MOH Facilitator’s Guide for Trainers of Community Based Volunteers FINAL

REPUBLIC OF ZAMBIA
MINISTRY OF HEALTH
Facilitator’s Guide
for Trainers of Community
Based Volunteers
2022
1
Facilitator’s Guide for Trainers of Community Based Volunteers
2
REPUBLIC OF ZAMBIA
MINISTRY OF HEALTH
Facilitator’s Guide
for Trainers of Community
Based Volunteers
2022
i
ii
Table of Content
Acronyms ...........................................................................................................................................................iii
Foreword .......................................................................................................................................................... iv
Acknowledgements ............................................................................................................... ...................... vi
Dedication ................................................................................................................................... ................... vii
Chapter 1: Introduction to the facilitators Guide .................................................. ..............................1
Chapter 2: Course Design ...................................................................................................... .......................4
Chapter 3: Participants orientation..........................................................................................................11
Chapter 4: Introduction to community Health Worker Training ..................................................12
Chapter 5: Introduction to Primary Health Care (PHC) ....................................................................18
Chapter 6: Role of Community Health Workers .................................................................................26
Chapter 7: Community Empowerment .................................................................................................32
Chapter 8: Communication and Counseling .......................................................................................49
Chapter 9: Child Health: (A) The well child ...........................................................................................59
Chapter 10: Child Health: (B) The sick child .........................................................................................66
Chapter 11: Paediatric HIV and AIDS ......................................................................................................84
Chapter 12: Nutrition ...................................................................................................................................88
Chapter 13: Health Promotion: (A) In children ............................................................ .....................109
Chapter 14: Health Promotion: (B) General ................................................................. .....................113
Chapter 15: Integrated Reproductive Health ............................................................ .......................119
Chapter 16: Malaria ....................................................................................................................... .............129
Chapter 17: Diarrhoea ................................................................................................................. .............140
Chapter 18: Acute Respiratory Tract Infection (ARI) .................................................... ...................148
Chapter 19: Water and Sanitation ....................................................................................... .................151
Chapter 20: Sexual Transmitted Infections (STIs); HIV and AIDS ........................... ....................164
Chapter 21: Tuberculosis .............................................................................................................. ...........175
Chapter 22: Leprosy .......................................................................................................................... .........181
Chapter 23: Mental Health Promotion & Substance abuse prevention ............. ....................186
Chapter 24: Non – Communicable Diseases (Chronic Diseases) ............................... ................197
Chapter 25: Emergencies and Other conditions .............................................................. ...............207
Chapter 26: Disease Monitoring and Control .................................................................... ..............221
Chapter 27: CHW Essential drugs ............................................................ .............................................224
Chapter 28: Monitoring and Evaluation ................................................ .............................................226
Bibliography ............................................................................................................ .....................................238
Appendix 1 Sample of community registers ................................... .................................................239
Appendix 2 Referral Note .............................................................................. ..........................................240
Appendix 3 Feedback from a health facility ..................................................... ................................241
Appendix 4 Sample of community based Agent Integrated aggregation form ..................242
Appendix 5. Pre/post-test questions.................................................................................................... 244
Appendix 6. Answers to pre/post – test .............................................................. ...............................250
i
Acronyms
AIDS Acquired Immune- Deficiency Syndrome

CARE Cooperative for Assistance and Relief Everywhere
HIV Human Immunodeficiency Virus
HSSP Health Services and Systems Program
JICA Japan International Cooperation Agency
MoH Ministry of Health
ii
Foreword
The Government of the Republic of Zambia through the

Ministry of Health aims at attaining Universal Health Coverage
(UHC) in which all Zambians have access to essential health
services without suffering financial hardship. Government
places a premium on attaining UHC through health systems
strengthening using an integrated Community and Primary
Health Care approach leaving nobody behind. To achieve this
objective, the government adopted a policy that every Zambian
household should be within a five-kilometre radius or one hour
walking distance of a health facility.
Community Health Workers (CHWs) have been acknowledged

as a vital component of PHC since the Alma Ata Declaration
in 1978. Forty years later, there is compelling evidence
demonstrating the valuable contribution of CHWs in delivering
basic and essential life-saving health services.
In Zambia CHWs include two main groups namely, Community Health Assistants (CHAs) and Community
Based Volunteers (CBVs). CHAs are formally trained and are part of the civil service while CBVs who are the
majority, work as volunteers.
Currently mobilization, training, and deployment of CBVs has been managed by various health
programmes in a vertical manner. In many cases the mobilization of CBVs has depended on funding from
partner projects in line with various ‘best practice’ ideas introduced by the projects. As a result, community
health services are currently a deeply fragmented space, with several types of volunteers all working in
different vertical programmes and with titles reflecting the ‘best practice’ concept being promoted. The
training for each of these groups of CBVs differs in content, length, and intensity. Selection criteria are not
always clearly stipulated, and there are no standard guidelines for training, working or incentives, which
differ depending on the funder, implementing partner and districts in which the work is implemented. The
net result is that despite the country registering the existence of 90,000 plus CBVs, none of the services
has attained the desired coverage for access. To optimise the contribution made by CBVs to the impact of
the National Health System it will be necessary to standardize trainings and refresher trainings to ensure
quality and access to uniform services.
The Ministry of Health has therefore decided to implement an integrated and harmonised Community
Health Services Package (CHSP). The concept of the Community Health Service Package is that all the
services in the package should be available as an integrated service, rather than being available in
piecemeal or as individual services or only through vertical programs. The CBV will be equipped with
knowledge, skills, Standard Operating Procedures (SOPs), Job Aides, Enablers, and incentives. This
approach is the best model to help Zambia achieve the required equity and adequacy of both quality and
coverage of community health services which will significantly improve the health and wellbeing of the
people in both rural and urban as well as in high or low population density situations.
iii
This guide has been designed to provide facilitators the necessary tools, knowledge and skills required to
train a CBV to provide services in line with the CHSP.
I therefore urge all facilitators to utilize this guide in the designing of training programmes for CBVs and
support the Ministry to optimise outcomes in health for the Zambian population.
Prof. Lackson Kasonka

Permanent Secretary – Technical Services
MINISTRY OF HEALTH
iv
Acknowledgements
The 5th edition of the Community Based Volunteer facilitators

guide has been developed through a consultative and
participatory process that included partners and stakeholders
involved in the implementation of Community Health Services
in the country. The Ministry of Health acknowledges the
contributions, commitment and technical support from all
stakeholders who participated in the face-to-face meetings and
the many virtual meetings that culminated in this guide.
Special thanks go to UNICEF who provided Technical Assistance

and financial support for the development of this Facilitators
Guide. I further wish to thank the consultant, Dr. J. J. Banda and
the line ministries that participated in the development and
validation of this document.
Our gratitude also goes to MoH leadership and Community

Health Unit who provided an enabling environment for the
development of this Facilitators Guide and to the officers from
various MoH Departments, Units, various health facilities,
Community Based Volunteers, and the members of the community for their invaluable contribution
during the writing process.
To all of you, we remain grateful for your unwavering support.
Dr. Patricia Mupeta Bobo
Acting Director Public Health and Research
v
Dedication
This manual is dedicated to all front-line Community Based Volunteers in Zambia.
vi
Chapter 1:
Introduction to the Facilitator’s Guide
What is a facilitator?
A facilitator is a person who helps the participants learn the skills presented in the course. The facilitator
spends much of his time in discussions with participants, either individually or in small groups. In your
assignment to teach this course, YOU are a facilitator. As a facilitator, you need to be familiar with the
material being taught. It is your job to give explanations, do demonstrations, answer questions, conduct
role plays, lead group discussions, and give participants any help they need to successfully complete the
course.
Role of the facilitator
As a facilitator, you do four basic things:
You instruct:
Answer the participant’s questions as they occur.
Explain any information that the participant finds confusing and help him understand the main purpose
of each exercise.
Promptly assess each participant’s work and give correct answers.
Discuss with the participant in order to identify any weaknesses in the participant’s skills or understanding.
Provide additional explanations or practice to improve skills and understanding.
Help the participant to understand how to use skills taught in the course in his own community.
Explain what to do in each session.
Model good skills, including communication skills, during sessions. Give guidance and feedback as needed
during sessions.
You motivate:
Compliment the participant on his correct answers, improvements, or progress.
Make sure that there are no major obstacles to learning (such as too much noise).
You manage:
Plan ahead and obtain all supplies needed each day, so that they are in the classroom. Monitor the progress
of each participant.
You encourage participation:
Encouraging participation of audience by learning and doing is an important quality of a good facilitator.
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How do you do these things?
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. Be available during scheduled times.
Watch the participants as they work and offer individual help if you see a participant looking troubled,
staring into space, not writing answers, or not turning pages. These are clues that the participant may
need help.
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. Always take enough time with each
participant to answer his questions completely (that is, so that both you and the participant are satisfied).
What NOT to do….
During times scheduled for course activities, do not work on other projects, or discuss matters not related
to the course.
In discussions with participants, avoid using facial expressions or making comments that could cause
participants to feel embarrassed.
Do not call on participants one by one as in a traditional classroom, with an awkward silence when a
participant does not know the answer. Instead, ask questions during individual feedback. Give introductory
explanations that are suggested in the Facilitator Guide. If you give too much information too early, it may
confuse participants. Let them read it for themselves in the handbook.
Do not review text paragraph by paragraph. (This is boring and suggests that participants cannot read
for themselves.) As necessary, review the highlights of the text during individual feedback or group
discussions.
Avoid being too much of a showman. Enthusiasm (and keeping the participants awake) is great, but
learning is most important. Keep watching to ensure that participants understand the materials.
Do not be condescending. In other words, do not treat participants as if they are children. They are adults.
Do not talk too much. Encourage the participants to talk.
Do not be shy, nervous, or worried about what to say. This facilitator guide will help you remember what
to say. Just use it!
2
To prepare yourself for each session, you should:
Read the handbook,
Read in this Facilitator Guide all the information provided about the session,
Plan exactly how work will be done and what major points to make,
Collect any necessary supplies for exercises in the session, and prepare for any demonstrations or role
plays,
Think about sections that participants might find difficult and questions they may ask
Plan ways to help with difficult sections and answer questions,
Think about the skills taught and how they can be applied in participants’ own community. Ask participants
questions that will encourage them to think about using the skills in their community. Questions are
suggested in appropriate places in the Facilitator Guide.
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Chapter 2:
Course Design
This training course is designed for community health service providers (community-based organisations,
Non-Governmental Organisations, and community resource persons). The course provides basic health
care knowledge in preventive and promotive, and basic curative activities. The training emphasizes doing,
and not just knowing. During the first day of the course, participants’ knowledge is assessed using a pre-
course questionnaire to determine their individual and group knowledge.
Evaluation
Within three to six months of qualification, its recommended that graduates be observed and evaluated
working in their communities by the health centre trainer or supervisor using a checklist.
Course syllabus
Course Description
This course is designed to prepare participants to acquire the knowledge, skills and attitudes needed
to prevent illnesses, promote good health care practices in the community. The goal of the course is to
provide participants with knowledge and skills needed to prevent illnesses and provide care to patients.
Participant Learning Objectives
(Write on the flip chart the learning objectives)
By the end of this training course, participants will be able to describe:
Organization and Management
· The concept of primary health care in community health services.
· Organisation of women groups such as SMAGS.
· The role of the Neighbourhood Committees (NHC) and Community Based Volunteers (CBV).
· The kinds of communication, and counselling skills.
· Community partnerships and empowerment.
· Community based health information system, and concept of monitoring and evaluation Promotive
Promotive services will include among others;
· Promotion of family planning including provision and distribution of Short-Acting Contraception

like Oral Contraceptive Pills
· Distribution of Condoms.
· Early Pregnant Women Identification and referral for booking, identification of danger signs in
pregnancy through home visits.
· Refer patients with perceived danger signs in pregnancy
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· Sensitise women on danger signs
· Active search of home deliveries and linkage for care and follow up,
· Maternal check-up for danger signs at home,
· New-born check-up for danger signs at home.
· Promotion of early initiation of breastfeeding.
· Promotion of exclusive breastfeeding and promotion of proper and supplementary complementary

feeding.
· Assessment of child development for early detection of developmental delays and disabilities
· Awareness raising to reduce stigma and improve access to social support and care.
· Counselling care givers / caretakers on nurturing care for Early Childhood Development (ECD)
using the four pillars in the ECD counselling cards (Feed the infant/child; Communicate with infant/
child (stimulation);
· Promote security and safety.
· Nutrition, growth monitoring and promotion.
· Provision of psychosocial support to mothers for optimal mental health. Promote Nurturing
care through intersectoral collaboration for holistic child development outcomes. Community
mobilisation,
· Promotion, and parenting education on nurturing care for ECD.
Preventive
Prevention is the cornerstone to disease reduction. At community level such activities are aimed at demand
creation for improvement of essential health services. The areas of Focus for prevention at community
level are;
● Immunizations
● Lost to follow tracing
● Linkage to service
● WASH - access to safe water supply
● Sanitation
● Hygiene promotion and education
● Promotion of Child and Safe motherhood Counselling on Cord Care (during Post Natal Service).
● Counselling and support on Kangaroo Mother Care.
● Counselling on prevention of childhood illnesses such as, Nutrition, upper respiratory tract
infections, diarrhoea, and malaria.
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● Prevention and care of HIV/AIDS, Tuberculosis, Leprosy and STIs
● Prevention and management of emergencies and other illnesses.
● Mental health promotion and substance abuse prevention
Curative
The following are the basic curative services undertaken at community level:
· The concept of integrated management of childhood illnesses (IMCI)
· Diagnosis, and treatment of common childhood illnesses using community IMCI such as malaria,
ARI, and non-bloody diarrhoea.
· Management of Mild to Moderate Acute Malnutrition during home visits.
· Encourage quick referral system for further management for Severe illnesses .
· Diagnosis and treatment of malaria at all ages.
· DOT
· HIV Testing
· Home care of chronic illnesses
· Management of mild conditions like anaemia and malaria during home visits;
Training/Learning Methods
• Lecture
• Demonstration
• Coaching
• Case studies
• Role plays
• Group discussions
Training Materials
The training course of Community Based Volunteers is designed to be used with the following
materials:
• Community Based Volunteer Handbook
• Facilitator’s guide
• Job aids (Community Health Counselling cards and flip chart)
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Participants’ selection criteria
Participants for this course should be volunteers selected by their own community and supported by the
Neighbourhood health committee. The selection criteria are as follows:
• Permanent resident in the Community.
• Mature person (Male or Female).
• Able to read and write in local languages and English.
• Must accept to be a volunteer.
• Must be 18 to 45 years
• Willing to be trained and work closely with the Neighbourhood Health Committee and the Health
facility staff.
• Willing to learn and change.
• Respected by Community.
• Able to interact with others.
• Familiarizes with the local situation.
Course Duration
The course will be conducted for duration of up to six weeks ( this will vary depending on whether the
candidate has attended some other courses like iCCM, Malaria or Safe motherhood training in which case,
the training will be adjusted accordingly)
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Course Schedule for training of CBVs
Afternoon sessions F
Day Morning sessions (08.00-13.00)
(14.00- 17.00) A
Day 1 Registration Communication Skills continued C
Introduction I
Official Opening. L
I
Pre-test
T
Workshop expectations A
T
Course Objectives
O
Roles of CBVs/NHCs
R
Introduction to Primary health care
Day 2 counselling
Communication Skills continued Using the flip chart JEC materials
Day 3 Using IEC materials continued Encouraging patients Levels of Community Participation
to seek further treatment Insider/Outsider knowledge
and importance of listening and
Community Empowerment: valuing
Community Partnership and NHC. the knowledge of the Community
M
Day 4 Social Map Field work E
Social Map Walk E
Day 5 Social Mapping Practice Doing a Social Map T
Doing a Social Mapping in the Community
I
Day 6 Prioritizing and Exploring Health Problems Classroom Practice — Prioritizing
N
Classroom Practice — Prioritizing Health Problems Health Problems: Part 2 Discussion
of activity G
Day 7 Debriefing continued

Field Practice — Prioritizing and Exploring Health Identifying solutions and
Problems in the Community. developing Action Plan.
Exploring Solutions to Health
Debriefing from field practice
Problems in the Classroom: Part I
Day 8 Field Practice — Community discussions to identify Development of the Action Plan
solutions to priority health problems. continued
Development of the Action Plan in the Classroom
8
Day 9 Introduction to Gender Water Sanitation— Water Sources
Identifying Gender issues and needs Safe Water Storage at Household
Gender Analysis
Level
Day 10 Hand Washing Methods Human Waste Disposal continued
Household Pests Control
Hand Washing Times
Management of Household Refuse
Human Waste Disposal
Day 11 Field Practice on Water and Introduction to Nutrition —
Breastfeeding
Sanitation
Discussion of field practice experience
Day 12 Complementary Feeding Growth Monitoring and Promotion
Growth Monitoring and Promotion continued
Day 13 Micronutrients Immunization Schedule
Maternal Nutrition Planning and Conducting
Malnutrition Immunization Sessions in the
Introduction to Immunization Community
Day 14 Field Practice Field Recognition of Target Diseases.
Debriefing
Disease Monitoring and Control
Introduction to Reproduction system,
Reproductive health & Safe Motherhood
Day 15 Ante Natal Care Post abortion care
Labour and Delivery Adolescent health
Women’s health problems Men’s health
Post Natal Care
problems
Family Planning
Day 16 Introduction to Malaria: Causes, Malaria Transmission Malaria
transmission, and Treatment Prevention
Field Practice
Malaria Treatment continued
Referral Procedures
Day 17 Introduction to Diarrhoea How to Refer a Child
Examination of Children with Diarrhoea Prevention of Diarrhoea
Examination of Children with Diarrhoea Prevention of Diarrhoea continued
continued
Home Treatment of Diarrhoea
Day 18 Field Practice: Examining Children with Introduction to Acute Respiratory
Diarrhoea arid identify those requiring
referral to health facilities. Discuss Infections: Cough, Cold and Pneumonia
experience from field practice.
Danger signs of Pneumonia
Measuring Breathing rate
Day 19 Recognizing Chest Indrawing Examining the Sick Child cont.
Recognizing and other Danger Signs Making referrals
Deciding when to refer and when Home Teaching Home Care
Care is enough
Examining the Sick Child
Day 20 Field Practice — Clinical Session Introduction to RIV/AIDS/STD HIV/ADS
Signs and Symptoms of HIV/AIDS
Discussion of Field Experience
9
Day 21 Transmission of HI V/AIDS Signs and Symptoms of TB
Prevention of HIV/AIDS Treatment of TB
Sharing Information about HIV/AIDS and Prevention of TB
STDs with the Community. Introduction
to Tuberculosis (TB)
— Definition and how TB is spread
Day 22 The Role of the CBV in die Worm Infestation and Common
Skin Conditions
Treatment, Prevention and Control of
TB Skin Conditions
Relationship between TB and HIV. Bites
Introduction to Menial Health & Common Accidents
Substance abuse prevention Burns and Scalds
Activities of normal life and meaning of Bleeding
mental health/illness
Management of Mental Patients in the
home and the Community
Introduction to Common Ailments.
Day 23 Poisoning Use of Health Information
Sprain and Dislocations Storage/Retrieval
Fractures Workshop Evaluation
Unconsciousness End of course
Shock
Introduction to monitoring & evaluation
Health Information
Reporting System
Data Collection
Data analysis
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Chapter 3:
Participants Orientation
Learning objectives
Participants and facilitators will work together to create a positive learning climate.
Duration: 45 minutes
Materials required
Flipchart paper, markers
Introduction of Participants
Welcome all participants.
Explain that during this introductory session, participants and trainers will examine the expected outcomes
of this training course and compare them with the expectations of the participants; they will begin to get
to know one another and to build good working relationships; and reach agreement on the working
norms that will be in effect during the training course.
Discuss administrative issues. For example, review and discuss (as needed) the following: · The training
course agenda, including hours, refreshments, and meals.
• Location of toilets.
• Explanation of logistical issues and other administrative issues.
Lead participants in an icebreaker exercise that helps them get to know one another and that helps
establish a positive learning climate. Suggested icebreakers is below
Sample icebreakers
Ask participants to sit in pairs and learn as much as possible about one another (name, community
• he/she is representing, family, hobbies, etc.).
• Give participants 10 minutes to sit in pairs and get to know each other.
Ask each participant to introduce very briefly the person she or he has been with in the last 10
• minutes.
Expected outcomes of the training course and Working norms
Explain that having reached agreement on the administrative issues and the training course outcomes, it
now remains for the participants and facilitators to agree upon and adopt working norms.
Ask participants to suggest working norms they have found useful in ensuring that a training course
proceeds smoothly, and work is accomplished.
Listen to all responses.
Write all responses on the flip chart.
Review the list with the participants when no more suggestions are forthcoming. Assist the group in
finalizing the list and adopting it. (It may be useful to leave the list posted where all can see – for later
reference, as needed.)
Summarise the main points covered in Chapter 3
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CHAPTER 4:
INTRODUCTION TO COMMUNITY BASED VOLUNTEER
TRAINING
This is chapter 1 in participants handbook
Learning objectives
At end of the session participants should be able to describe:
• The major role of CBVs
• Health system and Decentralization
• Health Sector Performance and Disease Burden
Duration:
45 minutes
Materials required
Ask participants to turn to Chapter 1: “Introduction” in the participants’ handbook
Explain that Community Based Volunteers (CBVs) play a major role in accelerating healthy communities,
through treatment of minor illnesses, preventive and promotional measures aimed at reducing diseases
and deaths affecting children, women, and men. The development of this fourth manual brings about
collective integrated health and related issues that CBVs are expected to know and participate to fulfil the
vision of the Health Reforms in the improvement of health for all. The contents of this chapter emphasize
on:
• The understanding of the health system and the decentralization process, as background
information.
• The health system’s performances and the disease burden affecting our population as challenges
for the whole health system including communities.
• Reasons for developing this current fifth edition for CBVs’ manual, and what additional information
is expected to be included to accelerate good health practices at the community level
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SECTION 1: BACKGROUND
Part 1: Health system and Decentralization
Ask one of the participants to read loud part 1in the participants’ manual, “lead a brief discussion
on the vision of health reforms and decentralization”
The government of Republic of Zambia (GRZ) has been implementing Health system aimed at improving
health service delivery since 1992. The reforms, developed by the Ministry of Health, were articulated in
the National Health Policies and Strategies of 1992 (NHPS/92). The vision of these reforms is to “provide the
people of Zambia with equity of access to cost-effective, quality health care as close to the family as possible.”
The underlying principle of these reforms is “decentralization” of health service delivery through the
delegation of key management responsibilities from the centre to the districts and hospitals, and ultimately
to the communities. Decentralization further aims at shifting resources from the centre to operational
levels where health care delivery services are conducted. The reforms also emphasized the importance
of community participation in the management of health services currently enforced by the National
Decentralization Policy of 2003.
Structures created in the process of decentralization were “popular” structures for public involvement and
participation to influence decision making, and the “technical and management” structures. These were
developed to ensure that health services are implemented and managed in a manner that is technically
sound and conform the best practices. The popular structures included: the Ministry of Health at national
level; Hospital Management Boards at hospital level; District Health Boards (DHBs) at district level; and the
Neighbourhood Health Committees and Health Centre Committees at community level. These are aimed
at policy decision-making influences. The technical structures are the management teams at Ministry of
Health (MOH) at national level; Hospital Management Teams (HMTs) at Hospital level; the District Health
Management Teams (DHMTs) at district level; and the Provincial Health Offices for technical support to the
DHMTs and HMTS.
Implementation of the reforms has been through a series of National Health Strategic Plan (NHSPs). The
fourth NHSP for the period 2006- 2011 focuses on a theme, “…. towards attainment of the Millennium
Development Goals (MDGs) and national health priorities….” The theme advocates for “prioritization” of
intervention strategies paying attention to areas that would make significant impact on health delivery
and improve the health status of Zambian.
Health services are provided by the government (public health sector), private and the mission as NGOs,
traditional healers, and volunteers, such as community agents at community level. There are currently
1,124 government health facilities, 88 mission health facilities and 115 private ones. These translate to
a total of 97 hospitals, 1,210 health centres and 20 health posts giving an overall total of 1,327 health
facilities, which are far beyond the reach of emerging health needs for the Zambian population, without
involvement of Community Based Volunteers in the delivery of health services.
PART 2: Health Sector Performance and Disease Burden: A Situation Analysis
Ask another participant to read loud part 2 in the participants’ manual, “lead a brief discussion on
health sector performance and disease burden”
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Despite Zambia’s effort on health development, health sector performance and disease burden has
continued to affect the population. The disease burden is increasing, and health care delivery continues
to be constrained by lack of sufficient human, material, and financial resources. The high disease burden
(malaria, respiratory infections, diarrhoea, eye infections, trauma (accidents, injuries, wounds, and
burns), skin infections, ear, nose and throat infections, intestinal worms, anaemia, cancers, strokes, etc)
is compounded by the high prevalence of HIV/AIDS, high poverty, poor geographic access, especially in
rural areas, and inadequate systematic research in alternation and traditional medicines. As a result, health
services are not fully appreciated by the public.
Performance against the Zambia Millennium Development Goals (MDGs) has been below expectations
(see table 1 below)
Table 1.1: Trend in Selected Impact Indicators
National Indicators Target 1992 1996 2002 2007

