 8: left - A child with severe deficiency of Zinc (Source: MoH/ IMCI guidelines)
right - Same child after administration of Zinc
 Storage of ORS and Zinc

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  Mothers and caregivers should store ORS and Zinc away from reach of children and away
from water.
 The prepared constitute of ORS should be stored in a hygienically safe place free from
contamination.
 IMPORTANT: Tell mothers and caregivers the following:
 Giving fluids is lifesaving.
 To breastfeed more frequently and longer at each feeding and not to stop giving other foods.
 To give frequent small sips from a cup or spoon or as much as the child will take. Use a spoon
to give fluids to a younger child.
 To continue giving extra fluids until the diarrhea stops.
 On the other hand, the CHEWs should teach and support the mothers and caregivers to:

• Give the child extra fluids as soon as the diarrhea start as well as regular foods.

• Give a child an extra meal a day while recovering from diarrhea for at least two weeks.

• Recognize danger signs and refer immediately.

 Feeding during diarrhea illness
A child with diarrhea loses weight and quickly becomes malnourished. A child with diarrhea
needs all the foods and fluids he/she can take. Food can help stop diarrhea and help the child
recover more quickly. If the child is 6 months of age or older, parents and caregivers should
encourage the child to eat as often as possible offering small amounts of soft mashed foods or
what the child likes. These foods should contain a small amount of salt. Soft foods are easy to eat
and contain more fluids than hard foods.

 Sources/channels and cost of ORS and Zinc

You will sensitize mothers on the diverse sources/outlets of ORS and Zinc close to where they
live. Specific source should be pointed out.

POINTS TO REMEMBER:
The essential details that need to be emphasized on this topic are the local sources at which ORS and
Zinc are available and in what formulation and price. These products are available in public health
care facilities for free. The other outlets that include private health care facilities, religious
organizations, shops, pharmacies and schools will charge a minimal fee of 50 shillings. STRESS on
the outlets relevant to the local area.

MATERIALS/PREPARATION:
 Measuring jar
 ORS packet
 Spoon

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  Clean boiled water
 Soap for hand washing
 leaky tins/tippy taps
 Flip chart
 Markers
 Notebooks
 Pens
 IEC materials
 Demonstration equipment

TIPS/NOTES FOR THE TRAINER

You will use the co-pack to demonstrate. You should also attempt to find out from the mothers if they
have ever used ORS alone or in combination with Zinc and where they had obtained it. Where else
would the mothers like to obtain the ORS and Zinc and at what price?

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 SESSION 4
SESSION TITLE: Duration: 1 hour
Prevention of future episodes of diarrhea

SESSION OBJECTIVES:
By the end of the session, the participants will be sensitized on:
1. Exclusive breast feeding for 6 months and continued breastfeeding up to 2 years
2. Immunization and Vitamin A supplementation
3. Proper hand washing with water and soap
4. Improved sanitation including proper faecal disposal
5. Proper personal and food hygiene (handling, preparation and storage)
6. Proper water treatment and storage
7. Proper drying of utensils

SESSION OVERVIEW:
During this session, revisit the concept of diarrhea and its possible causes and prevention.
 Emphasize that diarrhea is transmitted through 5Fs: Fingers, Flies, Faeces, Food, Fluids.
The disease can be prevented by breaking the transmission cycle by washing hands at the 4
critical times, proper faecal disposal, proper food handling, preparation and storage and
practicing proper household waste disposal.
 Teach mothers and caregivers on the recommended water treatment methods.
 Elicit from the mothers and caregivers what they think can lead to or cause diarrhea. Get an
idea of their knowledge of hygiene and sanitation and how diarrhea can be prevented.