• Infant mortality rate per 1000 36 107 109 95 70
• Under 5 mortality (0-4 years) rate per 1000 63 191 197 168 119
• Maternal mortality ratio per 100,000 162 200 649 729 591
• HIV/AIDS prevalence rate (%) * 20 18.0 15.6 14.3
• Malaria incidence rate per 1,000 75 255 * 388 378
• Acute respiratory infection prevalence (percent * 61.7 70.7 69.1 46.6
(%))
• Total fertility rate (TFR: number of live children per
woman) 4 6.5 6.1 5.9 6.2
Source: CSO 1992, 1996, 2002, 2007
The selected impact indicators between periods 1992-2007 has not reached the expected target of health
improvement (see Table 1.1). Infant and child mortality rates (70 per 1000 live births, and 119 per 1000
children) and maternal mortality ratio, i.e., death of women in childbearing ages, are still high (591 per
100,000 live births), compared with the expected target for achievements, even though there are gradual
recipient decline in the indicators, more so malaria and ART (CSO 2007). Most diseases affecting children
and adults are preventable.
Total fertility rate (TFR) has also increased to 6.2 live children per woman, when it should have declined
to meet the target of 4 live children per woman. Failure to reduce fertility has a bearing on morbidity and
mortality consequences of women and children in the country.
The need for concerted efforts through community mobilization and participation are primary care needs
for prevention which must be advocated to all individuals, family members and community.
Infant Mortality Rate (IMR)
Infant mortality rate (IMR) is the probability of dying or death of infants before they reach their first
birthday affects the rural (82 per 1000 live births) more than the urban (80 per 1000 live births), even
though the difference is little. There is also variation in the distribution IMR in provinces, ranging from 64
per 1000 (Central and Southern provinces) to 97 per 1000 live births for Luapula and Western provinces. It
shows that there are more children dying before the first one year of birth in the country.
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Under-Five Mortality
Under five mortality, defined as death of children between 0-4 years (<5mortality) is equally affecting
all provinces, ranging from 103 per 1000 children population for Southern province to 159 per 1000 for
Northern province. The rural are more affected indicating 139 per 1000 than urban with 132 per 1000
children population of this age-group.
Other conditions, such as malaria, acute respiratory infection (ARI), HIV/AIDS also vary and affect all the
provinces. Fertility is more in the rural, with over seven live children per woman than the urban indicating
slightly over four children per woman.
HIV Prevalence Rate
Even though HIV prevalence declined to 14 percent, it is still high affecting the urban area with a rate of
19.7% more than in the rural areas with only 10 percent. This does not necessarily mean that the rural
people are not affected with HIV/AIDS, but it may state that most of the rural people are not aware of their
HIV status compared with the urban ones. Therefore, seeking voluntary HIV counselling and testing (VCT)
is important to determine individual’s HIV status in order to seek medical care in advance including that
of children.
Despite discrete and sustained improvements in most indicators, Zambia is unlikely to meet most of its
MDGs by the target year of 2015. Even though the causes for the low performance against the MDGs could
be many, through the critical shortage of human resources at all levels of the health system, it is the most
important factor alongside lack or weak inter-sectoral collaboration required to address the important
cross-cutting health problems, such as the deteriorating nutritional status affecting many Zambians.
It is for this reason that in order to reverse the trends and improve the health sector’s general performance,
especially those against MDGs, the new National Health Strategic Plan (NHSP) 2006-2011 provides
considerable focus on dealing with the human resources crisis, fostering multi-sectoral response in
the priority areas, such as nutrition, HIV/AIDS, controlling epidemics, health promotion and increased
access to basic environmental health facilities and others that require extensive community resources or
participation.
The Country’s health vision of bringing health services to the individuals ‘as close to the family’ in the
context of primary health care has not yet fulfilled the community health needs and desire.
The health system has put much emphasis on delivery of health services at a health centre level. Yet, the
levels of delivery care within the health system starts at community level upwards to tertiary care system.
Management systems of health delivery care should be provided in the context of ‘primary’ as ‘prevention’
measure (initiated at community level; ‘promotive care’ as
‘secondary care’ (health centre level); and ‘tertiary care’ for advance medical care (at referral hospitals). The
basic entry point of health care for primary care is at community level. Hence, it has become vital to
recognize the integration of child health and maternal health with disease and environmental control in the
community-based health care system for prevention, curative and promotion of health comprehensively
for primary care approach.
15
SECTION 2: JUSTIFICATION: WHY DEVELOPING THE 5TH EDITION HAND-BOOK MANUAL
Explain that the development of this Community Based Volunteers handbook, 5th edition, as a reference
manual is a further recognition of effective community participation as one of the key principles of primary
health care. The vision is to create strong, sustainable partnerships among stakeholders involved in health
service delivery. Partnerships have been established already in each district at all levels of services delivery
points, i.e., at hospital level, health centre and health posts at community level. These partnerships allow
key stakeholders to work together to analyse health problems affecting the population in their respective
areas, identify possible solutions, develop joint work plans, implement, and evaluate progress of their
programmes.
This manual therefore places significant emphasis on families having a responsibility of disease prevention
and health promotion, an essential component of good health practices. Communities, through existing
structures of Community Based Volunteers (CBVs) and the Neighbourhood Health Committees (NHCs), must
therefore understand the necessary principles for organizing the community-based health services. They
should be able to participate in planning, implementation, and monitoring and evaluation of community-
based health care services in their localities. It is in this context that forms proceeding to the development
of this reference manual to empower knowledge of community-based health services among Community
Based Volunteers. This may enhance participation of CBVs to deliver comprehensive community based
curative services and preventive care to promote health of individuals and families in communities. The
development of this manual is not a new concept, but enhancement of contemporary emerging issues for
health promotion at community level as a pivotal point for national health development.
Part 1: Purpose
This manual deals with integration of maternal, new-born care and child health services alongside
health workforce for minimum package of primary health care focusing on the community. It enhances
participation of organizing community-based health service approach for equitable access to cost
effective and quality health care as close to the family as possible. It is aimed principally at the Community
Based Volunteers, but it will also be valuable in the context of staff training and as a guide to the analysis
and evaluation of community-based health services.
The manual is different from the previous fourth edition of 2005 which had focused mainly on the
integration of 16 key family practices with childcare to enhance child survival, growth, and development.
This current fifth edition manual is comprehensive in nature focusing on health care provision for children
and adults in communities. In the context of 16 key family practices for child survival, there were six (6) key
priority practices selected for Zambia which are:
1. Exclusive breastfeeding infants up to six months
2. Providing complementary foods at six (6) months old while breastfeeding up to 2 years.
3. Supplying vitamin, A capsules and de-worming tablets to under-five children and monitoring their
growth.
4. Ensuring that all children complete a full course of immunization as scheduled before the age of
one year.
5. Ensuring that all children are protected against mosquito bites by sleeping under insecticide
treated nets.
6. Providing health education on appropriate home management of sick children and prompt referred
to health facility.
16
The new emerging issues to be incorporated in this fifth edition of Community Based Volunteers’ manual
are focused in the following technical areas for child survival and growth development, and adult health
promotion:
• Malaria case management and use of rapid diagnostic tests (RDTs)
• Pneumonia case management
• HIV/AIDS including paediatric ART
• Home Based Newburn Care
• Diarrhoea management using low osmolarity ORS and zinc
• GMP and Nutrition management
• C-IMCI
• Integrated reproductive health including family planning and adolescent health
• All cross-cutting issues of the Basic Health Care Package of the fourth edition.
The manual has four major purposes:
First, to ensure that CBVs are well empowered with adequate update knowledge and skills in the provision
of community based integrated health services likely to yield positive health impact on child survival,
maternal health, communicable burden diseases and chronic illnesses affecting children and adults of a
minimum essential package of health care. The document is based on sound current scientific evidence
of community health care in the context of primary health care approach and national strategies of health
reforms and policies alongside consultations with various stakeholders.
The training of CBVs should be based on community - oriented and cantered on varied communities.
Therefore, adequate time should be spent on disease prevention and promotion of good health practices
that will be interlinked to other development activities for sustainable community development effort.
Second, ensures provision of community based integrated health services incorporating curative,
preventive care and health promotion to individuals and families.
Third, builds capacity of CBVs in the management of community-based information system and the use of
evidenced based information in decision making for planning purposes, implementation, monitoring and
evaluation of health problems and their performances.
Fourth, enhances community participation and collaboration with partners to achieve common goals of
health promotion and improve health status of people.
As the document is directed to Community Based Volunteers and stakeholders involved in community
health development, it is therefore anticipated that the book will be useful to all Zambian and
institutionalized in the public health sectors, private and NGOs with community health initiatives. It
contains relevant topics pertaining to community care, prevention, and promotion in context of key
family practices for children and adults.
Summarise the main points covered in Chapter 4 by going through the learning objectives.
17
CHAPTER 5:
INTRODUCTION TO PRIMARY HEALTH CARE
This is chapter 2 in participants handbook
Learning objectives
At end of the session participants should be able to:
• Define primary health care (PHC)
• Explain primary health care concept in context of integration
• Explain the importance of PHC
• List and explain the principles of PHC
Duration:
30 minutes
Materials required
The chapter is concerned with providing explanation of understanding the concept of primary health
care, how it was introduced and its importance in promoting community health development through an
integrated approach of service delivery care.
18
SECTION 1: DEFINITION OF PRIMARY HEALTH CARE (PHC)
Primary health care is the provision of integrated and accessible health care services by health providers
who are accountable for addressing a large majority of personal health care needs, developing a sustainable
partnership with patients, and practicing in the context of family and community perspectives.
In other words, it is essential health care based on practical, scientifically sound, and socially acceptable
methods and technology made universally accessible to individuals and families in the community
through their full participation and at a cost that the community and country can afford to maintain at
every stage of their development in the spirit of self-reliance and self-determination.
It forms an integral part of the country’s health system, of which it is the central function and focus, and of
the overall social and economic development of the community.
It is the first level of contact of individuals, the family and community with the national health system
bringing health care as close as possible to where people live and work and constitutes health care process.
Primary health care addresses the main health problems in the community, providing promotive, preventive,
curative and rehabilitative services accordingly.
SECTION 2: PRIMARY HEALTH CARE CONCEPT IN CONTEXT OF INTEGRATION
Since the formulation of the goal of “Health for All by the year 2000”, countries throughout the world
including Zambia have made efforts to strengthen and expand their systems of primary health care.
Part 1: Essential Elements of PHC
The Declaration of Alma-Ata in 1978 identified eight (8) essential elements of primary health care (PHC)
as:
• Education- concerning prevailing health problems and methods of identifying, preventing, and
controlling them. (Explain that unless the community are educated in dealing with health problems
the disease burden will remain a challenge for a long time)
• Promotion of food supply and proper nutrition. (Explain that nutrition plays a major in the children’s
immunity, growth, and development, tell the participants that this topic will be dealt with in detail
later in the course)
• An adequate supply of safe water and basic sanitation (Explain that safe water and good sanitation
also are important health parameters in disease prevention, more details to be covered later in the
course)
• Maternal and child health care including family planning
• Immunization against infectious diseases
• Prevention and control of locally endemic diseases
• Appropriate treatment of common diseases and injuries, and
• Provision of essential drugs.
Part 2: Concept of PHC
Explain that the concept of primary health care emerged from the realization that the curative medical
care system, i.e., the treatment of illness when it occurs, rather than on prevention of diseases. Such a
system relies on complex technology and sophisticated methods which require highly trained personnel
to carry out services. Adding to the system is the cost of services to provide standard of care that can only
be afforded by developed industrial countries.
19
Zambia, like most other countries, has attempted to develop a system of health care for her people.
Expenditure on health for curative medical care each year had increased more than other less developed
countries. However, money could have used to yield better positive effects on health.
Deficiencies show that the existing system of health care places much emphasis on treatment rather than
on prevention of diseases and promotion of good health.
Part 3: Importance of PHC
• It includes integration of curative and preventive services.
• It is the essential health care made universally accessible to individuals and families in the
community by means that are acceptable to them, through their full participation and at a cost
affordable by the community and country.
• It forms an integral part of the country’s health system and overall social and economic development
of the community.
SECTION 4: PRINCIPLES OF PRIMARY HEALTH CARE
Explain that primary health care (PHC) rests on the three fundamental principles or pillars which are:
• Equity of health services for all
• Community participation or involvement, and
• Inter-sectoral coordination
The concept of health for all by the year 2000 was forcefully expressed by the World Health Assembly in
1977. The Alma-Ata Conference endorsed it in 1978 and decided that primary health care should be the
principle means employed to realize health for all. The conference emphasized that this meant appropriate
health care, not second-rate care, which should cover at least the following:
• Education of people concerning prevailing health problems and methods of preventing and
controlling them
• Promotion of food supply and proper nutrition
• Adequate supply of safe water and basic sanitation
• Maternal and child health, including family planning
• Immunization against the major infectious diseases
• Prevention and control of locally endemic diseases
• Appropriate treatment of common diseases and injuries
• Provision of essential drugs
• Initiate community revolving funds
The key Alma-Ata strategies- community participation, intersectoral coordination and selection of affordable
technologies- should be simultaneously applied.
Emphasize that the district health system should bring together community leaders, health team members
and other community-based workers to work for health and development.
20
Part 1: Equity of Health Care
Ask participants to define equity and write a few responses on the flip chart
Definition
Equity means fairness and justice in the distribution of benefits and responsibilities in health care.
Principles of equity
• Equity in health care requires redistribution of resources.
• PHC is particularly concerned with ensuring that essential care is available to all.
• The unit cost of PHC- i.e., the cost per person of a specific intervention- is small
• The multiplying cost of the expansion that will be required to cover under deserved areas call for
significantly increased input from government and community resources.
• The utilization of community resources is therefore important to influence the quality of care.
There should be no allowance of inequities in the amounts of these resources that may influence
quality of care provided.
What are inequities in health care?
Ask participants to define inequities and write a few responses on the flip chart
Definition
Inequity is the unfairness in the distribution of resources in health care.
Inequities are:
• Unfairness occurs if the political and socioeconomic forces encourage distribution of health
resources in the larger cities, leaving rural populations with little organized care or even non in the
communities.
• Unfairness distribution of health care allocation between the rich and poor areas,
• Inequities that exist in health care allocation between certain population groups, and between the
sexes.
Overcoming unfairness
• Distribute resources equally to meet the needs of the poor
• Identify the vulnerable people and be provided with adequate resources to meet their health care
needs.
Part 2: Community Participation
• Community participation is the basic principle of primary health care.
• Close contact between health services and the community is essential and should be a two-way
process.
• Health workers and the services they provide must remain responsive to the perceived and real
needs of the people they serve.
21
• The community must understand the objectives and constraints of health system and seek ways of
making its task easier and increasing its effectiveness.
• Community members: an invaluable health resource for:
- solving socio-cultural and economic problems that are so important to good health
community
- leaders are particularly valuable in mobilizing resources and assisting health workers to
understand needs and take appropriate action.
• In true involvement, the community is influential in areas as:
- Setting of community health priorities
- Dismissal of health staff
- The organization of clinics and services
- Various community organizations and social networks, such as village development

communities, young people’s associations, women’s groups, religious groups, or family
association or clubs serve as strategies for enhancing participation in health.
• The community is the most valuable resource for improving health.
Part 3: Inter-Sectoral Coordination and Literacy
Coordination
The third pillar of primary health care is intersectoral coordination. As health services have grown more
diversified, and awareness of the impact on health of other sectors, such as agriculture and education,
coordination is of vital importance.
Formation of an intersectoral committee which includes representatives of the following sectors and
groups is important:
• Water and sanitation
• Education
• Agriculture
• Transport and communication
• Unions or employee groups
• Religious groups
• Women’s groups
• Social clubs
• Local politicians
• Local employers or merchants
Such intersectoral committee can be formed at community level to suit community needs
Encourage adult literacy:
22
Literacy
Literacy of women deserves special mention because its influence on maternal and child health, primary
health care is important.
Women who are able to read and understand about health and development are open to new ideas for
protecting their own health and that of their families (see Figure 2.1 below).
Figure 2. 1: Adult literacy is a critical part of community health development
As a result, they may change their ways of preparing food, their attitudes towards pregnancy, childbirth
and contraception, and their sanitary practices and working habits.
 Community Based Volunteers may accordingly want to encourage literacy programmes in their
communities.
SECTION 5: PRIMARY HEALTH CARE ELEMENTS OF INTEGRATION
Primary health care includes elements of first-contact care, comprehensive care, coordinated or integrated
care and care that is sustainable rather than ad hoc.
• First contact care – is the extent to which a patient contacts the health provider or a health care
giver whenever that person receives a new need for care.
• Comprehensive care- means that it includes all the health care problems of the individuals.
• Coordination of care – entails a health care provider’s ability to provide for continuity of information
within that provider’s practice setting and to other health care systems in a vertical integrated care.
• Integration of care takes place in several ways, notably “horizontal” and “vertical.”
Horizontal integration aims at linking together and coordinating the broad range of developmental
services, including health, education, agriculture, water supply and sanitation, transport, communication,
and other cross cutting issues. If integration is to be achieved with maximum efficiency and have maximum
impact, the inter-dependence of all these facets of development must be fully recognized.
Vertical integration- is concerned with ensuring the vital linkage between different levels of care, from
the national level down through the district and the health centre levels to the community and individual.
This vertical linkage should be used for: a) Planning and implementing services
23
b) Monitoring impact
c) Keeping health and development systems responsive to, and directed by, the needs of the people.
Summary
Integration in primary health care has both horizontal for coordination purposes and vertical links to
levels of care components. It is widely accepted that the provision of a fully comprehensive health service
requires the efficient integration incorporating horizontal (coordinating range of developmental services)
and vertical (considering levels of health care systems) links of health development.
SECTION 6: IMPLEMENTING THE MINIMUM PACKAGE OF INTEGRATION:
CHILD SURVIVAL, SAFEMOTHERHOOD AND HEALTHY COMMUNITY
It is important to recognize that the minimum package of care can significantly address the Health for All
(HFA) or Millennium development goals (MDGs) of child survival, safe motherhood (maternal health) and
healthy community. Specific interventions that can be required to ensure the achievement of the goals
are illustrated in Figure 2.2 below.
Figure
Figure 2.2:2.2: Specific
Specific Interventions
Interventions for a Minimum
for a Minimum Package
Package in Support
in Support of Child Safe
of Child Survival, Survival, Safe
motherhood,
andmotherhood, and Healthy Community
Healthy Community
CHILD SURVIVAL
Neonatal care, breastfeeding, weaning diets, growth
monitoring, control of diarrhoeal diseases and respiratory
infections, malaria, vitamin A and iodine deficiency etc
MINIMUM
Clinical care
Maternal health
Disease control
Basic immunization
Family planning
Ess.drugs, Health
education, Food
security, Water &
Sanitation
PACKAGE
SAFE MOTHERHOOD HEALTHY COMMUNITY

Maternal risk screening, control of Accidents and violence prevention,
malaria & anaemia, tetanus toxoid Control of alcohol, tobacco-drugs abuse,
immunization, basic obstetric care mental health, adolescent health,
cancer screening, ambulance services, HIV/AIDS &STIs control & prevention,
Pre-natal care, postnatal care, blood Non-communicable disease control,
transfusion food safety, healthy housing
Child Survival:
• Care of the new-born to reduce neonatal mortality i.e., the probability of dying for first one month
of birth (currently at 34 per 1000 live births as per 2007 ZDHS) enhances child survival.
• Promotion of breastfeeding and regulation of breast milk substitutes are important elements for
Child Survival:
growth.
• •Promoting production
Care of the new-born of locally neonatal
to reduce suitablemortality
weaningi.e.,
foods by women’s
the probability groups
of dying for and careful
first one
supervision
month of birth (currently at 34 per 1000 live births as per 2007 ZDHS) enhances childwith
of weaning by participation of Community Based Volunteers in collaboration
trained traditional birth attendants and health staff.
survival.
• Promotion of breastfeeding and regulation of breast milk substitutes are important elements
for growth. 24
• Monitoring of child growth and development by Community Based Volunteers and members
of community health committees in collaboration with women’s organization, health staff and
trained traditional birth attendants.
All these activities promote growth development to lengthen child survival in communities.
Other aspects of controlling diarrhoeal diseases, respiratory infections and paediatric HIV/AIDS are critical
important activities covered under safe-motherhood and integrated management of childhood illnesses
(IMCI).
Control of malaria in the domestic setting through the use of impregnated bed mosquito nets, early
recognition and treatment of fever and malaria using available community based essential drug kits and
prompt action at the health centre.
Prevention and control of vitamin A deficiency and community-based distribution of vitamin A supplement
are possible ways of sustaining child survival and reduction in infant and child mortality rates.
Child survival can be further ensured by day nursery care and school of health to promote health
awareness and the conscious adoption of health promoting behaviours.
Safe motherhood:
Provision of safe maternal health care involves maternal risk screening that every pregnancy would receive
diligent antenatal care with clearly defined risk screening for traditional birth attendants and Community
Based Volunteers as well as health professionals with clear directions for referral.
Community involvement should be provided as an appropriate logistic. Control of malaria and anaemia
using impregnated mosquito bed nets and prophylaxis antimalaria medication during pregnancy
Increasing consumption of vitamins containing foodstuffs can promote maternal health.
Households should be encouraged to initiate vegetables backyard gardening and receive dietary advice-
overcooked green vegetables destroy folic acid- and iron and folic acid supplement tablets to prevent
anaemia. Risk women are evacuated to suitable equipped referral centres.
Healthy Community:
A high priority for sustaining a healthy community should be accident and violence prevention; prevention
of abuse of alcohol, tobacco and drugs can be achieved through well-organized community efforts. In
this context, a mental health and holistic adolescent health components of the community package
emphasizing health awareness and lifestyle issues affecting males and females are important to facilitate
healthy communities.
Other aspects should include healthy housing as shelter required to minimize environmental risks
(e.g., insect vector diseases) and promote comfort and wellbeing (e.g., vision, hearing, and sleep). Food
safety activities can diminish morbidity (diseases) and mortality (death) from diarrhoeal diseases and
intoxications. The disease control component of the community package must emphasize on:
- HIV/AIDS prevention targeting especially the young in school as adolescents with a view to
promoting responsible sexual behaviour (discussed in chapters 15).
Summarise the main points covered in Chapter 5 by going through the learning objectives
25
CHAPTER 6:
ROLE OF COMMUNITY BASED VOLUNTEERS
This is Chapter 3 in the participants handbook
SECTION 1: UNDERSTANDING COMMUNITY HEALTH
This session introduces the participants to the community groups that are the link between the health
facilities and the community.
Learning Objectives
By the end of the session, you will be able to describe:
• The roles of the Neighbourhood Health Committee and Community Based Volunteers.
• The selection criteria of a CBV.
• The functions of a CBV.
• The characteristics of a good CBV and how to motivate and retain them.
Duration: 45 minutes inclusive of discussion and group feedback
Materials:
CBV handbook, flip chart, and markers
Training Methods:
Divide the group into four, assigned one of the following topics to each group, give each group 10 minutes,
then conduct a plenary session of 5 minutes for each group
1. The Neighbourhood Health Committee and Roles of the NHCs
2. Selection of a CBV.
3. Functions of a CBV.
4. Characteristics of a good CBV. Motivation and retention of CBVs.
This chapter outlines the role of Community Based Volunteers, understanding the concepts of community
health, and the definition of community health. It explains further in details the functions of these CBVs,
their characteristics and how they should be selected in communities.
The extent responsibility of the Community Based Volunteers will vary widely according to national
requirements. Trained health staff working at higher levels alongside the neighbourhood health committee
should consider them as their “eyes” and “ears” in the community and seek ways of improving their skill,
understanding and prestige.
26
When health centre staff go into the community to provide mobile health services, it is important for them
to take Community Based Volunteers alongside with them to improve their skills and to benefit from the
information they can provide about specific problems.
For many villagers, Community Based Volunteers represent the first point of contact with the health
care system. In addition to receiving families in need of help, Community Based Volunteers also carry
out regular or special home visits. In caring for the “whole” person or “whole” family, a number of things
besides traditional health problems become important:
• What are the social relationships of the person or the family in the village, at school, with relatives,
or at home?
• What is the family’s financial situation, and are they prepared for unexpected problems?
• What about the family’s housing, water, and sanitation- both the actual facilities and how they are
used by each family member?
• What are the sources of the family’s income and /or food? · Is their income secure?
• Are there disciplinary problems with the children?
All these questions and many more are of direct relevance to a family’s health in the broadest sense and
to the success of its members in following improved health practices. This type of information can be
understood only by someone who personally knows the family fairly well and can regularly spend time
with them as a friend interested in their welfare. This is a role for which Community Based Volunteers are
ideally fitted and one that permits them to identify risk factors before they cause significant problems. A
friendly relationship is also extremely important when helping a family to deal with a problem or change
a health practice.
SECTION 2: DEFINITION OF COMMUNITY BASED VOLUNTEER
WHO IS A COMMUNITY BASED VOLUNTEER?
Ask the participants to define the following terms: community, health, Community Based Volunteer
Reinforce the responses given and summarise by giving the definitions below.
Community
A community is a group of people or families, government agencies, Faith-Based Organizations, Non-

Governmental Organizations, Private Organizations, or Institutions, who work together to improve their
health status.
Health
This is defined as a state of complete physical, mental, social, and spiritual well-being and not merely the
absence of disease, or infirmity (WHO 1990).
Community Based Volunteers
Explain that the Community Based Volunteers are the lowest- level health workers known by a variety of
titles in different countries- primary health workers, peripheral health workers, health aides, village health
agents, community agents and many others- usually in a local language. A Community Based Volunteer
27
(CBV) is a volunteer, selected by the community and trained in certain aspects of health and serves the
same local community. The CBV is accountable to the community and supported by the Neighbourhood
Health Committee (NHC). His/her main functions are the promotive and preventive interventions of health
that are initiated and accepted by the local people.
Community Based Volunteers are volunteers who are selected by the community and trained in certain
aspects of health to serve the same local community.
In countries where they are volunteers may receive some compensation from their community.
Their formal training is usually minimum, and they are chosen because of their respected position or
potential influence in the village.
Depending upon the local situation and their responsibilities, they may be men or women aged between
twenty-five and fifty-five years.
POPULATION COVERAGE FOR A COMMUNITY BASED VOLUNTEER
Explain that one CBV should be able to serve a population of 500 people in a catchment area. In order to
realize the Ministry of Health vision of providing equity access to cost effective quality health care as close
to the family as possible, there is need to train the CBVs who can serve as a link between the community
and the entire health system.
SECTION 3: SELECTION OF COMMUNITY BASED VOLUNTEERS
Ask the participants to explain the selection criteria of the CBV
Summarise with the information given below.
CHOOSE COMMUNITY BASED VOLUNTEERS WHO UNDERSTAND PEOPLE
Selection Criteria of a Community Based Volunteer (CBV)
• Permanent resident in the Community.
• Mature person (Male or Female).
• Able to read and write in local languages and English.
• Must accept to be a volunteer.
• Must be 25 years and above.
• Willing to be trained and work closely with the Neighbourhood Committee and the health facility
staff.
• Willing to learn and change.
• Respected by Community.
• Able to interact with others. · Familiar with the local community.
28
Characteristics of a Good CBV
• Flexible and able to delegate
• Patient
• Honest and trusted
• Approachable
• Advisable
• Good observer
• Knowledgeable
• Ability to facilitate problem solving.
• Willing to learn and interested in family welfare
WHAT MAKES COMMUNITY BASED VOLUNTEERS VALUABLE?
Lead a short discussion on what makes Community Based Volunteers particularly valuable?
Emphasize that what makes Community Based Volunteers particularly valuable is the fact that they
personally know all the families in their area. Because of their knowledge of local circumstances,
Community Based Volunteers are extremely important members of the health team. It is imperative for
the health centre staff and district health staff to understand their role and to lend them full support.
SECTION 4: FUNCTIONS OF A COMMUNITY BASED VOLUNTEER
Ask participants to list the functions of a CBV, write the responses on the flip chart.
Summarise with the information given below:
Explain that when a problem is brought to light, the Community Based Volunteers should know what
resources are needed to deal with it and be able to make them available to the family concerned.
Many of the traditional functions of maternal and child health clinics can be carried out by the community.
These functions include distributing contraceptives or packets of oral re-hydration salts, monitoring
children’s growth, immunizations and illnesses, record keeping, providing health education, and
performing first aid.
a) Broad Functions:
Home visiting- important supplement in health care and it is best for CBVs to have a regular visiting
schedule that families get used to and that ensures that no one is neglected.
Assessing community risk factors or health problems- Community Based Volunteers are an important
source of information on additional needs that are not being met. Communities need to know
what their health problems are and identify solutions to solve them. Participation in community
health problems or needs assessment identification is an important function of CBVs.
29
Collaboration/Networking- Linking with NHCs and Clinic staff is valuable for regular dialogue about
health-related problems and opportunities.
Provision of preventive and treatment of simple illnesses Promoting disease prevention as well as
some management of simple illnesses.
Ensure referral of complicated cases
Collection and maintain a community-based health information.
b) Specific Functions (see Box below)
Specific Functions of a CBV

1. Record keeping of the following: -
(a) Community Register for catchment area, reflecting population by sex and age
group, birth, and deaths.
(b) Client Register on common diseases including outbreaks; promotive/
preventive interventions; stocks and supplies; referrals and patients under
home care.
2. Provide promotive and preventive health and related activities.
3. Community empowerment which includes the following process: -

• Community mobilization for involvement in local, national, and international
health events (such as Disease outbreaks, National Immunization Days, Child
Health Week, World T.B. Day, World Health Day, World AIDS Day and other
commemorations).
• Problem identification that involves identifying disease outbreaks e.g.,
measles, cholera, malaria, scabies, and several others.
• Prioritization and deciding which problems are more important than others.
• Problem solving that involves finding means of local solutions with community
participation and appeal at higher level for assistance where it is necessary.
• Implementation that involves identifying the roles of the community when

implementing the necessary interventions.
• Monitoring and Evaluation of programme implementation in liaison with
health facility staff.
4. Provision of home management of illnesses and identification of referral cases.

5. Distribution of supplies such as condoms and contraceptives.
6. Provide follow-up Care. Carry out home visits of patients with chronic conditions such
as TB, AIDS, high-risk pregnancy/Postnatal mothers, defaulter tracing (malnourished
children, immunization drop-outs, TB patients, etc).
7. Liaise with other community-based agents.
8. Link between the community and the health facility.
30
SECTION 5: ASSESSING COMMUNITY RISK FACTORS
Ask the participants to explain how assessing community risk factors can be done.
A community diagnosis is useful when dealing with a particular problem like a contaminated water supply,
measles outbreak, or increasing malnutrition. The key issues involved should be identified as the focus
for investigation. It is important to write down the results of any community assessment, together with
observations and interpretations so that a record can be kept for the future as well as for immediate action.
Children and pregnant women may have problems which are usually recorded on the under five cards
and ante-natal cards. Community Based Volunteers can use these cards to help identify these problems
(poor nutrition, inadequate immunisation, poor follow up for or HIV exposed or infected children, vitamin
A supplementation, deworming)
SECTION 6: MOTIVATION AND RETENTION OF COMMUNITY HEALTH WORKERS
Ask the participants to mention some ways that can help in motivation and retention of CBVS.
In order to provide an optimal working environment for CBVs, all stakeholders should ensure that:
• CBVs have monthly meetings with Health facility Staff to review achievements, constraints, future
plans and to re-stock, with new supplies.
• Community members provide CBVs with stationery, kits, and identity for recognition.
• Communities provide innovative ways of motivation to support the CBVs.
• CBVs participate in major health events.
Summarise the main points covered in this chapter 6 by going through the learning objectives.
31
CHAPTER 7:
COMMUNITY EMPOWERMENT AND HEALTH
This is chapter 4 in the participants handbook

Learning Objectives
At the end of this unit, the participants will be able to:
1. Explain community empowerment
2. Describe community resources
3. Explain the principles considered in community development
4. Describe the types and composition of partnership
5. Explain the composition & formation of the Neighbourhood Health Committee (NHCs)
6. Explain the roles and functions of the NHCs
7. Explain the Participatory Learning and Action (PLA)
8. Explain Gender and Health

Duration: 5 hours.
Teaching Materials:
- Flip charts
- Flip stand
- Markers
Teaching Methods
- Lecture
- Discussion
Explain that community empowerment in Health is the vehicle for providing cost effective and quality
health care as close to the family as possible. It encourages partnerships and involves communities to
identify their health problems, prioritize them, plan for them, and manage them. This enhances ownership
of health programmes and motivation of community members to ensure continuity of capacity building
in developing community initiatives. The chapter presents the concept of community empowerment and
identifying the various types of partnerships alongside their specific roles. Community empowerment is
therefore characterized by:
• Individual to grow to community: Empowering networks
• Community Development: Helping communities change
• Varied partnerships
• Developing and participation in/of innovative activities, and
• Intellectual skill performance in community development sustainability for good health practices.
32
The concept of empowerment is based on the understanding that if people are prepared for events or
circumstances with both information and community support systems, they can become empowered. They
are able to make their own action.
An Empowered community, members enjoy broad participation in health policies, choosing priorities for
health services and initiatives, and in developing appropriate conditions for living and working.
By participating in decisions that affect daily life members of healthy communities are able to feel they
have some control over their action and sustainability of the community’ current and future potential.
They feel a sense of belonging to one another or in union with others which benefits all members of the
community by making them feel a sense of commitment to one another. This builds bonds of trust, which
help the community develop structures and process to enhance health.
SECTION 1: INDIVIDUAL -TO- GROUP- TO- COMMUNITY:
EMPOWERING NETWORKS
To make decisions for ‘Good health,’ individuals need to feel a sense of control to participate in successful,
collective political and health action for the benefit of the community itself. Neighbourhood groups, for
example, can become empowered by joining forces to improve the conditions of their neighbourhood
e.g., formation of income generating activities (IGAs) through fish farming and chicken rearing. Self-help
groups also create both personal and group empowerment. As part of a self-help group or network,
individuals are able to communicate with people who have had a similar experience and receive advice
on how best to use available opportunities. They may learn that they have access to community resources,
such as:
• Transportation services
• Emergency ambulance services
• Nearest treatment centre/health post
• Supportive environments for social services such as childcare or gender violence victim support units,
and community structures to assist with physical and psychological needs, such as rehabilitation units
and home-based care.
• Personal skills to monitor or evaluate progress and health services that are responsive to needs and
provided at an affordable cost
Explain that describing a community that is empowered includes the psychological empowerment of
individuals and collective political will to effect ‘improvements to health’ or ‘prevention of illness’
Personal and community empowerment thus operate in conjunction with one another to create and
sustain the processes of community development. Once community residents begin to develop common
goals and a more inclusive partnership approach, they have a greater chance of overcoming inequities
and moving forward as ‘a group,’ ‘network’ or ‘community.’
SECTION 2: COMMUNITY DEVELOPMENT: HELPING COMMUNITIES CHANGE
Community development is a ‘continuous striving to help develop the conditions for people to be inclusive,
to share and care.’ The principles considered in community development:
• Ensuring services are empowering that is, applied with dignity and cultural sensitivity.
• Organizational actions should be focused on altering structural conditions to prevent isolation or

self- blame among community members.
33
• Collaborative strategies are employed to help clarify the task and empower the community in terms
of their purpose and vision of the community.
These principles must be embraced in a set of values:
• in the absolute worth of individuals.
• that people are able to learn and change.
• that people can work effectively together to change conditions that may be beyond individual
control.
• that one individual may change one aspect of their life and that this may improve their overall
health.
• that community participation and group process are enhancing in and of themselves.
• that people are genuinely interested in participating in their own health.
One of the challenges of community development is to ensure that health workers do not impose their
agendas on the community. Instead, members of the community should decide what they wish to change;
what services they need to assist to change; and what support mechanisms are required to maintain the
change.
The role of health workers is to provide enough information so that the community will have the skills and
knowledge to plan for improved health outcomes. Another important role is to monitor the extent to which
both government and non-government health organizations actually support community development.
SECTION 3: TYPES AND COMPOSITION OF PARTNERSHIP
Ask the participants to describe the types and composition of partnership
Reinforce the responses given and summarise by giving the descriptions below.
Partners in health are people and groups of people or communities working together to improve the
health of the community. Partners include involvement of all individuals. These are health workers,
community leaders and members, Neighbourhood health committees, other community groups. Other
partners are District Health Management Teams and Boards, other government agencies, churches, non-
governmental organizations, and the private sector.
Health Centre-Community Partnership and the Neighbourhood Health Committee
Partners in health are people and groups working together to improve the health of the community.
Partners include everyone. These are health workers, community leaders and members, Neighbourhood
health committees, other community groups. Other partners are District Health Management Teams and
Boards, other government agencies, churches, nongovernmental organizations, and the private sector.
The Neighbourhood health committee is a group of men and women in the community whose work is
mainly to prevent diseases and promote health in coordination with partners.
Type of Partnerships
Partnerships in each district of Zambia are on three levels:
• District Level Partnerships
• Health Centre Level Partnerships
• Community Level Partnerships
34
COMMUNITY LEVEL PARTNERSHIPS
Neighbourhood Health Committee (NHC)
The Neighbourhood health committee is a community or village health committee composed of a group
of men and women in the community whose work is mainly to prevent diseases and promote health in
coordination with partners. The community leaders and the Health Centre Staff assist communities to form
Neighbourhood Health Committees (NHCs). The Health Centre staff will sensitize the community through
leaders who will call a public meeting where members of NHC, including community health volunteers
are selected by vote. For the NHC, a Chairman, Secretary, Treasurer, and other committee members are
elected. It should be a sub-committee of the community development committee undertaking the
following functions:
Composition & Formation of the Neighbourhood health committee
The Community Based Volunteer and Health Centre staff assists the communities to form Neighbourhood
Health Committees (NHC). A NHC is composed of 5 – 15 members that are selected by the community of
which half of members should female. The NHC should also represent the whole community. It should
include traditional leaders, both women and men representatives from the poorest families and different
cultural groups.
“It can also include representatives from NGOs, Government departments working in the area. NHC should
serve a population of 3,000 people.
• The NHC consists of community representatives and other sectors.
• The Health Centre Committee consists of representatives from NHCs, Health Centre staff and
other sectors.
• The Area Board consists of representatives from Health Centre Staff and other sectors.
The District Board of Management consists of members from the Area Board actually one member of the
District Board will come from the NHC.
Roles and Functions of NHCs
Ask the participants to list the roles and functions of NHCs.
Roles of NHCs.:
• Identify community needs and integrate these into health centre action plans
• Link between community, health centre staff and community-based organizations
• Initiate and participate actively in the health-related activities at household and community level.
• Develop mechanisms for sustainability for community-based health care workers.
• Initiate and strengthen all local development initiatives with other sectors, such as within education,
agriculture, housing, social welfare, etc.
• Identify needs for and support community-based health care volunteers (i.e., CBVs, CBDs and TBAs).
• Collect relevant community-based information
• Involved in the prioritization of community health problems
• Establish strategies to manage, monitor and evaluate community-based activities · Initiate

implementation of community based intervention.
35
• To identify, initiate the training support and supervise the community-based volunteers (e.g., CBVs,
TBAs and CBDs).
• Mobilization and accountability of local resources to implement community-based volunteers (e.g.,