POINTS TO REMEMBER:
 The points that you need to emphasize are:
 Dispose all faeces in a latrine or bury them.
 Wash hands with water and soap or ash and water at the critical times.
 Improved water supply quantity and quality, including treatment and safe storage of
household water.
 Promote and exclusively breastfeed for 6 months.
 Vitamin A supplementation. Explain to participants how and where to get Vitamin A
 Rotavirus and measles vaccination.
 Community wide sanitation promotion.
 Use of dish racks to dry utensils

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  For any attacks of diarrhea, treatment with ORS and Zinc prevent future attacks.
Administration of Zinc also reduces the duration of an attack and prevents the occurrence of
pneumonia.
 Tell the participants that diarrhea can be prevented by mothers and care caregivers by
adhering to the following:
1. Promotion of early and exclusive breast feeding and appropriate complementary feeding. Tell
them that they exclusively breast feed their children for the first 6 months, this greatly reduces the
risk of common childhood illnesses such as diarrhea
Why is breast feeding important in prevention of diarrhea? Because:
 Breast milk has immunological properties (especially antibodies) that protect the infant from
infection, and especially from diarrhea; these are not present in animal or formula milk
 Breast-feeding is clean; it does not require the use of cups, bottles, water, and formula milk
which are easily contaminated with bacteria that may cause diarrhea
 Breast milk is a complete food; it provides all the nutrients and water needed by a healthy
infant during the first 4-6 months of life.
 Breast-feeding immediately after delivery encourages the bonding' of the mother to her infant;
this has important emotional benefits for both and helps to secure the child's place within the
family.
2. Vitamin A supplementation
 Vitamin A is essential for the functioning of the immune system and the healthy growth and
development of children.
 Vitamin A supplementation is a critical preventive measure, and contributes to reduction of
child deaths attributable to diarrhea.
 Vitamin A supplementation has also been shown to reduce the duration, severity and
complications associated with diarrhea.
3. Rotavirus and measles vaccination
 Rotavirus is the leading cause of vomiting and severe diarrhea among children worldwide.
The vaccine prevents most cases of serious diarrhea from rotavirus.
 Children who have measles, or have had the disease in the previous four weeks, have a
substantially increased risk of developing severe or fatal diarrhea or dysentery. Hence,
measles immunization is a very cost-effective measure for reducing diarrhea morbidity and
deaths.
4. Promotion of hand washing with soap
Parents can help to protect young children against diarrhea by adopting certain hygiene practices.
One very important practice is hand-washing. Hands should be washed carefully after defecation,
before handling food and before feeding. Good hand washing requires the use of soap (or a local
substitute) and plenty of water (see figure 9).

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 Figure 9: Mother or caregiver washing hands before mixing the ORS
5. Proper use of water for hygiene and drinking
Most infectious agents that cause diarrhea are transmitted by the faecal-oral route. This includes
transmission by contaminated drinking water or contaminated food and person-to-person spread. A
plentiful supply of clean water helps to encourage hygienic practices, such as hand washing,
cleaning of eating utensils. These practices can interrupt the spread of infectious agents that cause
diarrhea. Clean water is essential, however, for drinking and for preparing food.
6. Improved sanitation
Human faeces should be disposed off in a way that prevents them from coming into contact with
hands or contaminating a water source. This is best achieved through regular use of a well-
maintained latrine. The proper use of latrines can reduce the risk of diarrhea to almost the same
extent as improved water supplies, but the greatest benefit occurs when improvement in sanitation
and water supply are combined and education is given on hygienic practices.

MATERIALS/PREPARATION:
 Clean boiled water
 Soap for hand washing
 leaky tins/tippy taps
 Flip chart
 Markers
 Notebooks
 Pens
 IEC materials

TIPS/NOTES FOR THE TRAINER

Do not disparage/criticize/laugh at the local culture.

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ENDING THE SESSIONS:
• Remember to help participants prepare an action plan take to manage diarrhea based on any
of the sessions they have learnt
• Remember to thank them for their time, participation and commitment to what they have
planned to do.
• If you will see them again, tell them so. This helps them to plan and look forward to your
engagement with them again.

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 SESSION 5
SESSION TITLE: DURATION: 1 hour
Guidelines for shopkeepers FBOs representatives, ECDE and primary school teachers

SESSION OBJECTIVES:
This session introduces ORS and Zinc co-pack packaging and a recap on storage and dosage. By the
end of the session, the participants should be able to:
1. Ensure a smooth flow of ORS and Zinc co-packs in the market.
2. Record the correct data on the flow of ORS and Zinc co-packs.