CBVs, TBAs and CBDs).
Mobilization and accountability of local resources to implement community-based interventions.
B. Health Centre Level Partnerships

Health centre level partnership is a community link relationship with the health centre through provision
of technical support. It constitutes health centre committee which spearheads implementation of health
services and activities at the community level.
SECTION 4: COMMUNITY PARTICIPATION
Participation is taking part in community activities. This can be taking many different forms: It can be
either ‘passive’ participation in which little participation is undertaken, or no parting the decision to carry
out activities, or ‘full participation’ involving actual taking part in community activities, making decisions
on what to do and how it can be done to achieve results.
Types of Community Participation

Full community participation
This is the highest level of community participation. In this type of participation, the community
decides what to do and how things will be done. Everyone in the community is allowed to
participate.
Community members implement and oversee the progress of community project s.
The community asks the health centre to staff and other outsider partners for help if it is needed.
Passive Participation
This is lowest level of community participation. In this type of participation, the community just
receives existing services or programmes. The person providing service is usually from outside the
community and is considered an “expert.” The community members are not asked to give their
ideas or opinions but just follow directions.
Participation with labour, Materials or Funding
This is the middle level of community participation. In this type of participation, the community
contributes labour, materials, or money to community programmes in the area. The decision
about what programmes to implement is made by persons from outside of the community. The
community members are asked to help , but do not decide what do or how it should be done.
SECTION 5: IMPORTANCE OF LISTENING AND VALUING THE KNOWLEDGE OF THE COMMUNITY

AND EXTERNAL EXPERTISE
In this section the outsider will be the EXPERT and the insider will be the COMMUNITY MEMBERS. This
is the consideration we shall take. JOHARI’s window may be used to print out the differences between
what experts know (outsiders) and what community members know (insiders). Usually, what experts
know is not what the community knows. What the community knows is not what the experts know. These
differences bring the expert and the community to conflicting ideas. JOHARI’s Widow aims not only to
show the differences between expert and community, but also to show that the community is ‘expert’ in
what it knows about health.
36
Table 4.1: Johari’s window
What Expert and Community both know Expert Knowledge
Community Knowledge What Expert and community both do not know
Table 4.2: Johari’s window - an example of malaria
What experts and community both know Expert knowledge about malaria
about malaria
Treatment of complicated malaria with quinine
• Treatment of malaria with Fansidar
• Causative agent is plasmodia
• Body hotness as a sign of malaria
• Examination of malaria germs under a microscope
Community knowledge What both experts and community do not know about
malaria
• Treatment of malaria with local herbs
To prevent death from malaria
• Various causes of malaria such as
witchcraft, drinking dirty water or • To eradicate malaria - create malaria free environment
being soaked by rain
For an outsider expert to know community belief, attitudes, and practices he or she needs to listen to what
the community is saying and to respect their knowledge and expertise.
Increasing People’s Confidence in their own Abilities
Particularly at community level, people may feel that because ‘they never went to school’ or ‘only got
primary grades’ they can play little or no part in community activities. They may also have difficult in
expressing their opinions, particularly in public. They may find it difficult, at first, to understand people
from outside their own community. They frequently feel that they themselves are not clearly understood
by such people, whether those people belong to their own community or whether they come from
outside the community.
One way of helping people at community level to see that they do have various advantages and capabilities
when it comes to participation in various community activities is to help them realize that:
• They already know a lot about the area, its characteristics, benefits, and disadvantages (for
example, the type of land and its seasons).
• They know how people live, who is related to whom, who holds power and why, how people feel,
what they value most, how they cope with problems, and what they hope for or fear.
• They know what people feel they can do, what they wish to avoid, what they wish to learn, and
how they wish to use what they learn.
Some may already know and be familiar with regular community health activity monitoring, such as
collecting statistics and information, carrying out surveys, writing reports and holding meetings. It is
important to recognize such potential people in the community in order to use them for educating other
community members as well as strengthening community participation in their own community. The
challenge is to find the best ways in which people can be helped to make their own contribution when
participating in community activities.
37
SECTION 6: PARTICIPATORY LEARNING AND ACTION (PLA)
Explain that there are various types of steps involved in PLA presented in section 4 of this part and in
section 5 of the other part.
PLA STEP 1: Mapping
Participatory learning and action (PLA) is a method applied to explore community needs for developing
action and knowing about its structure and geographical location by the participation of community
members. The method is facilitated by the knowledge of ‘social mapping.’
Social Mapping for Creative Learning
What is mapping?
Ask the participants to define mapping, state the advantages of social mapping and the main
features to be included.
Mapping is a structured activity whereby individuals or groups draw or paint graphic representations of the
context in which they are living. This may be a whole village, a section of a town or city, a region of country
or entire country.
Advantages of Social Mapping
They can help to show:
• Geographical features, such as mountains, rivers, forests, deserts, or sea as some situations.
• Physical features, such as the size of a village, neighbourhood or town, the location of houses
by number and type, and the location of public and private buildings, such as schools, local
shops, and clinics.
• Features which affect lifestyle and well-being, such as water sources, livestock, and sanitation
facilities
• Communication networks, such as roads, bridges, paths, and distances to the next population
centre.
• Social structure, for instance, location of leadership (chiefs, headmen, etc), social creation
centres, kinship groupings, neighbourhood boundaries, land boundaries and ownership
• Manpower for development, including the location and number of development agents, such
as agriculturalists, adult educators, teachers, and health workers
• Development features and resources, such as development centres and organizations, stores
for fertilizers and agricultural tools, cooperatives, groups, health centres, health posts and
hospitals.
• Changes with time- These can be recorded, and the map can be regularly updated. For example,
village transformation to an urbanized town
38
Figure 4.2: A Social Map
What is a Social Map?
An example of a map is demonstrated in Figure 4.2 below.
A Social Map
Figure 4.2: A(or community
Social Map map) is a map drawn by the community with help from the CBV
and the NHC. It is drawn by the community What is a members
Social Map?on the ground with natural materials
(sticks, rocks, leaves) arewe used to represent houses, churches, etc. The CBV and NHC may also
A Social Map (or community map) is a map drawn by the community with help from the CBV
develop and
a checklist
the NHC. Itbefore
is drawnand ask
by the the community
community members onto the
include
groundthe withitems
naturalon the list
materials in the map.
(ticks,
Once the map is done, community members onto paper using markers copy it. The community
rocks, leaves) arwe e used to represent houses, churches, etc. The CBV and NHC may also develop
a checklist before and ask the community to include the items on the list in the map. Once the
map shouldmap be keptcommunity
is done, in the community
members onto and displayed
paper in the
using markers copyPrimary Health map
it. The community Care Unit. The map
should
can be used by inthe
be kept theNHC and the
community and CBV forinathe
displayed variety
PrimaryofHealth
purposes such
Care Unit. Theasmap
planning home visits,
can be used
by the NHC and the CBV for a variety of purposes such as planning home visits, locating high risk
locating households.
high risk
households.
A community map
Sample Mapping Checklist

• Main roads and paths
• Houses
Sample Mapping Checklist
• Households with children under five years of age
• Main •roadsHouseholds
and pathswith an under 5 death in the past year
• •
Houses Streams and dambos
• •
Households with
Wells andchildren
boreholesunder five years of age
• Households
• with an under 5 death in the past year
Latrines
• Streams
• and dambos
Health facilities (clinics hospitals)
• Wells• and Markets
boreholesand stores
• Bars and taverns
• Churches
• Key leader locations (traditional headers, TBA, CBV, Chief, Headman, etc.)
44
• Schools
39
Anything else the community thinks is important to include (e.g., fields, cattle kraals etc.)
The community map should be kept in the community and displayed in the primary health care unit.
The map can be used by the NHCs and CBVs for a variety of purposes, such as planning, home visits, and
locating high risk households.
Maps may not be familiar to participants at community level. Lines and figures representing
‘reality’ may be a new idea for them to grasp. If the uses and simple techniques of mapping are introduced
carefully, individuals and groups can be helped to participate in creating maps for their own purposes. It
is helpful to show a real map made by another group, or a photograph of one.
Maps can give participants a clearer and wider view of where they are living. This can help discussion,
analysis, decision-making, planning, management and evaluation of health problems and performances.
People see and understand things about their own environment that may be new to them.
SECTION 7: PRIORITIZING AND IDENTIFYING HEALTH PROBLEMS
PLA STEP 2: Listing, prioritizing and Selecting Health Problems
Purpose of the activity: This activity allows the NHC and CBV to work together to list and prioritize their
health problems and select three to work on first. The process to be followed is called Matrix Ranking.
NOTE: Explain that experience in Zambia has shown that communities often do not list HIV and AIDS as
a problem. Given its seriousness as an underlying factor, if HIV and AIDS is not selected by the community,
facilitate a discussion, and ensure that HIV and AIDS is one of the three problems selected.
Process:
1. Get a large group of community members together. Make sure that those groups which are often
let out of decision-making including women and young people are active members and allowed to
participate.
2. Draw a large matrix (see the diagram below) on the ground with sticks.
3. Ask community members to discuss and decide what they think are the community’s five most
important health problems. Each of the problems the community members decides upon should
then be represented with a symbol (for example, a rock = malaria, a leaf = Diarrhoea, etc.) on the
matrix under “Health Problems”
Note: Check if the Population Health and Nutrition (PHN) issues have been raised; 1– Safe motherhood
(problems related to pregnancy and birth/ Family planning); 2 – Child Health and Nutrition; 3 – Malaria;
4 – HIV and AIDS; 5 – STDs. If not ask the community members if there are problems related to these
issues. Again, Ensure that HIV and AIDS is one of the problems listed.
4. Once the five problems are listed, ask the community to rank which problem is most common in
the community. Ranking of each health problem may be done with small sticks or stones. There
is no set number of sticks or stones that are used. Some communities prefer to set a maximum
number, while others let everyone present put a stick down to indicate their preference. At the end
of the exercise, the problem with the largest amount of sticks or stones is considered to be the most
common; those with the medium amount are medium, while those with few stones or sticks are
least common.
5. Then ask the community to rank which is most serious (those which cause the most illness, death,
or pain), using the same ranking method with sticks or stones as described above.
6. Look at the matrix results and discuss them as a group. Ask the community to pick a total of three
problems they would like to work on in their community first. What are they?
Note: Make sure that HIVandAIDS is one of the three problems selected on the list.
40
7. Copy the final matrix and decisions made onto a piece of paper for safekeeping by the NHC
The following is the matrix that each NHC could use with the community to list, prioritize and select
health problems. It could first be drawn in large scale on the ground, and then once it is completed
transferred to paper. Or if the community prefers, the matrix may be done on a large piece of paper
right from the beginning.
Community Listing, Prioritization and Selection of Health Problem:

Rank in order of
Most Most serious
Health Problems common priority. Select the
problem problem
top three for action
1.
2.
3.
4.
5.
PLA STEP 3: Exploring selected Health Problems and Identifying Solutions
Process
There are two methods that the NHCs and CBVs may use to help the community to explore the 3
health problems they selected. One method is the ‘Group discussion,’ and another is the use of a
‘Problem analysis tree or diagram.’ The NHC and the CBV should do both the focus group discussions
(FGDs). Before you begin, review the Basic Principles for conducting a focus group discussion (FGD)
below:
a) Focus Group Discussion
• A focus group discussion is a group discussion of 6-12 persons guided by a facilitator/

moderator during which members talk freely and spontaneously about a certain topic.
• The purpose is to obtain in-depth information on beliefs, attitudes, and ideas of the groups
towards a particular problem.
• It aims at question- answer interaction.
• It is a useful method of collecting information and exploring health problems that may not
be known, and supplements information on knowledge, beliefs, attitudes, and behaviour
already available.
• Community members are able to learn from each other about a certain topic being
discussed.
• From a small group of 6-12 community members to discuss each of the 3 problems selected.
Again, remember to include those who are often left out of decision-making. Depending
upon the subject matter, the team may decide to divide the focus group into two: a group
of women and another one of men, in order to allow women to speak more freely.
• Decide which of the 3 selected problems is to be discussed first.
• Start by asking questions about that problem (Below is a sample interview guide which may
be used by the NHC and CBVs to guide the discussions).
• A recorder should note down the answers given for the first problem on a piece of paper.
Also note down the nonverbal expressions of members of the group.
41
• Once the questions for the first problem have been answered, then do the same thing for the
second problem.
• Note down the answers given for the second question on a piece of paper.
Basic Principles of Conducting Focus Group Discussion
Preparation:
• Selection of two expert people: one should play a role of a facilitator or moderator,
and another as a recorder to take notes on a piece of paper or use a notebook during
discussion.
• Preparation of a discussion guide- prepare a written list of topics and few questions,
e.g., weaning practices of children below 24 months, family planning methods,
measles of children and so on relevant to community health problems.
• Recruitment of participants- should be the same socio-economic background that

is same age-groups (the young or old people, working or not working) and gender
composition, i.e., men or women to facilitate free discussion.
• Obtain information from different categories- e.g., group of men and group of
women, or young men/women and older men/women.
• Physical arrangement- conducive atmosphere to allow free discussions e.g., under a

tree, classroom, or a small hut
• A small notebook to record notes – useful to the recorder to take notes during
discussion
Conducting An FGD
Facilitator’s Role:
• Introduce the session- Facilitator should introduce the recorder and himself/herself and
participants to introduce themselves by name for acquaintance or rap pour.
• Encourage discussion- ask one question at a time and all participants must participate in giving
in their opinions
• Control rhythm of the discussion- The role of the facilitator is to ask the questions and LISTEN
CAREFULLY to the answers. Make sure that members of the team do not give the answers or
lecture community members if they disagree with a response.
• Move the discussion from topic to topic
• Encourage involvement- take note of those not participating and ask them a question to get
their views. Make sure that everyone has a chance to give their opinion. Do not let one person
dominate. Ask the people who are quite what they are thinking.
• Build rapport and emphasize- observe nonverbal communication or ask yourself what are they
saying?
• Do not use leading questions (questions which imply the answer such as “You do use mosquito
nets, don’t you?). Instead, use open-ended questions (for examples, “What do you do to prevent
malaria in this community?).
• Take time at the end of meeting to summarize, check for agreement and thank the participants.
42
Recorder’s Role:
• Keep record of the content of discussion, emotional reactions, and important aspects of group
interaction.
• Record date, time, place, names, and characteristics of participants
• Provide a general description of the group dynamics- level of participation, presence of a

dominant participant, level of interest and so on.
• Opinion of participants- recorded as much as possible in their ‘own words’ e.g., key statements
• Emotional aspects- e.g., reluctance, strong feelings attached to certain opinions.
• Vocabulary used- i.e., language or tribe used.
Examples of Questions to be Asked about each of the 3 Health Problems.
• What do we think are the main causes or community risk behaviours of this health problem?
• What do we do in this community and in our families to prevent the health problem?
• Which of the prevention methods do we feel is most effective?
• How can we tell when someone is sick from this health problem? What are the symptoms?
• What do most people in our community do first, second and third to treat the person who is sick
or affected with this health problem? What do most people do at home? Is there a traditional
cure?
When is the patient taken to the health centre? What is done there?
b) Flow Chart or Problem Analysis Tree or Diagram
Flow Charts
Flow charts are special types of diagrams that express the logical sequence of actions or decisions.
Problem Analysis Diagram or Problem Tree
A diagram is a figure with ‘boxes’ or ‘circles’ containing reasons or causes of problem and arrows
indicating the links between these stated reasons.
In a focus group discussion on changing weaning practices might provide information on reasons
for early or late weaning that we could satisfactorily summarize in diagrams, for example
43
Problem Analysis Tree or diagram
Form a small group of community members (you can use the same focus group if you prefer).
Make sure that those groups, which are often left out of decision-making including women and
young people, are active.
• Decide which of the health problems to begin with.
• Draw a square or circle in the middle of a large piece of paper and put the name of the
health problem in the middle (i.e., Malaria).
• Start by asking community members what most people in the community think causes
this health problem. As they answer, write all the answers down and draw a line connecting
each one to the central circle. · Once all the responses have been noted then ask, “BUT
WHY?” for each response. This method will lead the community to discover the causal
relationships between things. Write the new answers down and connect them to the
other answers with a line. Continue going back causally until the community group runs
out of responses. Repeat this process on another paper, this time using the second health
problem in the centre.
For example: Why people get malaria? Displaying the Reasons in a problem tree or problem
analysis diagram is:
Cannot Afford MosquitoNets Mosquito Bites
MALARIA
c) Identifying and Selecting Solutions to the Three Health Problems Using Matrix Ranking
of Solutions
Purpose
Explain that this activity empowers the community to discuss and analyse possible solutions to each
of the 3 selected health problems (including HIV/AIDS). These solutions will later be used to develop
the Community Action Plan.
Process
Once the NHC has worked with the community to explore each health problem using Focus Group
discussions and Flow Charts, then the community is asked to freely list the solutions they feel are
appropriate for each of the health problems. Rank them using the following method.
44
Identifying and Selecting Solutions to the Three Health Problems
(Matrix Ranking of Solutions)
1. Get a group of community members together, making sure to include women and
adolescents.
2. Draw a large matrix on the ground or a large piece of paper.
3. Determine which of the 3 health problems will be discussed first.
4. Ask the community to freely list all possible solutions to that health problem.
5. Ask the community to then rank each solution according to which they feel will have the best
results in preventing illness or reducing the number of deaths from the health problem. The
facilitator should assist the community with ranking of solutions according to best results.
6. The NHC and community are now ready to pick the solutions they will implement in the
coming year. For each health problem, the group should pick some solutions that the
community can do without a lot of resources from the outside, and some solutions that are
good but will require help from external partners.
7. Copy the results of the Matrix down on paper.
8. Now do the second problem as you did the first one.
Health Problem and Solution Matrix
What is a matrix?
 A matrix is a chart that looks like a table, but contains words instead of numbers
Health Problem and Solution Matrix: (do one matrix for each health problem)
Health Problem_________________________________________________________________________
Possible Solutions to the health problem Likelihood that each Solution will Prevent
the Problem or Reduce Deaths from the
(freely list all the solutions the group mentions) Problem (high, medium, or low)
 Do one Matrix for each health problem
Step Four: NHCs and Communities explore the three Selected Health Problems and Identify
Solutions
NHCs assist community members to do the next three methods they have learned: 1) Focus Groups, 2)
Flow Charts, and 3) Identifying and selection of solutions to each health problem. This process usually
takes about 1 – 2 days in the community.
45
Step five: Information Sharing and Community Action Plan Development
NHCs meet at the HC to share information and develop Community Action Plans
Sharing Results:
When the community consultation field work is completed, the HC and representatives from
NHCs meet again at the HC to share the results of the community work. Each NHC presents what
their community said about each of the health problems, and what solutions were identified and
selected by the community.
Placing Results within the Context of the Essential Health Package:
At this time, the HC will assist the NHCs to place their priority health problems within the framework
of the Essential Package, using the following categories:
• Integrated Reproductive Health (includes family planning, antenatal care, birthing, postnatal
care, STDs),
• Child Health and Nutrition (includes growth monitoring promotion, immunizations,

childhood illnesses),
• HIV/AIDS and TB
• Malaria,
• Water and Sanitation
Developing Community Action Plans:
• Each NHC draws the Plan format (below) with coloured markers on a large piece of paper.
• Each NHC decides which of the 3 health problems to write up first.
• Under that, the NHC lists the solutions that their community picked for that health problem
and the activities that will take place in order to implement the solution.
• Once the solutions and their related activities are listed, the NHC must go back and list the
resources that will be needed to implement each of these activities.
• For each of the activities, the NHC then needs to identify who will provide them whether it
is the community or a local or district partner (HC, DHMT, NGO, other).
• For each of the activities, the NHC then writes down when it is planned to take place (what
month of the year).
The Plan for each NHC should be based upon the 3 health priorities identified by the communities
(including HIV/AIDS in all communities) and on those solutions and related activities which were selected
by the community as having the greatest chance of preventing or reducing deaths from the health
problems being discussed. Try to think through and detail out the steps to implementation of each of the
activities in the Plan, Including dates will let everyone know which activities will be done when. The HC
will help each of the NHCs develop and write down their Plan. A suggested format for the Plan is provided
in section 6 as follows.
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SECTION 8: HEALTH PROBLEM ANALYSIS, INTERPRETATION AND ACTION PLAN DEVELOPMENT
It is important that the NHCs and HC analyse and note down the resources that will be needed to
implement each of the activities in the plan. For each activity, list the resources and where these will come
from during the year. This is the time that the DHMT and HC commit themselves to certain support for
community-initiated activities. It is at this time when the potential partners external to the community
may be identified to participate in the development of action plan. These potential partners are called to
meet with the NHCs and HCs during HC and district level meeting.
Table 4.3: Community Action Plan
When activity
Solution When Activity will be
Resources Needed Responsible Where resources
and related Will be done completed or
for each Activity person (s) will come from
Activities (timeframe) not completed
(outcome)
e.g.: to a. Spraying: • NHC • Community July 2009 August 2009
prevent • Money Chairman Development
mosquito bite • Mosquito sprays or Treasurer Fund, or
in all • Pumps or
households/ • Staff from clinic/ • MOH District
Activities: local office • CBV (agreed Health Office
• Spray upon by Budget
each house b. Purchase & NHC)
distribution of
• Distribute Mosquito bed nets:
mosquito
Bed-nets • Money
to all • Mosquito bed nets
households
Summarize the main points of the session.
Exercise: Arrange for field practice of PLA steps with the nearby NHC
SECTION 9: GENDER AND HEALTH
Explain that this section provides Community Based Volunteers with the understanding of gender and its
implications on health.
Definition
Ask participants to define gender, gender equality, gender equity and gender roles, write a few
responses on the flip chart
Gender refers to the socially defined roles and responsibilities of men and women, boys, and girls. These
roles and responsibilities are learnt and change overtime.
Gender Equality
Gender equality means equal treatment of women and men in laws and policies, and in access to
resources within families, communities, and society at large.
Gender Equity
Gender equity means fairness and justice in the distribution of benefits and responsibilities between
women and men, and often requires women-specific projects and programmes to end existing inequalities.
47
“…Advancing gender equality, equity, empowering of women and ensuring women’s ability to control their
own fertility are cornerstone of population and development – related programmes.” (ICDP Programme of
Action, Principle 4)
Gender roles
Ask participants to list some examples of gender roles.
Inform participants that gender roles for women and men vary greatly from one culture to another and from
one social group to another within the same culture. Gender roles are constructed by society. They are learnt,
can be interchanged, and be changed over time.
Gender roles are duties given to men and women in a community that are interchangeable. These roles
are learned behaviour in a given society. Gender roles for women and men vary greatly from one culture
to another and from one social group to another within the same culture. Gender roles are constructed by
society. They are learnt, interchanged, and change over time.
Examples:
Men/ Women
 Head of household/Manage kitchen
 Own and inherit property/ Do not inherit property
 Issue instructions/Obey instructions
 Making decision /Is the very last in making decision
 Protect families /Are protected
Ask participants to list biological differences. If gender (sex) for both men and women as in the example
above.
Explain that sex or biological roles cannot be transferred from male to female or vice versa
Ask participants on factors that make women’s health more vulnerable than men.
Women’s Health
Explain that there is concern about women’s health because health opportunities and hazards are not
the same for men and women. Women are biologically different from men. Because of their biological
attributes women suffer from ill health or are more vulnerable to certain disease than men. Certain health
problems are also more prevalent in or unique to women.
Addressing Gender and Health
Communities to design health care activities that encompass the whole life cycle for both men and women.
These activities must ensure reproductive family planning disease Control mental health nutrition and
health are include and reach young girls adolescents and adult women. Involve women in the decision
making of community-based health initiatives. Ensure that men actively take part in providing childcare
and are involved in reproductive health including family planning.
Emphasize the importance of involving men in the advocacy for gender and health and that women
should be involved in the decision making of community-based health initiatives.
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CHAPTER 8:
COMMUNICATION AND COUNSELING
Learning Objectives
At the end of this unit, the participants will be able to:
1. Define communication
2. State 2 reasons why communication is important
3. Explain what communication is.
Duration:
2 hours.
Teaching Materials:
- Flip charts
- Flip stand
- Markers
Teaching Methods
- Lecture
- Discussion
- Role plays
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INTRODUCTION
Explain that this chapter is broadly presented into seven (7) sections. It broadly covers definition and
importance of communication, challenges or problems and barriers of communication, communication
skills, counselling skills and stages health flip chart, encouraging patients to seek further treatment and
care at health centre, and adult literacy.
SECTION 1: DEFINITION AND IMPORTANCE OF COMMUNICATION
Ask participants to define communication
Definition: Communication is the transfer of information from one person or group of people to the other.
Ask participants to explain the importance of communication
Importance of Communication: Communication enables us to share feelings, thoughts and information

as well as learn from each other, to work together towards a common goal.
Emphasize that Effective communication is a meaningful method of conveying information to

achieve results.
Examples of Communication
The usual way people communicate is by talking to each other and listening to what is being said in order
to reach some agreement. In some cases, people just give information to other people without giving
them a chance to reply or give their own views. The speaker cannot know if the people they have been
talking to understand what has been said. Example of communicating by beating drums: Sometimes in
the villages people communicate by beating drums. It means that there is a celebration and beating a
drum in a different tune may convey a message of a funeral. These messages sent through the beating
of drums are received by the people, understood, and acted upon. This kind of communication can give
information to people, but they cannot tell you what they think of the message.
The following groups of people use this way of communication:
• Church Leaders
• Politician
• Chief
• Some teachers
General Tips for Good Communication
Some important tips of communication are:
• Greetings
• Introduce your self
• Act respectively, but with confidence
• Explain why you are visiting or meeting today
• Indicate how long you hope to be together
• Speak in a gentle tone of voice and be clear in your vocabulary
• Ask if there are any questions:
- Answer simply and clear, and check if you have been understood
50
- If you do not have the answer, explain that you will find out and get back with the information next
visit. Misinformation can be dangerous
• Thank the individual or group for the visit or meeting
• Agree when you will return or when the next will happen.
Conduct a role play
Make a role play on Good and Poor Communication. Participants should make comments. Write all the
main points on the flip chart. Hang it on the wall.
Ask one person to beat a drum using a beat that is used to inform people that beer is ready in one village
for a celebration. Ask if the drum passed a message. But if it did not pass a message ask why? Ask what
message was passed.
Role play
Select two participants. Give a slip of paper to each one of them. One should be mother of a child
with diarrhoea who has not breastfed for one day because the baby was refusing to feed. The
mother is convinced the milk has gone sour. The other is a health worker trying to ask the mother
to continue breastfeeding. Let the role play for 5 minutes.
Lead a discussion on what they observed. Did communication take place; if yes why, if not why. Write the
main points on a flip chart. If the group feels communication has not taken place, ask others to repeat the
role play.
Communication can be used to pass information from one person to another or from one person to
community members. Lead a discussion on the drums beating. The usual communication that takes place is
the communication where two people exchange information and reach an agreement. In conclusion discuss
the importance of communication.
Points to bring up
• When communication takes place, people learn from each other.
• People can adjust their activities, putting in consideration what the others said.
• A health worker can persuade the mother to breast feed the baby when they know what made the
mother stop breastfeeding.
SECTION 2: TYPES OF COMMUNICATION
Explain to the participants that as Community Based Volunteers they will have to understand what people
say with words as well as what they say without words. And they will need to be aware of what their bodies
are saying, even when they are not using words.
Ask participants to list down the ways they think communication takes place. List all the suggestions on
the flip chart.
Now ask 3 participants to demonstrate an emotion such as: Angry, Hungry, Sad, or Happy. When this is
done, ask participants what each emotion was. Then ask the same people to act out their emotion again,
but this time talk at the same time.
• Ask participants whether what the role plays depicted happens in normal life.
• Which of these is the most common way of communicating?
• Which one is the most effective?
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Ask two participants to participate in a role play; one to act as a woman with an STD and the other as a
health worker. Give slips of paper to each one of them explaining their roles.
The woman with STD

Ask her to walk in with legs apart looking like in real pain and holding her lower abdomen. When
received by the health worker she sits down and continues to show pain on the face once in and while
there.
When asked what the matter by health worker is the woman says “headache”.
The health worker receives the woman, observes her walk and signs of abdominal pains.
Tries to persuade the patient to explain what is really wrong. The H/W should appear belittling and
unkind.
Practice
The rest of the participants observe. Then divide them in groups of 4 to come up with what they think the
woman was suffering from.
• What made the woman not tell the truth
• What is the behaviour and body language of the Health Worker could have caused the woman to tell
lies.
• Why is it important for you as a CBV to think about what you say without words
Explain that body language is just as important as the use of words in communication. It is important for
the Community Based Volunteer to be aware of body language. They should observe their clients and also
be aware of what they say.
Explain that there are different types of communication. Therefore, it is important to choose the most
effective so that messages can reach the audiences and feedback given. The choices of the kind of
communication will determine whether your messages will be understood and accepted.
a) Verbal:
• Communication can be by talking to each other
• Communication by using Words
• Communicating by using words at a meeting.
• Communicating by using words during a drama performance
b) Non-Verbal:
• Communication without words, posters, picture cord, drawing, brochures, and signs
Tips for Non-verbal communication
• Use signs to communicate: You can use your face, hands, feet, whole body, drawing, etc.
• Use body language to communicate: For example, how you present yourself in front of other
people will communicate something to them.
• Become comfortable with conveying your message through illustrations
52
SECTION 3: BARRIERS OF COMMUNICATION
Explain to the participants that for a person to communicate well, that person need certain skills that will
help others understand what is being said. Say that in this session we will talk about some of the problems
you may face as CBVs in communicating with the other members of the communities, and together you
will identify ways to overcome those problems.
Group work:
Divide the participants into small groups and ask each group to come up with the following:
• What are some of the barriers of communication and how do they make it difficult to communicate.
• What are some of the reasons why a mother may not do what an H/W asked her to do? The group
work takes 15 minutes. After 15 minutes all the group spokespersons make presentations. Ensure
that each group names the barriers of communication. Write the points on flip charts.
When the discussion is over, ask the participants how they can overcome the things that make
communication difficulty. Ask them to be specific in their suggestions, lead a discussion of their
ideas.
Ask participants to turn to page 44 of the Communication chapter of the CBV Handbook about barriers of
communication. Go through the barriers together.
The following are some of the reasons that hinder effective communication:
Language
The language used by a person can make communication difficult. For example, a person who does
not understand a certain language will find it difficult to respond to instruction in that language. Even
when people understand the language and familiar words used, the person listening may fail to get the
meaning of the message.
Overcome this barrier:
• Be clear in your vocabulary
• Know language well.
Age
The age difference between two people can make communication difficult. A young person may find it
difficult to discuss sexual issues with an elderly people.
Overcome barrier by:
Finding someone within the same age group that can convey the meaning.
Social Status
The difference in social status between two people can make communication difficult. If a CBV holds a
meeting with the Chief and his messengers, the messengers may not speak in the presence of the Chief.
Overcome the barrier by:
• Always remain respectful
• Speak through somebody they suggest
53
Gender
Gender difference can be a barrier.
• Men may not listen to women
• Women may feel shy around men

Overcome barrier:
• Remain respectful
• Find somebody of the same sex to speak to the individual
• Ask women questions so that they feel more comfortable to share and ask questions.
Custom and Beliefs
Some beliefs can make communication difficult. For example, if people believe epilepsy cannot be cured
by modem medicine, even if you ask them to take a child with epilepsy to the clinic, they may not go.
Overcome these barriers:
• Explain the relevant advantages and disadvantages about the beliefs or traditions to the topic.
• Continue to sensitize, do not stop, even if they do not want to listen to you. · Stay motivated.
SECTION 4: COMMUNICATION SKILLS
Explain that communication skills are important to make it possible for people to communicate effectively.
Without these skills, messages may not be received and understood. Inform them that they will see a role
play, discuss the outcome, and ways to make sure what they are say is heard and understood. They will also
practice some of those ways.
Effective Communicating Skills Attending
• Greet the other person
• Ensure that the other person comfortably
• Provide privacy
• Ask questions
• Pay close and respectful attention to the other person
Listening
• Listen attentively. Indicate by words, expressions and gestures that careful attention is being
given to what is being said · Praise any good action that the client has achieved
Eye Contact
Use eye contact that is appropriate in your area to indicate interest in what the other person is saying.
Clarity
• Use language that is understood by the other person
• Use the words that are used and familiar to everybody
• Use a clear voice that will be understood by everyone
Keeping confidence
• Keeping what the client has said.
Demonstration
Invite the two participants to come forward and do the role play.
54
Role play
Choose two participants to do a role play. Ask one to be the CBV at home and the other to be
a community member who has come to see the CBV. Ask the CBV to welcome the other. Make him
comfortable. Ask what could be done for him and listen carefully to what the other has to say. Tell the
community member to explain that his child is sick and to ask whether the CBV can help. They can stop
at that point.
When they have finished, thank them for their work. Ask participants to think about what they have just
seen in the role play, and to come up with answers to the following questions:
• Ask the participants of the role play how they performed
• Ask other participants to comment on how the conversation went on in the role play?
• Ask on what they did well?
• Ask what they think could be done better?
SECTION 5: COUNSELING SKILLS AND STAGES
Explain to the participants that as CBVs they will be working closely with community members to help
them understand their problems better and to solve them. Sometimes they will work with groups of
people. But at other times, they will talk with one or two people at a time, and they will need certain skills
to be able to counsel those people well.
Explain that in this session, they will practice skills they need to have to help counsel people effectively.
Counselling is a vital component of the process of educating and motivating individuals, family, or
community to make decisions that affect their health and general wellbeing. It is important that people
are counselled on all aspects of health so that they can have a better understanding of their environment,
their needs, and their capacity to solve their social or health problems and change behaviour. counselling
helps people make decisions and choices that may help solve their problems or make it possible for them
to live with their problems
Do the role play with the volunteer.
Role play
Before beginning the session select on participant to do a counselling role play with you. Tell the
participant that you will be the CBV, and he will be a community member. Ask him to approach you in the
neighbourhood. He greets you to let you know that he has an extremely sick child. You should show that
you are finding a quiet place to talk and then ask questions to guide the conversation through the three
stages of counselling.
Lead a discussion after the role play to help trainees recognize the three stages of counselling; perhaps
starting with questions like the following until all three stages have been identified. Look for the general
meaning of the three stages:
• “What happened first in the role play?
• “What happened next?”

When participants have identified the stages, summarize the three stages of counselling with the following
statement:
“So, from what you have told me, the CBV helped the client describe what the problem was, helped him figure
out possible ways to solve the problem, and helped him make a choice on what to do. They made a plan of
action, and then they agreed on getting together later so that the CBV would be able to know how well the
client was able to solve the problem.”
55
Ask participants to turn to the Communication chapter of the CBV Handbook and describe the three
stages of counselling.
Continue the discussion with the following questions:
• How would their discussion have been different if the CBV had just told the client what to do to
solve the problem? (Possible answers: The CBV’s advice may not have been followed, because there
may be important things the CBV does not know about the client’s problem or about the client’s
situation).
• Why did the CBV ask so many questions? (Possible answers: The CBV asked questions to understand
the client’s problem better and what would make it easier or harder to solve the problem).
Three Stages of counselling (see box below)
1. Stage One — Identify the problem

• Ask questions in a respectful way
• Ask client to explain the problem or problems at hand
• Ask questions about anything that is not clear
• Ask what actions client has taken up to that point
2. Stage Two- Identify a solution
• Ask what the client thinks could be done next
• Ask if there are other possible choices
• Ask questions about each of the choices to help client recognize possible consequences of
each decision made.
• Ask client what choice will be made.
3. Stage Three — Develop a Plan of Action
• Ask client what actions will be taken
• Ask client questions about each action to help develop a strategy · Make an appointment for
follow-up.
SECTION 6: USING THE HEALTH FLIP CHART
Explain to participants that although much of the work of the CBV will be done with individuals and
families, there will also be times when the CBV may wish to talk with groups of people. For example, one
such occasion might be during a Growth Monitoring and Promotion section, while caretakers are waiting
to have their children weighed. Ask the group what topic they would like to discuss. Also use whatever
information is at hand, whether it be a survey or perhaps a report that someone has made in the areas to
identify health issues.
Demonstration
Choosing a topic
Explain to participants on how to choose a topic. If participants need help, you may use the following
questions to help them:
• “How can you find out what the health problems in your area are?”
• “Who could help decide health topics to discuss with different groups of people in the community”
• “How can you know what people would like to discuss” Write their responses on the flip chart.
56
Ask one of the participants to summarize how to choose a health topic.
Show the participants the flip chart. Ask the participants to sit in a circle and join them. Tell them you are
going to demonstrate how to lead a discussion on one of the topics on the flip chart. Do the demonstration,
using the participants as your group. If you wish, consult the guidelines given below.
Guidelines to choosing a topic
1. Ask the group you are talking to what topic they would like to discuss.
2. Use information at hand whether it is a survey, or perhaps a report that someone has made in
the area about common diseases or other health problems to identify topics.
3. Talk and find out what the following think about the main health problems:
4. Clients (people whom the CBV intends to talk to).
5. Headman.
6. Health Centre staff. 7. Neighbours
8. Choose a topic of interest to the people who will participate in the discussion.
9. Make sure that all participants can see the flip chart and hear what is being said.
10. Introduce the topic by explaining why it has been chosen. For example, if immunization rates
were low, that would be a good reason to discuss the importance of immunization.
11. Speak clearly, using language that all can understand.
12. Ask questions listed on the back of the flip chart to lead the discussion.
13. Make everyone in the group participate in the discussion.
14. Keep the discussion short and focused on the topic.
15. Show appreciation for the participation of all members.
16. At the end, ask one of the group members to repeat the main points that have been made.
57
Using the Flip Chart to Lead the Discussions
• If possible, sit with the group to lead the discussion (instead of standing while they sit).
• Make sure that participants can see the flipchart picture and can hear what is being said
• Introduce the topic by explaining why it is important. For example, if immunization rates are low
there, that would be a good reason to discuss the importance of immunization
• Speak clearly, using language and words that all can understand.
• Ask the questions listed on the back of the flipchart to lead the discussion.
• Encourage people to talk. Discussion in the group helps people learn.
• Try to get people who are not talking to speak by asking them what their opinion is Show appreciation
for the participation of all members, even if what they say is not correct. If so, ask others in the group
what they think. If it is necessary to correct something, do it respectfully.
• At the end, ask the group members to repeat the main points that have been made.
• Thank everyone for their participation, even if some did not speak. Perhaps encouragement given
this time will lead them to speak up next time
SECTION 7: ENCOURAGING PATIENTS TO SEEK FURTHER TREATMENTS AND CARE AT THE HEALTH
CENTRE*
Emphasize to participants that encouraging patients seek further treatment from one level of health care
to the other is of utmost importance to both the health care system and to the patient.
If this is done in the most effective way, the patient will receive prompt, efficient and effective care for
their ailment.
On the other hand, if this was not done effectively, the patient may get delayed receiving treatment and
the disease may become more severe, and treatment and care become more difficult.
SUMMARY
A CBV with good communication skills and listens to fellow members of the community will become a
successful facilitator that conveys health messages successfully. If communication problems arise, learn to
overcome them through staying calm and working with others.
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CHAPTER 9:
CHILD HEALTH: (A) THE WELL CHILD
Learning Objectives
At the end of the unit, the learner will be able to:
1. Define the well child
2. Describe the physical assessment of a child
3. List the benefits of good nutrition
4. Explain the breast-feeding techniques
5. Describe the importance of growth monitoring and promotion
6. Describe the importance of immunizations
Duration:
24 hours
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
- Brain storming
Explain that wellness is not merely the absence of illness. A child is not currently seen by parents or
others as sick it does not necessarily man that he is in the best possible health. A well child exhibits many
characteristics, and not merely the absence of an obvious illness. For a child to reach his or her full potential
it is important that he or she is maintained in good mental and physical well-being through adequate
nutrition and care.
Explain further that child health is one of the indicators of the performance of the National Health Care
system. Well Child services are provided up to five (5) years.
Physical Assessment
Every child is assessed from head to toes to check for any signs suggesting illness.
Child health is one of the indicators of the performance of the National Health Care system. Well Child
services are provided up to five (5) years.
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SECTION 1: POLICY STATEMENTS
In Zambia, all health services for children under the age of five years are free
SECTION 2: CONTINUUM OF CARE
Explain the Continuum of care to participants as indicated below:
Interventions at Home and Community
Pregnancy Promote and support Ante Natal care, Information and counselling and self-
care, nutrition, safer sex, Breast feeding, Family planning, Sleeping under
insecticide treated bed nets
Birth and one to two Promote and support skilled care at birth, promote and support key practices
hours after birth e.g.
• Clean delivery
• Social support (companion) during birth
• Early initiation of breast feeding
• new-born thermal care (keeping baby warm)
new-born period • Promote and support key practices
• Exclusive breast feeding
• Thermal care (keeping baby warm)
• Hygiene cord care
• Extra care of low-birth-weight infants
• Prompt care seeking for illnesses
Infant and • Promote key practices e.g.
childhood
• Exclusive breast feeding
• Complementary feeding
• Insecticide treated bed nets
• Water, sanitation, hygiene
• Care seeking for preventive interventions e.g., vaccines
• Care seeking for illness
Community case management of diarrhoea, pneumonia, and malaria
SECTION 3: Immunization
Explain that Zambia has been conducting Immunization services since inception of Expanded Programme
of Immunizations (EPI) in 1975.
What is immunization?
Explain that this is the introduction of dead or weak germs in the body, which then cause a reaction that
protects the body against a given disease. Immunization prevents children from getting certain diseases,
therefore every effort should be made to reach all children in Zambia and be immunized against all
immunizable diseases at the right age.
60
Explain to the participants that an important part of their work as CBVs will be to help people in their
areas/villages recognize the importance of immunizing young children and women of childbearing age.
Therefore, they need to understand and be able to explain how important the protection offered by
immunization is to the children in their areas/villages.
Ask participants whether children in their villages have died from tetanus, whooping cough or TB. Let
participants tell you about those children.
Ask whether those children were given medicine or other treatment when they became ill, and did it help.
State that those diseases are exceedingly difficult to cure, but they are easy to prevent.
Ask what diseases can be prevented by immunization. If most or all participants can read, write the
diseases on flipchart paper as they are mentioned. Then go over the list, crossing out diseases that cannot
be prevented by immunization, so that the following diseases remain.
- Tuberculosis (TB)
- Poliomyelitis
- Neonatal Tetanus
- Diphtheria
- Measles
- Whooping Cough
- Pneumonia
- Meningitis
- Hepatitis B
- Haemophilus influenza type B
Ask the participants to list who should be immunized against these diseases. (Answer: young children
should receive all these vaccines, and women of child-bearing age (15 – 49) and especially pregnant
women, should be immunized against tetanus).
Ask the participants to state why pregnant women should be vaccinated against tetanus.
Explain that this is to protect both the mother and the child from tetanus during childbirth. If the instrument
used to cut the umbilical cord is not absolutely clean, both the mother and child are at risk for getting
tetanus.
Ask why women of childbearing age should be given 5 doses of tetanus.
Although one tetanus shot helps protect a person against tetanus in a short term, it is not enough to give
full protection. A person needs to receive five tetanus injections to be fully protected against tetanus for
life.
Ask the participants whether there are any myths in their area that keep some caretakers away from
attending immunization and antenatal units. Discuss with the participants the number of immunizations
that should be given.
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Table 6.1: Immunizable childhood diseases in Zambia
Type of vaccine that prevents