SESSION OVERVIEW:
Give instructions to all sellers, FBO representatives, ECDE and primary school teachers (participants
in your training) on the process of purchase, maintenance of quality stock, sale and book keeping of
information on ORS and Zinc stock flow.

POINTS TO REMEMBER:
 Transportation of the ORS and Zinc co-packs.
 Give the shopkeepers instructions on how to transport the drugs from the distributors to their
business centres.
 They should carry the drugs in secure water proof packages like nylon papers and to ensure
the drugs are not exposed to high temperatures during the transportation.
 Purchase and selling of ORS and Zinc co-packs.
 Let the participants know that the drugs can be purchased from any of the appointed
distributors
 Drugs will be sold at the given constant price
 Credit facilities.
 The participants should know that credit facilities will not be given except during special
circumstances
 Re-order levels and resupply
 The participants should ensure that they never run out of ORS and Zinc stock.
 A re-order level of 20% is advised to ensure that they are always stocked for effectiveness in
the management of diarrhea.
 ORS and Zinc co-packs distribution points i.e. distributor/ wholesalers and location
 The ORS and Zinc co-packs should always be available with a distributor/ wholesaler.
 Storage and shelf display of drugs
 The participants should be carefully taught on drug storage and quality shelf display of the
drugs in order to maintain these supplies in good condition.

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 • The shelf display of the ORS and Zinc co-packs should be well visible to the customers
but away from direct sunlight.
• On drug storage, all the participants should be taught on the following:

 Exposure to heat and moisture can make medicines less potent before their expiration date.
 Medicines should be kept in a cool, dry, secure place out of a child's reach.
 You may need to use a locked cabinet or box.
 The containers (co-packs) should stay tightly closed.
 If you store medicines in a kitchen or an adjacent room, keep them away from the stove, sink,
and any hot appliances.
 In rare cases, medicine that is improperly stored can become toxic. To prevent danger, they
must follow these tips:
 Always store drugs out of children's reach.
 Always keep medicines in their original container.
 Never use a medication that has changed colour, texture, or has odour, even if it has not
expired. Ask your pharmacist about any specific storage instructions.
 Be aware that children or adolescents can abuse medicine or accidentally poison themselves.
 Throw out unused medicine safely and promptly by burying, or burning far from homestead.
 Never give any of your medicines to other people.
 Security of the Drugs to avoid drug losses – such as theft and fraud.
 Provide information for forecasting drug needs.
 The Ministry of Health should be able to provide a forecast of when incidences of diarrhea
are expected to be high.
 Data collection tools (Book keeping).
 Data collection tools will be provided and shown how to fill in the required information.
 Inform them that they will be collected on monthly basis.

MATERIALS/ PREPARATION:
 ORS Zinc co-packs (see figure 10)
 Flip chart
 Markers
 Notebooks
 Pens
 IEC materials

TIPS/NOTES FOR THE TRAINER

 Recap on Q&A / Any info felt needed

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  Remember to give them contacts for Help and Support

Figure 10: ORS and Zinc Package Figure 11: Number of ORS Sachets and Number of Zinc
Strips in the co-pack

ENDING THE SESSIONS:

• Remember to help participants prepare an action plan take to manage diarrhea based on any
of the five sessions they have learnt
• Remember to thank participants for their time, participation and commitment to what they
have planned to do.
• If you will meet with participants again make sure you let them know when. This helps them
to plan and look forward to engaging with them again.

References
Pneumonia and diarrhea - Tackling the deadliest diseases for the world’s poorest children: UNICEF,
June 2012;ISBN: 978-92-806-4643-6
Diarrhea: Why children are still dying and what can be done about it: WHO and UNICEF 2010:
ISBN : 978-92-806-4462-3 (UNICEF) and ISBN: 978-92-4-159841-5 (NLM classification: WS 312
(WHO) http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.7.pdf accessed on 20/6/2012

Appendix: Certificate

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