Diseases Number of doses
disease
TB BCG 1 dose
Poliomyelitis OPV 4 doses before 1 year
Diphtheria DPT - HepB - Hib 3 doses before 1 year

Whooping cough
Tetanus
Severe pneumonia
Severe meningitis
Severe blood infection
Hepatitis B (liver disease)
Measles Measles 1 dose
Neonatal Tetanus TT 5 doses
SECTION 4: RECOGNITION OF TARGET DISEASES
Explain that target diseases are those diseases that can be prevented by immunization. This section helps
the CBV to know the cause, transmission, signs, and symptoms of the target diseases. It also gives the CBV
advice on what do when they have a child with a target illness.
Table 6.2: Target Diseases
Target Signs and

Cause/transmission Advice
disease Symptoms
• Caused by a small • Fever • Report every case of
measles germ. suspected measles to the
• Spread through the • Generalized body health facility.
Measles rash - lasting
air by Urgently refer all suspected
three or more •
measles
days
• infected children • Together with • children who have mouth
breathing out the any of the sores or patches on their eyes.
measles germ. following:
Spread rapidly • If one case is reported there
in large families, o Cough must be a follow up to look
crowded places, for more cases.
hospitals, clinics, o Running nose
markets, homes o Red eyes • No herbal medication should
be put in the eye.
• Encourage the caretaker to
give extra fluids and small
frequent feeds to the child.
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Target disease Cause/Transmission Signs and Symptoms Advice
• Caused by a polio • Sudden weakness • Report all cases of sudden

germ. or paralysis of legs weakness or paralysis to the
• The germ is spread and arms health centre.
Polio through water that has
been contaminated • Refer all cases of sudden
with faeces. weakness
or paralysis to the health
centre.
Target disease Cause/Transmission Signs and Symptoms Advice
• Caused by a diphtheria • Severe sore throat, • Urgently refer the child to the
germ. a swollen throat nearest health facility.
• Spread through air and fever.
Diphtheria by an infected person
who breathes out the
germs.
SECTION 5: IMMUNIZATION GUIDELINES AND SCHEDULE IN ZAMBIA
The national immunization guidelines say that every woman of child-bearing age and every child from
birth to 5 years of age should be immunized against certain diseases. In addition, children of school
going age are required to receive BCG and Tetanus Toxoid. Immunization cards are distributed by health
workers at the health facility. Immunizations are recorded on the immunization and antenatal cards by
health workers. It is important to keep these cards safe so that immunization status of an individual can be
established. A CBV should check the immunization record of every child and woman at every contact and
advise accordingly. The only contraindications are:
• BCG should not be given to a child with AIDS.
• DPT 2 or DPT 3 should not be given to a child who has had convulsions or shock within three days of
the last dose of DPT.
Role Play
Explain that you will play the part of the CBV, and the participants will be a parent looking for advice as to
whether his or her child, who is two months old, needs an immunization.
Role play
Ask the participants to say that the child has already received a shot on the forearm and to point
to the place on the arm where the BCG is given. Ask the participants to then ask you whether the
child needs more immunizations or is that enough. Ask that the child in fact needs several more
immunizations to be truly protected from some extremely dangerous diseases. Add that the child
should be taken to the health facility as soon as possible to receive two important immunizations
against diphtheria, whooping cough, tetanus, hepatitis B, Haemophilus Influenza type B and polio.
End the role play at that point.
Read over the vaccination schedule with the participants
Explain that although they will have their Handbooks to tell them when a child or a woman should be
vaccinated, they may want to memorize the schedules to avoid having to look at them every time they are
asked to give advice on immunization.
Immunization Schedule for Children (see table 6.3)
63
Table 6.3: Immunization Schedule for Children
Number Minimum time

Vaccine Age of Child
of doses between doses
BCG At birth 1 -
OPV 0 (should not be given From birth to 13 1 -
when baby is less than 13 days old) days
OPV 1 6 weeks
OPV 2 10 weeks 3 4 weeks
OPV 3 14 weeks
DPT 1 - HepB - Hib 6 weeks
DPT 2 - HepB - Hib 10 weeks 3 4 weeks
DPT 3 - HepB - Hib 14 weeks
Measles 9 months 1 -
OPV4 is given if OPV 0 was missed 9 months 1 -
Immunization schedule for TT in women of childbearing age (Go to Chapter 12 page 109 in
participant manual)
You should note the following
- Multiple vaccines can be given on the same visit
- If measles vaccine has not already been given, it should be administered whenever the child is
admitted to the hospital to prevent contracting measles from the hospital
- Mass measles immunization campaigns are usually planned for every 4 to 3 years interval when the
susceptible are expected to increase (those that did not sero convert or were not vaccinated)
Target Group for Vaccinations
Explain that target groups eligible for immunizations include:
- Children under 5 years of age
- School age children
- Pregnant women
- Women of childbearing age (15 to 49)
- At risk groups (e.g., travellers)
Contraindication to Immunizations
Explain that there are few absolute contraindications to the EPI vaccines. The risk of delaying an
immunization because of an undercurrent illness is that the child may not return, and opportunities lost.
Generally, all live vaccines should not be given to individuals with immune deficiency diseases or to
individuals who are immune-suppressed due to malignant disease, therapy with immunosuppressant
agent or irradiation. However, all antigens except BCG and yellow fever should not be given to children
with symptomatic HIV and AIDS. Measles and oral poliomyelitis must be given to these children.
64
All the infants should be immunized except in these rare situations:
- Sever reaction is an absolute contraindication to subsequent doses of a vaccine. Persons with a

known allergy to a vaccine component should not be AIDS.
- Do not give BCG or yellow fever vaccine to an infant that exhibits the signs and symptoms of AIDS.
A severe event following a dose of vaccine (reaction, collapse, or shock, none fever fitting) is a true
contraindication to immunization.
Planning and conducting immunization unit in the community
Explain that they as CBVs can play an important role in helping a community prepare for a vaccination unit.
Together with the Neighbourhood Health Committee (NHC), they can work with community members
and health facility staff to arrange vaccination units for the convenience of the community. In addition,
they can assist with various tasks during vaccination units.
Add that during this unit, they will look at some ways that they can work with community members as
well as health facility staff to help ensure that children, mothers and mothers-to-be get all the protection
that immunizations can provide.
Community Mobilization
Explain to the participants that though immunizations are available at health facilities on a daily basis, at
times the health facility staff seeks to organize vaccination units in the communities they serve. They carry
vaccines with them to the communities and give them to the children and women there who need them.
Ask participants how they think that they as CBVs can help their communities get the immunization
protection they need. Ask them to be specific.
Allow group members to write their answers on the flip chart.
If any answers are general or vague, ask participants to be more specific, especially about ways to involve
the community in general, and the NHC in particular, in the planning of immunizations unit.
If no one mentions involving other community-based workers, such as TBAs, CBDs or organizations, such
as churches, schools, NGOs, and women’s groups, mention them and ask how involving them in planning
for and carrying out vaccination activities may be helpful.
It is important to coordinate scheduling with other individuals and groups so that conflicts do not keep
people away from the vaccination unit.
SECTION 6: Promoting the child’s mental and social development
Explain that in order to develop well, children need to be close and feel secure with caretakers. The
caretakers should stimulate them to learn and develop physically, mentally, and emotionally by talking,
playing, and showing love. Showing anger and violence to a child will have a negative effect on the
child’s development. Activities that encourage behavioural change and promote children’s mental and
social development are encouraged. Community leaders, teachers and health workers need to explain to
caretakers the importance of assisting children to develop well mentally, emotionally, and physically. The
following are what caretakers can do:
• Smile and speak to the child
• Cuddle and play with the child
• Maintain eye contact with the child
• Listen to the child and encourage them to respond with words or body movements
• When the child is older, discuss things with them when you talk to them
• Promote the child’s physical development by adequate feeding and health care
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CHAPTER 10:
CHILD HEALTH: (B) THE SICK CHILD
This is Chapter 7 in participant handbook
Learning Objectives
At the end of the unit, the learner will be able to:
1. General assessment of sick children
2. Define a danger sign in a sick child
3. Define difficult breathing in a sick child
4. Describe chest indrawing in a child with cough or difficult breathing
Duration:
24 hours
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
- Brain storming
Explain that childhood illnesses in the community still remain as a major challenge towards child survival,
growth, and development. A CBV who is able to identify an ill child and decide on treatment and when to
refer a sick child within 24 hours of onset of problems, can make a difference in the survival of children in
the community. A child may be brought to the CBV for a particular problem or symptom.
Tell participants that they should record the weight in the child’s record book.
Explain to participants that they should ask the caretaker of the child for the following:
- Name of the child
- Age of the child
- What are the child’s problems
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Section 1: Caring for the Sick Child
Explain that the next thing to do is assessment of the child following the process as indicated below:
OVERVIEW: CARING FOR THE SICK CHILD
O V E R V I E W : C A R IN G FO R TH E S I CK C H I LD IN TH E C O M M UNITY
( c h i ld a g e d 2 m o n t h s u p t o 5 y e a r s )
Identify problems:
Section 1: Caring for the Sick Child ASK and LOOK
If any SI C K If OTHER PROBLEMS or

DANGER SIGN but NO Danger any condition you cannot
Sign manage
REFER CHILD WITH

DANGER SIGN TREAT
URGENTLY TO diarrhoea, fever,

HEALTH and fast breathing
at home and Refer child to
FACILITY
health facility
Begin treatment ADVISE on home
and care
ADVISE caregiver
Ass ist referral
on
immunization
If child
becomes sicker
or does not improve,
Fol low up child
Fol low up child REFER
on return
in 3 days URGENTLY TO
HEALTH
FACILITY
Section 2: Detailed General Assessment of Sick Children

80
Ask participants to define a danger sign.
Reinforce the responses given and summarise by giving the definition below explain the process of
assessment.
Danger signs in ill children
A danger sign is a sign in a sick child that tells you that the child needs urgent care at a health
facility. The CBV must always look for them in every sick child.
List of questions used during assessment of danger signs in a child aged 2 months to 5 years.
Checking for danger signs

ASK LOOK
- Has the child had fits during this illness? - Is the child having fits now?
- Is the child able to drink or breast feed? - Is the child weak? Is the child awake or
deeply asleep or unusually sleep? Are you
- Is the child vomiting everything? able to wake up the child?
- Chest indrawing - Swelling of feet?
- Cough for more than 21 days
- For a child aged 6 months up to 5 years
- Diarrhoea for 14 days or more RED on MUAC tape
- Blood in stool
- Fever for the last 7days or more
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A child with any of the YES answers to the above questions has a danger sign.
Assessment of danger signs in a newborn baby aged up to 2 months.
Checking for general danger signs

ASK LOOK
- Has the baby had fits? - Is the baby having fits now?
- Is the baby looking weak? Is the caretaker able to wake up
the baby? - Is the baby not moving their arms and legs
like a normal baby?
- Count the breaths in one minute; 60 breath per minute or

more is fast breathing
- Repeat the count, if the same then the infant has fast
breathing.
- Look for severe chest indrawing (see the unit on pneumo-
nia)?
- Look and listen for grunting
- Yellow colour of the eyes, palms, or soles
- Look for skin rashes
- Look at the umbilicus. Is it red? Does it have pus?
- Measure the temperature or feel the baby. Is the baby
hot or cold?
A new-born with any of the YES answers to the above questions has a danger sign.
ALWAYS REMEMBER to refer all children with danger signs to the health facility.
Assess Cough or Difficult Breathing
Some children with cough or cold may have pneumonia, and that they will need to be referred urgently
to the health facility. An important part of the CBV’s job will be deciding which children need medical
treatment. Tell participants that they can treat pneumonia at the community using Amoxicillin if
they are trained in Community Case Management
Difficult Breathing
Difficult breathing means any unusual pattern of breathing which mothers may describe in different
ways. For example, they may say that their child’s breathing is “fast,” “noisy” or “interrupted.” There
are 3 signs that indicate the presence of difficult breathing: fast breathing, chest indrawing and
noisy breathing.
Three important signs that can help them decide whether a child has pneumonia and must get medical
attention are the following:
- Fast breathing
- Difficult breathing like chest indrawing
- Harsh noise when breathing
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Assessing for cough or difficult breathing
Signs to look for Classification Decision
- Presence of danger sign or Very Severe Refer urgently to health facility

illness or Severe
- Chest indrawing or Pneumonia
- Harsh or whistling noise when
breathing in or out
Count breath per minute - Fast Pneumonia Treat with Amoxicillin for 5 days. Follow
breathing after 2 days
- No fast breathing Cough or Cold Sooth the throat with safe remedy
i.e., Tea with honey; Tea with lemon
and continue breast feeding Follow up
after 5 days if no improvement
Fast breathing cut-offs
If the infant or child is: Fast breathing is:
Up to 2 months 60 breaths per minute or more
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
Difference between Pneumonia and Cough or Cold
Explain that it is important to recognize fast or difficult breathing, but that just recognizing it is not enough.
In the next session you will learn to measure how quickly a child is breathing, and that measure will tell
whether the child has pneumonia or not.
Measuring breathing rate
CBVs will need to be aware that all children who present with cough or difficult breathing should have
their breathing rate measured. This will help show if they are going into “fast breathing,” which is a sign of
pneumonia. In this session, they will learn how to measure a child’s breathing rate.
Using the timer
The ARI timer is a device used to measure the breathing rate of a sick child. It produces clicking sounds per
each timing second, 30 second it sounds loudly once, at 60 seconds (Indicating end of one (1) minute) it
sounds twice loudly.
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Breathing Rate is the number of breaths in one minute
- Breathing rate must only be counted when the child is calm.
- The best way of counting breathing rate is when it is done for one complete minute.
- In a young infant, fast breathing is 60 breaths per minute or more, counted twice. Only decide
that the breathing rate is faster if it is fast on both counts.
- For children 2 months up to 12 months (1 year), fast breathing is 50 breaths per minute or
more, counted twice.
- For children 1 year up to 5 years, fast breathing is 40 breaths per minute or more.
The breathing rate for young infants is normally faster than for children and adults. Breathing rate must
only be measured when the child is calm and relaxed. If the child is crying, wait until he or she is calm to
measure breathing rate.
Importance of counting breaths per minute
Explain that different people will have different ideas about what is fast breathing and what is not. It is
important to count to be certain. Children when breathing at times the pause and then continue breathing,
that is why it is important to count breaths per minute. (DO NOT count breaths for 15 minutes then
multiply by 4 nor for 30 minutes then multiply by 2)
When to measure breathing rate
Narrate to the participants the following story:
One day a CBV in another district was called to examine a sick child. When the CBV arrived at the
parent’s house, the child was coughing and crying, and its nose was running. The CBV immediately
took out a timer and measured the breathing rate of the crying child. According to what the CBV
had learned about breathing rate, the child had pneumonia! So, the CBV told the parents to take the
child to the health centre right away.
The health centre was far away, and so the parents took some time to prepare for the journey. As
they did, the child calmed down a bit, stopped crying and fell asleep. The CBV decided to measure
the child’s breathing rate again. This time the breathing rate was normal! The CBV repeated the
measure, and again it was normal. The CBV quickly told the parents that a trip to the health centre
was not necessary at that time, and then the CBV gave the parents advice on how to care for that
child at home.
What does this story tell us about when to measure a child’s breathing rate.
Tell the participants that it is important to count the breath rate when the child is calm
Explain that as CBV you should all know the fast breathing cut off rates by heart and they should always
refer to the chart booklet if not sure.
Video (on danger signs and assessing cough or difficult breathing)
70
Exercise: Drill on Fast breathing:
Then practice using the cut-offs for determining fast breathing. Talk through with participants the
following situations:
- What is the cut-off for determining fast breathing in a child 2 months up to 12 months? Answer
(50 breaths per minute or more)
-
What is the cut-off for determining fast breathing in a child 12 months up to 5 years? Answer (40
breaths per minute or more)
-
What is the cut-off for determining fast breathing in a child who is exactly 12 months old?
Answer (40 breaths per minute or more)
Practice using the cut-offs to determine fast breathing by talking through the following situations:
-
What is fast breathing in a child who is:
9 months old? Answer 50

3 years old? Answer 40
4 years old? Answer 40
5 years old? Answer not included in the range “up to”
TREATMENT OF PNEUMONIA
If fast breathing gives a dose of oral antibiotic (amoxicillin tablet—250 mg):
Age 2 months up to 12 months—1/2 tablet 3 times per day for 5 days
Age 12 months up to 5 years—1 tablet 3 times per day for 5 days
Recognizing chest in drawing
Explain that children presenting with cough or difficult breathing should be assessed for chest indrawing,
which is a sign of severe chest infection. In the last session we talked about fast breathing as a sign that a
young infant or child may have pneumonia, in this session you will learn about another sign of pneumonia
– chest indrawing.
Picture 2, a child has chest indrawing. This picture shows a child with chest indrawing, which is a danger
sign in a child aged 2 months to 5 years. In a young infant, chest indrawing is a danger sign only when
it is severe. The chest wall of a young infant is still soft and may be seen to draw in a little during normal
breathing. In the photo on the left, the child is breathing OUT. Chest indrawing is not visible. In the photo
on the right, the child is breathing IN. Chest indrawing is clearly visible. When children have pneumonia,
it is difficult for them to breathe. For that reason, the chest moves in an unusual way when they breathe.
71
The lower chest moves in when the upper chest and abdomen move out.
If it is truly chest indrawing, it happens every time the child breathes, even when the child is calm.
Chest Indrawing
Chest indrawing means that the lower chest wall goes in when the child breathes in. When children have
severe chest infection, they require greater effort to breathe. As a result, the chest wall moves in an unusual
way when they breathe. This unusual way is called “chest indrawing.”
Young Infant Mild chest indrawing in a young infant is normal, because the chest wall is soft. Only
count chest indrawing in the young infant when it is severe and easily seen.
Child
When a child has chest indrawing, the whole area of the lower part of the chest moves in, not only the skin
between the ribs. The inward movement happens when the child breathes in.
When to Check To check for chest indrawing, the child should be calm. For it to be chest indrawing, it
has to be there all the time, even when the child is calm.
Deciding when to refer a child with cough and when home care is enough
Exercise
- What is cough and cold?
Answer: Cough or cold is classification (signs and symptoms) in a child with cough or difficult breathing whose
breath per minute is normal and has no danger sign, no harsh noise nor whistling noise when breathing in or
out and with no chest indrawing
- Do cough and cold need medical treatment? Answer: No
- What is pneumonia?
72
Answer: Pneumonia is an infection of the lung commonly caused by bacteria and viruses (germs). In
Zambia, like in most developing countries, pneumonia is mainly caused by bacteria. When children
develop pneumonia, their lungs become stiff. One of the body’s responses to stiff lungs and hypoxia (too
little oxygen) is fast breathing. When the pneumonia becomes more severe, the lungs become even stiffer.
Chest indrawing may develop. Chest indrawing is a sign of severe pneumonia.
- Can a child with cough and cold develop pneumonia? Answer: Yes
- What is a child with pneumonia to be treated with? Answer: Antibiotic (Amoxicillin)
- What may happen if a child with pneumonia is not treated?
Answer: The Child may die from hypoxia (too little oxygen) or sepsis (generalized infection).
- Who should treat a child with pneumonia? Answer: Health worker or CBV trained in CCM
- For pneumonia assessment, children under 5 years of age are divided into two age groups. What
are those two age groups?
Answer: Age 2 months up to 12 months and Age 12 months up to 5 years
- Can you tell whether a child is seriously ill just by the nature of the cough itself? Answer: No
- What is the breathing cut off for a less than 2 months old? Answer: 60 breath per minute or more
- What is the breathing cut off point for 12 months to 5 years old? Answer: 40 breath per minute or more
- Explain the steps involved in measuring breathing rate using the timer.
Answer: Expose the chest of the child, the child has to be calm, press start/stop button of the timer and start
counting the breath of the child and stop when the timer sounds for the second time twice signifying end of one
minute.
- What is chest indrawing? Answer chest indrawing is when the lower part of the child’s chest is moving in
when the child is breathing in.
- Is chest indrawing serious for both age groups. Answer: Yes
- What are the danger signs that are only serious for the young infant (less than 2 months old)? Answer:
Yellow colour of eyes, palms, or soles; grunting; Baby not moving their arms and legs like normal babies
do when awake (less movements of arms and legs when wake); red umbilicus or pus on the umbilicus,
skin rashes, baby very cold.
- What are the danger signs only serious for children aged 2 months to 5 years old? Answer: blood in
stool, child aged 6 months up to 5 years Red MUAC trap and Oedema of both feet
- What is the danger sign that is serious for both young infants and children? Answer: Fits or convulsions
Exercise:
Clinical practice
Take the participants to the Hospital/ Clinic clinical practice.
Objective: To practice recognizing cough or difficult breathing, measuring breathing rates, and observing
chest indrawing.
Explain that to strengthen their skills in examining children with cough or difficult breathing, CBVs need to
put into practice what they have learnt. In the previous units, CBVs have learnt about recognizing cough or
difficult breathing, measuring breathing rates, and observing chest indrawing. In the clinical practice they
will have an opportunity to practice examining children with cough or difficult breathing
73
This is a practical unit. The following are steps for preparing a clinical unit: - -
Visit training site.
- Select children, about ten.
- Children should include more of those with fast breathing and a few others with no fast
breathing.
If there are any children with chest indrawing, they should be demonstrated to the
participants, but not used for practical because they will be too sick.
ASSESS FOR DIARRHOEA
Explain that children with diarrhoea may die from dehydration and that they will need to be assessed in
order to determine whether to refer urgently to the health facility or not. Add that an important part of the
CBV’s job will be deciding which children need medical treatment. Demonstrate the process as indicated
below:
Two of the following signs: Refer urgent to the Health facility

Lethargic or unconscious - SEVERE
Sunken eyes
DEHYDRATION
- Not able to drink or drinking
poorly
- Skin pinch goes back very slowly
Two of the following signs: Some dehydration Give ORS and Zinc tablet at health
post and observe for 4 hours Plan B,
if no
- Restless, irritable
- Sunken eyes improvement refer to health facility
with caretaker giving frequent sips
- Drinks eagerly, thirsty of ORS on the way.
- Skin pinch goes back slowly.
- Not enough signs to classify as No dehydration Give fluid, zinc supplements and
some or severe - dehydration. food to treat diarrhoea at home
(Plan A).
- Advise caretaker when to return
immediately.
- Follow-up in 5 days if not
improving.
and if diarrhoea 14 If with some dehydration Refer to health facility with caretaker
days or more giving frequent sips of ORS on the
– Severe Persistent way.
Diarrhoea. - Advise the mother to continue
breastfeeding.
If With No Dehydration
– Persistent Diarrhoea
and if blood in Dysentery Refer to health facility
stool
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ASSESS FOR FEVER / MALARIA
Explain that children with fever may be suffering from malaria and that they will need to be assessed and
treated or referred to the health facility. Demonstrate the process as indicated below:

Any danger sign with Fever (Temp Severe illness Refer urgently to health facility
37.5 °c and above) or fever more
than 7 days
Fever (Temp 37.5 °c) DO RDT Malaria treat with an oral anti-malarial
- RDT positive - Give one dose of paracetamol
in clinic for high fever (38.5°C or
above).
If RDT is negative DO NOT give - Refer to the health facility for
antimalarial reassessment
Ask if the child had measles within If the child had mea- Refer to the health facility
the last 3 months? And sles within the last 3
months or
Look for signs of MEASLES
has signs of measles
- Generalized rash and
now
- One of these: cough, runny
nose, or red eyes.
ASSESS FOR EAR PROBLEM
Tell the participants that children with ear problem may develop a complication of severe brain illness;
they will need to be assessed and referred to the health facility. Demonstrate the process as indicated
below:

Any painful swelling behind the ear Ear infection complica- Refer urgently to health facility
tion (Mastoiditis)
Pus seen draining from ear, Acute ear infection Refer to health facility
discharge reported less than 14 days
or ear pain
Pus seen draining from the ear, Chronic ear infection Advise drying the ear by wicking,
discharge reported more than 14 then refer to health facility
days
ASSESS FOR MALNUTRITION
Explain to participants that children with malnutrition may fail to grow and develop as expected hence
they will need to be assessed and treated or referred to the health facility. Under nutrition or poor nutrition
in children less than two years of life is detrimental to the development of the brain during a period when
its development is particularly active. This may result in permanent mental impairment which can affect
the future economic success of the individual. It is for this reason that assessment for malnutrition in ALL
sick children is compulsory.
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Assess for malnutrition as indicated below:
Any other danger sign Severe illness Refer urgently to health facility
Oedema of both feet and for child Severe malnutrition Refer to the health facility
aged 6 moths up to 5 years red on
MUAC strap
Extremely low weight for age or Very Low Weight Give appropriate feeding recommen-
dation and refer for counselling for HIV
Growth faltering Or Growth infection
Faltering
Not very low weight for Not Very If child is less than 2 years old, assess
age and the child’s feeding and counsel the
Low Weight And caretaker on feeding accordingly.
No growth faltering and No
other signs of malnutrition. No Growth If feeding problem, follow-up in 5 days.
• Give routine Vitamin A every 6
Faltering months beginning from 6 months of
age
Note: Visible severe wasting in a child is when s/he is very thin, has reduced subcutaneous fat, and looks
like skin and bones.
To look for visible severe wasting, with permission from the caretaker/mother, remove the child’s clothes.
Look for severe wasting of the muscles of the shoulders, arms, buttocks, and legs. Look to see if the outline
of the child’s ribs is easily seen. Look at the child’s hips. They may look small when you compare them with
the chest and abdomen. Look at the child from the side to see if the fat of the buttocks is missing. When
wasting is extreme, there are many folds of skin on the buttocks and thigh. It looks as if the child is wearing
baggy pants.
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Explain the use of the MUAC trap
The MUAC strap is used as indicated below:
How to use a MUAC strap

1. The child must be age 6 months up to 5
years.
2. Gently outstretch the child’s arm to
straighten it.
3. On the upper arm, find the midpoint between
the shoulder and the elbow.
4. Hold the large end of the strap against the
upper arm at the midpoint.
5. P ut the other end of the strap around the
R ED section: child’s arm. And thread the green end of the
SEVERE strap through the second small slit in the
MA LNUTRITION strap — coming up from below the strap.
6. Pull both ends until the strap fits closely, but
not so tight that it makes folds in the skin.
7. Press the window at the wide end onto the
strap, and note the colour at the marks.
8. The colour indicates the child’s nutritional
status. If the colour is RE D at the two
marks on the strap, the child has SEVERE
MA LNUTRITION.
Thread the green end
of the strap
through the second sli t
Show a Video on MUAC tape
Show a Video on MUAC tape
77
Assess for Anaemia
Assess for Anaemia
Explain to participants that children with Anaemia may fail to grow as expected and may not develop
well mentally; hence they will need to be assessed and referred to the health facility. Anaemia has similar
effects on mental development of the child less two years just like malnutrition.
LOOK for palmar pallor.
Palmar pallor is a sign of anaemia. To see if the child has palmar pallor, look at the skin of the child’s palm.
Hold the child’s palm open by grasping it gently from the side. Do not stretch the fingers backwards. This
may cause pallor by blocking the blood supply.
Compare the colour of the child’s palm with the mother or caretaker’s palm and with the palms of other
children. If the skin of the child’s palm is pale, but has some pink areas, the child has SOME PALMAR
PALLOR. If the skin of the palm is very pale or so pale that it looks white, the child has SEVERE PALMAR
PALLOR.
Look for palmar pallor Severe Anaemia Refer urgently to health facility
(white appearance of palm).
Is it:
- Severe palmar pallor?
- Some palmar pallor? Anaemia Refer health facility
How to hold the child’s hand when looking for palmar pallor.
78
Assess for HIV and AIDS
Explain that children with HIV and AIDS may fail to grow as expected; hence they will need to be assessed
and referred to the health facility for possible enrolment on ART. Emphasize that all sick children must be
assessed for HIV and AIDS
If the child has no danger signs proceed as Possible HIV Refer to health facility
follows:
Infection/HIV
Does the child have one or more of the following
conditions: Exposed
- Pneumonia now
- Persistent Diarrhoea now
- Chronic ear infection now - Very low
weight for age OR growth faltering OR
history of loss of weight
ASSESS CHILD FOR IMMUNIZATIONS, VITAMIN A AND DEWORMING
Tell participants that they should check on the under-five card if present and encourage the mother/
caretaker to take the child for immunizations or vitamin A or deworming if due.
79
The General assessment of a sick child can be summarized on the sick child recording form as indicated
below:
Sick Child Recording Form

(for community-based treatment of child aged 2 months up to 5 years)
Date: _____/_____/20____ CBV: ____________________
(Day / Month / Year)
Child’s name: First ______________________ Family ___________ Age: __Years/__Months Boy / Girl
Caregiver’s name: ___________________ Relationship: Mother / Father / Other: _______________
Address, Community: ___________________________________________________________________
1. Identify problems
Any DANGER SIGN or other

problem to refer? SICK but NO Dan-
ASK and LOOK
ger Sign?
ASK: What are the child’s problems? If not reported, then ask to be
sure.
YES, sign present Tick  NO sign  Circle 
 Cough for 21 days or more

  Cough? If yes, for how long? __ days
  Diarrhoea (3 or more loose stools in 24 hrs)? IF YES, for how  Diarrhoea for 14 days or  Diarrhoea
long? ____days. more (less than 14
days AND
  Blood in stool no blood in
 IF DIARRHOEA, blood in stool? stool)
  Fever (reported or now)?  Fever for last 7 days or  Fever (less
more than 7 days)
If yes, started ____ days ago. in a malaria
area
  Convulsions?  Convulsions
  Difficulty drinking or feeding?  Not able to drink or feed
anything
IF YES, not able to drink or feed anything? 
  Vomiting? If yes, vomits everything?    Vomits everything
  Any other problem I cannot treat (for example, problem breast  Other problem to refer:
feeding, injury, burn)?
See 5 If any OTHER PROBLEMS, refer.
LOOK:
  Chest indrawing? (FOR ALL CHILDREN)  Chest indrawing
IF COUGH, count breaths in 1 minute: _______
breaths per minute (bpm)  Fast breathing:
Age 2 months up to 12 months: 50 bpm or more
 Fast breathing
 Age 12 months up to 5 years: 40 bpm or more
 Unusually sleepy or
  Unusually sleepy or unconscious? unconscious
For child 6 months up to 5 years, MUAC strap colour: ______  Red on MUAC strap
 Swelling of both
  Swelling of both feet?
feet
80
2. Decide: Refer or treat child
(tick decision)
3. Refer or treat child

(tick treatments given
and other actions)
If any danger sign, If no danger sign,
REFER URGENTLY to health facility: TREAT at home and ADVISE on home care:
ASSIST REFERRAL to health facility:  If Diarrhoea Give ORS. Help caregiver give
Explain why child needs to go to health child ORS solution in front of you
facility. (less than 14 days until child is no longer thirsty.
FOR SICK CHILD WHO CAN DRINK, BEGIN AND no blood in Give caregiver 2 ORS packets to
TREATMENT: stool) take home. Advise to give as much
as child wants, but at least 1/2 cup
ORS solution after each loose stool.
Give zinc supplement. Give 1
 If Diarrhoea  Begin giving ORS dose daily for 14 days:
solution right away. Age 2 months up to 6 months
1/2 tablet (total 7 tabs)
Age 6 months up to 5 years—1

tablet (total 14 tabs)
Help caregiver to give first dose

now.
 If Chest  Give first dose  If Fever Do a rapid diagnostic test (RDT).
indrawing, of oral antibiotic
or (amoxycillin (less than 7 days) __Positive __Negative
tablet—250 mg)
 Fast  Age 2 months up If RDT is positive, give oral
breathing to12 months 1/2 antimalarial (co-Artem).
and danger tablet
sign Age 2 months up to 3 years—1
 Age 12 months up to tablet (total 6 tabs)
Age 3 years up to 5 years—2
5 years—1 tablets tablets (total 12 tabs)
 fever and Help caregiver give first dose now,
danger  Quickly do a rapid and 2nd dose after 8 hours. Then
sign diagnostic test give dose twice daily for 2 more
(RDT). days.
__Positive Advise caregiver on use of an
ITN.
__Negative
 If RDT is positive,
give stat dose of oral
antimalarial –
81
Coartem if the child is  For ALL
able to take orally.
children
 Age 2 months up to 3 treated at
years—1 tablet home, advise
on home care
 Age 3 years up to 5
years—2 tablets
 For any sick child who can drink,  If Fast  Give oral antibiotic (amoxicillin
advise to give fluids, and continue breathing tablet—250 mg).
feeding. Give three times daily for 5 days:
 Age 2 months up to 12 months
 Advise to keep child warm if child is
1/2 tablet (total 5 tabs)
NOT hot with fever.
 Write a referral note.  Age 12 months up to 5 years—1
tablets (total 15 tabs)
 Arrange transportation and help solve Help caregiver give first dose
other difficulties in referral. now.
OR
amoxycillin syrup—125 mg per 5
 FOLLOW UP child on return at least once mls).
a week until child is well. Give twice daily for 5 days:
 Age 2 months up to 12 months—
7.5mls
 Age 12 months up to 5
years—15mls Help caregiver
give first dose now.
OR
amoxycillin tablet—125 mg
dispersible tablets).
Give twice daily for 5 days:
 Age 2 months up to 12
months—1 1/2 tablet (total 15
tabs)
 Age 12 months up to 5 years—3
tablets (total 30 tabs)
Help caregiver give first dose
now.
 Advise
caregiver to
give more fluids
and continue
feeding.
 Advise on
when to
return. Go to
nearest health
facility or, if not
possible, return
immediately if
child
 Cannot drink or
feed
 Becomes sicker
 Develops a fever
(for a child that
did not have a
fever)
 Develops blood
in the stool (for
a child that has
diarrhoea)
 Follow up
child in 3 days
(schedule
appointment in
item 6 below).
82
4. CHECK VACCINES RECEIVED
(tick  vaccines completed,
circle  vaccines missed)
Age Vaccine  Advise caregiver,

Birth  BCG  OPV-0 if needed:
 DPT—Hib - HepB 1 WHEN is the next

6 weeks*  OPV-1 vaccine to be given?
10 weeks*  DPT—Hib - HepB 2 WHERE?
 OPV-2
14 weeks*  DPT—Hib - HepB 3  OPV-3
[Give OPV-4, if
9 months  Measles OPV-0 not given at
birth]
5. If any OTHER PROBLEM or condition I cannot treat, refer child to health facility, write
referral note. (If diarrhoea, give ORS. Do not give antibiotic or antimalarial.)
Describe problem: _________________________________________________________________
6. When to return for FOLLOW UP (circle): Monday Tuesday Wednesday Thursday Friday Weekend
7. Note on follow up:  Child better—continue to treat at home. Day of next follow up: _________.
o Child is not better—refer URGENTLY to health facility.
o Child has danger sign—refer URGENTLY to health facility.
Sick young infant age up to 2 months
For any sick young infant age up to 2 months: refer URGENTLY to the health centre
For the young infant who is well:
Advise the caretaker on how to care for the young infant:
EXCLUSIVELY BREAST FEED up to 6 months of age
• Give only breastfeeds or replacement feeds to the young infant
• Feed frequently, as often and for as long as the infant wants, day or Night
MAKE SURE THAT THE INFANT STAYS WARM AT ALL TIMES
• In cool weather cover the infants head and feet and dress the infant with extra clothing
ADVICE ON CORD CARE
CHECK THE INFANT’S IMMUNISATION STATUS
• Birth: BCG OPV0
• 6 weeks: OPV1 DPT-Hib-Hep B 1
83
CHAPTER 11:
PAEDIATRIC HIV AND AIDS
Learning objectives
At the end of the unit, the participants will be able to:
1 Define HIV and AIDS
2 Describe signs and symptoms of HIV and AIDS in children
3 Explain how HIV is transmitted from a mother to the child
4 Explain
5 Discuss
Duration:
45 minutes
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
84
SECTION 1: WHAT IS HIV/AIDS?
Divide the participants into 3 groups. Ask each group to define HIV and AIDS; discuss risk sexual behaviours
found in the communities and explain the impact AIDS on the individual, family, and community. Let
them get back to plenary and make group presentation on their responses to the assignment.
Definition of HIV/AIDS
- HIV stands for Human Immuno-deficiency Virus.
- AIDS stands for Acquired Immune Deficiency Syndrome and is caused by HIV. Think of AIDS
as advanced HIV disease. A person with AIDS has an immune system so weakened by HIV that
the person usually becomes sick from one of several opportunistic infections or cancers such
as PCP (a type of pneumonia) or KS (Kaposi sarcoma), wasting syndrome (involuntary weight
loss), memory impairment, or tuberculosis.
Explain that they need to read the notes about the facts on HIV/AIDS.
Explain that HIV stands for Human Immuno-deficiency Virus. It is virus that can get into the body through
contact with blood or body fluids from an infected person. Body fluids containing HIV include blood (as
well as menstrual blood), semen, vaginal secretions, and breast milk. HIV makes it difficult for the body
to fight other diseases by weakening the immune defence system. This in turn leads to development of
Acquired Immune Deficiency Syndrome (AIDS).
When an individual becomes infected with HIV, that person becomes “HIV positive” and will always be HIV
positive. Over time, HIV disease infects and kills white blood cells called CD4 lymphocytes (or “T cells”); and
make the body unable to fight off certain kinds of infections and cancers.
SECTION 2: SIGNS AND SYMPTOMS OF HIV AND AIDS IN CHILDREN
Divide the participants into small groups and give each group a piece of paper. Ask each group to list all
the signs and symptoms of HIV/AIDS that the can think of.
Then call participants together into plenary and present their lists. Discuss the responses. Then refer to the
notes and compare. Cancel out what does not appear in the notes.
Suspected Symptomatic HIV/AIDS in a child
Now explain to the participants how one can identify a child with suspected symptomatic HIV infection
using the signs and symptoms listed below. A child who has four or more of the following signs and
symptoms must be referred to the health facility for assessment for Suspected Symptomatic HIV Infection.
The child’s caretaker will get counselling and be offered an HIV test. The test will only be done if the
caretaker agrees:
· Repeated coughs
· Repeated attacks of diarrhoea
· Pus in the ear which lasts more than 14 days
· A child who is very low weight for age or has growth faltering or the caretaker says that the child
has lost weight
· The presence of white patches in the mouth
· Swellings in the neck, arm pit and groin
· Swellings below the ears (they lo ok like mumps) for 14 days or more
85
Summary
Wrap up by saying that, although it is important to know these signs and symptoms of HIV/AIDS, it is
equally good to remember that having any one or more of them do not always mean that a child has HIV/
AIDS. The only way to be sure is to have a special test for HIV.
SECTION 3: HOW HIV IS TRANSMITTED FROM A MOTHER TO THE CHILD
Divide participants into 3 groups and let them come up with ways of how HIV is transmitted
from mother to child. After 10 minutes, reconvene the group for plenary session. Summarise the
presentation as indicated below.
Explain that HIV transmission from mothers to babies occurs during pregnancy, at the time of labour and
delivery, and postnatal through breastfeeding. Out of 100 babies born to HIV-positive mothers:
• About 63 may not be infected with HIV.
• About 7 may be infected during pregnancy.
• About 15 may be infected during labour and delivery.
• About 15 may be infected through breastfeeding
During Pregnancy
Tell the participants that the virus can pass from an infected mother to her unborn baby during pregnancy.
Conditions that increase risks of a mother and her baby becoming HIV positive include:
• Having multiple sexual partners puts the pregnant woman at risk of contracting HIV.
• Becoming HIV positive during pregnancy
• Poor diet weakens her blood and immune system which may in turn expose the pregnant woman
to infection.
During labour and delivery
Explain that during this time, infection is passed on to the baby through direct contact between the
mother’s blood or vaginal fluids and the baby’s blood due to:
• Delayed and prolonged labour increases the chance of exposure to other infections which may
give way to HIV.
• Tears and cuts of the birth canal may cause the mother’s infected blood to mix with that of the baby.
• Risky home deliveries are likely to expose the mother to tears. · Too many vaginal examinations
done by unskilled birth attendants.
86
During breastfeeding
Explain that infection can also be passed on to a baby through breastfeeding if the mother is HIV positive
through:
• Breast milk.
• Poor breastfeeding methods that bring about cracked nipples which may bleed during
breastfeeding.
• Irregular feeding can cause swelling of breasts; and swollen breasts can leak infection into the
breast milk
• Poor antenatal care for early detection of sexually transmitted diseases may expose the pregnant
woman to greater risk of HIV.
SECTION 4: PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV (PMTCT)
Ask participants to mention ways of prevention of mother to child transmission of HIV. Summarise
with the information given below.
HIV counselling and Testing
Explain that women and their partners should know if they have HIV by going for voluntary counselling
and testing (VCT). Couple counselling must be encouraged to empower the couple to make joint decisions.
Prevention of new HIV infections during pregnancy
Tell the participants that women who are newly infected in pregnancy are at increased risk of transmitting
infection to their babies because the amount of virus in the blood stream. All HIV positive pregnant women
should go for antenatal advice and care early in the first trimester.
Screening and treatment of sexually transmitted diseases
Emphasize to participants that STIs are associated with increased risk of MTCT. Prevention of STIs as well
as the early detection and treatment of both partners can reduce MTCT.
87
CHAPTER 12:
NUTRITION
This is chapter 9 in the participant handbook
Good nutrition in early life lays the foundation for proper growth and development. Breastfeeding
continues to be one of the most important practices for child survival. Although almost all Zambian
women breastfeed their children, they do not feed them on breast milk alone from birth up to 6 months
of age, even though it is recommended to do so. It is important that CBVs promote, protect, and support
exclusive breast-feeding during the first 6 months of a child’s life and promote continued breastfeeding up
to 2 years and beyond. Good health is important for the growth and development of children. Without an
adequate diet and proper childcare or protection from disease, children are unlikely to grow well and may
suffer from malnutrition. Malnutrition is a serious and growing problem in Zambia. Most of the children
seen at health centres with childhood illnesses like URTI, diarrhoea, measles and malaria and other cases
admitted in hospitals also have malnutrition.
Learning Objectives
Upon completion of this session, participants will be able to:
• Explain Growth Monitoring and Promotion (GMP.
• Explain the assessment of health and feeding in Children
• Explain the benefits of Breastfeeding for children up to 2 years or beyond.
• Explain replacement feeding.
• Explain complementary feeding.
• Explain micronutrients deficiencies
• Explain maternal nutrition and how to prevent it
• Explain malnutrition in children and how to prevent it
Duration:
24 hours
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
- Salter scale
- Weighing bag
- Bathroom scale (Recommended)
Teaching Methods
- Lecture
- Discussion
- Role plays
88
SECTION 1: GROWTH MONITORING AND PROMOTION
Ask participants to define Growth Monitoring and Promotion (GMP, summarise the responses with
the information given below.
Explain that most children in Zambia become malnourished during the first two years of life. Most
malnourished children do not have obvious signs of malnutrition, and are likely to be missed by care
takers and health providers relying only on the children’s physical appearances
Growth Monitoring and Promotion (GMP) is a regular and systematic monitoring of growth that helps
to detect malnutrition through early detection of growth faltering (failure to gain weight of a child over
a moth). This is in order to provide information to caretakers or mothers on the growth and health of
children. It helps them make informed decisions. GMP activities take place in health centres and outreach
points. As more health centre-community partnerships become operational, it is expected that more GMP
activities should be implemented in the community.
Lead a discussion with the participants the process of growth motoring and promotion; summarize
the discussion with the information below.
Growth Promotion
Ensures behaviour change on feeding practices that enhances proper growth of the child. Advise the
caretaker to ensure that the child:
· Receives nutritious foods in adequate amounts and frequently:
- 0-6 months of age – exclusive breastfeeding at least 6 times in 24 hours
- 6-12 months- 3 meals other than breast milk
- 12-24 months- at least 5 meals a day.
Growth Monitoring
So long as they are healthy and well-nourished young children from all parts of the world continue to grow
within standard growth patterns, although there is a variation in the growth rate of different children.
Slowing in a child’s established growth pattern is one of the earliest and the most easily measured signs
of a change in the child’s health and nutrition. Recognizing the slowing in growth helps to alert us so that
we find the cause and take action to stop it. Causes of growth faltering are illness or poor feeding. Growth
monitoring therefore helps us to take action to prevent malnutrition before it develops.
A child is supposed to be taken for growth monitoring regularly at the health centre or in the community
until the age of 5 years., it should be carried out as follows:
• From birth to 24 months monthly
• 24- 60 months every 3 months
Explain growth curve to mothers, showing that the baby is growing well. (refer to Graphs A, B, and C
showing adequate Growth below).
Regular assessment of the child to determine weight gain
Use of information on growth curve to make decisions on what action to take
89
Growth Monitoring and Promotion Package
The following are the main aspects of the Growth Monitoring and Promotion Package:
• Assessment of health and feeding
• Actions are consisting of counselling about feeding, medical care when needed, referral to other
services when indicated, and promotion of health-enhancing behaviours.
• Follow-up on the effects of the action taken
Regular assessment of the child’s growth
Point out that assessment of the children’s growth should be done monthly during the first two years of
life, because large numbers of children become malnourished during the period.
Table 6.4: Weighing Schedule
Age in Months Time frame

All children under 24 months Once a month
All children 24-36 months Every two months
All children including those between three Whenever they are brought in for health services
and five years and GMP in the community
NOTE: Plot the weight on the weight chart. If the child has already been weighed that month, write down
the weight and the date weighed on the growth card.
90
Growth Monitoring Promotion Equipment:
• Weighing scale (the Salter hanging scale is the most commonly used scale in Zambia)
• Weighing bags
• Other standing (Bathroom scale) and baby weighing scales
Lead a discussion with participants on weighing procedure and conduct a demonstration.
Weighing Procedure- Salter Scale
• Every day before each session, check the scale with an object of a known weight (it could be 1 kg of
sand or sugar, a brick, or any other object) to determine whether the reading on the scale is correct.
Write the weight down in a notebook for future reference. · Before each session, adjust the scale to
zero with the weighing bag attached to the scale.
• Hang the scale from a strong support with the dial at eye-level so that it can be accurately read.
• Weigh the child in minimum clothing, without shoes. Check to make sure there is nothing heavy in
the child’s pockets.
• Children should hang freely without their hands and feet touching the walls or the floor.
• Wait until the pointer is steady, then read the weight to the nearest 100 gm. If the pointer continues
to swing slightly, estimate the mid-point of the swing and user the number as the weight.
• Use a standing scale (bathroom type) to weigh children who are more than 2 years old. · To plot the
weight on the growth card, the month and the year of the child’s birth must be known.
• If the child’s age is unknown, use a local calendar to estimate the age. A local calendar may be based
on events such as:
- The beginning, middle or end of the rainy or dry season
- Planting and harvesting season periods
- Other important local events
- Review the calendar each year since the dates for events may change.
Using a doll, a bundle of rags tied around a rock or other object that weighs about 3 – 5 kilos or perhaps a
real child, demonstrate how to weigh a child. Explain each step as you do it (See steps below).
Steps to weigh a child
- Hang the scale from a strong support with the dial at eye level so that it can be correctly read.
- Every day before each unit, check the scale with an object of a known
- Place the child in the weighing bag
- Wait until the needle is steady then read the weight to the nearest 100 gm.
- Use a standing (bathroom) scale to weigh children who are more than 2 years old.
Invite participants to repeat the demonstration. After the demonstration, ask other participants to give
feedback.
Tell participants that next they will have an opportunity to practice this very important task.
91
Activity
Divide participants into small groups
Give each group weighing equipment and assign each group a location where the members can practice
setting up and using the equipment. Weigh to determine if the scale is recording correctly. Be sure all
children will hang freely.
Complete the growth card
Remember to fill in the other blanks on the card, such as the child’s name, date of birth and reasons for
special care (i.e., low birth weight, sick mother etc). Ensure that the birth weight and birth date are well
recorded on the Children’s Clinic card
Plotting weights on the children’s Clinic Card
Demonstrate to participants how to plot on the children’s Clinic Card as indicated below.
At the base (horizontal) of the card, there is a box for each month in the child’s life until he or she reaches
5 years of age and on the left vertical side, there are different weights starting from 0 Kg up to 28Kgs.
The first box on the horizontal line is used for month one. E.g., if the child was born in December insert
January in month one, which is box 1. The birth weight will be filled in separate spaces provided on the
vertical side
Plot the child’s subsequent weights on the Children’s Clinic card and REMEMBER to indicate the actual
weight just above the dot you have plotted, this helps in determining of growth faltering especially if the
plotted weights are not whole numbers e.g., 3.2kg and 3.3kg.
Emphasize that it is important that after the weight has been plotted, a line should be drawn from a
previous dot if any, to the current dot you have just made in order to link up the dots with a continuing
line, to form a continuous curve. The curve will help you to know how the child has been growing in the
past month. It also reviews the health and nutrition status of the child. If a child missed being weighed
for a month or more do NOT draw a line from a previous dot to the current, but you should instead draw
a broken line (i.e. - - - - -).
Explanation of Z score lines- Weights For Age
Z – Scores Growth Indicator
Above 3 A child whose weight for age falls in this range may have a growth problem, but
this is better assessed with weight for length / height or Body Mass Index (BMI) for
Above 2 age.
0 (Median)
Below –1 Mildly underweight (This line is not seen on the card to reduced congestion)
Below –2 Moderately underweight
Below –3 Severe underweight
92
Below –3 Severe underweight
EXAMPLE: The
EXAMPLE: Theinfant is 2ismonths
infant old and
2 months old weighed 2 kg Here
and weighed 2 kgisHere
how the CBV determined
is how the child’s the
the CBV determined
weight for age.
child’s weight for age.
EXAMPLE: A child is 27 months old and weighs 8.0 kg. Here is how the CBV determined the
child’s weight for age.
112
93
EXAMPLE: A child is 27 months old and weighs 8.0 kg. Here is how the CBV determined the child’s
weight for age.
Note: Use the blue weight-for-age chart (under 5 card) if the child is a boy and the pink weight-for-
age chart if the child is a girl
Checking for Growth Faltering
Explain that Growth faltering is inadequate weight gain, static, or loss of weight of the child over a month.
Compare the weight of the child now to any weight of the child that was recorded one month earlier. If
the weight now is greater than the weight from one months ago, then child’s growth is not faltering. If the
weight now has not increased compared to the weight from a month or more previously, then the child
is growth faltering. Growth faltering affects mental development especially to child less than 2-year-old
and if not corrected may result in permanent mental underdevelopment. This will in turn affect the child’s
performance at school and future developmental issues as whole.
EXAMPLE A:
As shown in the figure below, a child is now 19 months old and weighs 8.5kg. One month ago, when he
was 18 months old, he was seen in the clinic and weighed 8.3 kg. He has gained weight over the last 2
months. Therefore, the child does not meet definition of growth faltering.
EXAMPLE B:
A child is now 25months old and weighs 9.5 kg. One month previously when the child was 24 months
old, he was seen in clinic and weighed 9.5 kg. The child has failed to gain weight over the last 2 months.
Therefore, the child has growth faltering.
94
SECTION 2: ASSESSMENT OF HEALTH AND FEEDING
Ask the caretaker about the child’s health today and since last week Ask about the child’s feeding using
the following tool:
Table 6.5: Feeding Assessment
Do you breastfeed at night? If yes, how many times during the day?
Do you breastfeed at night? If yes, how many times during the night?
Does the child take other food, water, or If yes, what food or fluids? other fluids?
How many times a day is he/she fed?
Who feeds the child and how?
Is he/she served in a separate bowl or late?
The caretaker is more likely to work with you if you talk to her/him with respect and dignity.
If the child has adequate weight gain and is healthy:
Show the child’s growth curve in relation to the reference curve.
Congratulate the caretaker on her/his child’s good health and nutrition
Talk with the caretaker about appropriate feeding practices for the child’s age or the age-group the child
is about to enter.
Check on the card if vitamin A supplementation and immunization, and de-worming is needed and tell
the caretaker to take child to the clinic, if not given.
SECTION 3: BREASTFEEDING
Ask participants to define exclusive breast feeding. Reinforce the responses given and summarise
by giving the information below.
Babies must be Breast fed exclusively for the first 6 months. This means that during this period, do not give
any other food or drink not even water. A normal baby is born with enough water in the body. During the
first 6 months of life, a baby needs BREAST MILK ONLY. It is important for the CBV to encourage mothers to
practice exclusive breast-feeding.
95
Benefits of Breast milk
Ask participants what are the benefits of breast feeding? Write the answers on the flip chart, lead a
discussion. Summarize as indicated below.
Benefits of Colostrum (first milk)
• It is the first milk. It is made in the mother’s breast in the first few days after delivery. It is yellow and
thicker than the milk that is produced later.
• It contains substances that protect the baby from disease. Gives the baby the first immunization
protection.
• It has growth factors which help baby to digest and absorb milk.
• It is a laxative (it gives the baby comfort because the baby passes soft stools).
Benefits of mature milk
Tell the participants that mature milk is the milk that is produced in the mother’s breast after colostrum.
The following are its advantages:
• It contains exactly what the baby needs for growth and development.
• It is easily digested by the baby.
• It is clean and always ready to use. It does not go sour in the breast.
• It promotes growth of the baby.
• It protects a baby from diseases.
• It strengthens the bond between mother and baby.
• It does not cost any money.
Successful Breastfeeding
• It should be started within 30 minutes of delivery.
• Babies should receive the colostrum. Colostrum is the first milk the baby gets and is important for
fighting diseases in the baby.
• Mothers should exclusively breastfeed their babies for the first six months.
• Children should be breastfed on demand and for as long as they want.
• Children under-6 months should be breastfed at least 10 – 12 times per day.
• Breastfeeding should be continued up to 2 years or beyond.
• Caretakers should begin to introduce other foods at six months. · Mother needs support from the
family and the community.
Expressing and Storing Breast milk
Explain that expressed Breast milk is important in the feeding of babies is some circumstances.
• Expressed breast milk is important for small babies (low birth weight — less than 2.5.kg) or sick
babies who cannot suckle.
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• Expressing breast milk prevents the mother’s breast from becoming swollen which can be painful
experience.
• Expressed breast milk is also important for feeding a child who is separated from his or her mother
such as when the mother is ill and is unable to breastfeed.
• It is also important when the mother is away from home, and she cannot take the baby with her such
as she has gone for work or the market.
How to Express Breast milk
• Wash hands thoroughly before touching the breast.
• Wash container in which milk is being expressed thoroughly.
• Sit comfortably and hold cup near the breast.
• Put thumb on the black part of the breast above the nipple and the finger on the black part of the
breast below the nipple, opposite the thumb.
• Press thumb and finger inwards towards chest wall to allow for milk flow.
Storage of Expressed Breast milk
Expressed breast milk should always be put in a clean cup/container.
Expressed breast milk can be stored for 8 hours at room temperature. If kept in a refrigerator, it can be
stored for 48 hours and it can be stored for 6 months in a deep freezer.
Positioning of baby while breast feeding
Lead a discussion on positioning of baby while breast feeding, summarize the discussion with the
information below
Explain that it is important for mothers to put a baby on to the breast in the correct position for breastfeeding
to be successful. Let the mother sit in a comfortable place so that she is relaxed. A low seat is usually the
best. Show the mother how to hold her infant. The following steps should be used for correct positioning
of a baby for breastfeeding:
• With the infant’s head and body straight
• Facing her breast, with infant’s nose opposite her nipple
• With infant’s body close to her body
• Supporting infant’s whole body, not just neck and shoulders.
How to help the infant to attach to breast
• The mother should touch her infant’s lips with her nipple,
• Wait until her infant’s mouth is wide open,
• Move her infant quickly onto her breast, aiming the infant’s lower lip well.
To check correct attachment, look for:
• Chin touching breast
• Mouth wide open
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• Lower lip turned outward
• More areola visible above than below the mouth.
Attaching the baby to the Breast
Proper attachment to the breast is important because it ensures constant milk production as well as
sufficient milk flow, and also prevents nipples from developing cracks or sores. Make sure the mother sits
comfortably and holds the baby facing her. The baby is properly attached to the breast if his or her mouth
is wide open covering the mother’s black part (areola) of the breast and with the lower lip curled outwards.
Ask participants to mention some Common Problems Associated with Breastfeeding, summarize
with the information given below
Table 8.1: Common Problems Associated with Breastfeeding
The Solution OR
Problem Possible Cause
Ways of Preventing the problem
Swollen, painful • Delayed breastfeeding of child Breastfeed the new-born baby within 30
breasts minutes of the baby’s birth.
• Long spacing in between feeds
Breast feed the baby any time the baby wants
• The breast not being emptied at to feed
each feed
Breast feed until the breast is empty Express
some milk and store.
Apply warm towel.
Sore or cracked Poor position and attachment of the Good position and attachment. Be sure that
nipples baby to the breast when breastfeeding child’s mouth is wide
open covering the mother’s black part (areola).
Mother feels Poor attachment. Child could be Continue breastfeeding

she does not fussy. Pressure from others to give
have enough liquid to the child Counting how often the baby passes urine.
The baby should pass urine 6 times or more in
milk one day
Weigh the baby. The weight of the baby goes
up at by least 125g
Little milk • Delayed breastfeeding of child Breastfeed the new-born baby within
produced 30 minutes of the baby’s birth.
• Mother giving other liquids to
baby Exclusive breastfeeding for the first six months
• When the mother is worried
Section 2: Feeding options for infants of mothers who have HIV/AIDS
Lead a short discussion about why feeding options for infants of mothers who have HIV/AIDS
should be considered
Explain that in Zambia there is a risk that some pregnant women will pass on HIV infection to their babies
during pregnancy, delivery or during breastfeeding. Most of the infection from mother to baby will take
place during delivery. The more HIV the mother has in her body, the bigger the risk that she will pass it on
to her baby. This is the case when the mother is newly infected with HIV or has AIDS. Other conditions that
will increase the chances of the mother passing HIV on to her baby are sores or infections of the breasts
and also sores in the baby’s mouth. Exclusive breastfeeding is recommended for HIV-infected women for
the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable, and
safe (AFASS) for them and their infants before that time.
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This means that there are only two main options when the mother is HIV positive which the CBV should
be aware of:
 Exclusive breastfeeding – This means feeding an infant only on breastmilk with no solids or fluids
not even water unless medically indicated.
Or
 Exclusive Replacement feeding – This is the process of feeding a child who is not breastfeeding
with a diet that provides all the nutrients the child needs until the child is fully fed on family food.
The recommended infant feeding recommendation in this category is infant formula.
NOTE: Home modified animal milk is no longer recommended because of nutritional inadequacies
(micronutrients & essential fatty acids)
Exclusive breastfeeding
Emphasize that even though breastfeeding has a risk that the mother will give HIV to the baby, breastfeeding
exclusively is still the safest and best way for a mother to feed her baby. Early cessation reduces the chance
of HIV transmission by reducing the length of time that the baby is exposed to HIV. It means breastfeeding
is stopped early, at least after 2 months when other forms of feeding become easier. This option should be
considered when the mother has difficulty with exclusive breastfeeding; the mother is able to get breast
milk substitutes; or the mother becomes ill with AIDS. The method does not completely take away the risk
of HIV transmission and the mother will need information on suitable methods of replacement feeding to
use at that time depending on the age of her baby and circumstances.
An HIV positive mother, aware of her status, may decide to continue breastfeeding her infant in an
environment where breastfeeding is a custom, for the fear of being stigmatized. Such mothers should be
supported to safely breastfeed their infants.
There are other feeding options that HIV positive mothers could use to provide good nutrition to infants.
The CBV can provide HIV positive mothers with the correct information on feeding their babies. The
following are the other feeding options:
SECTION 4: REPLACEMENT FEEDING
Explain that this is a method of feeding the infant who is not receiving any breast milk. The baby is fed with
a diet that provides all the required nutrients until the infant is able to eat the family diet. Replacement
feeding can be started at any age. Adequate replacement feeding is needed until the child is two years
old. This is the time when the infant is at greatest risk of malnutrition.
In addition to milk, the mother will need water, fuel, and utensils to prepare replacement feed. Replacement
feeding can be discussed in three stages according to the age of the child:
• From birth up to 6 months
• From 6 months up to l2 months
• From 12 months up to 24 months
During these stages, the child needs different foods.
1. From birth up to six months of age milk is required. The recommended infant feeding
recommendation in this category is infant formula infant formula which is bought from the market
or shops.
NOTE: Home modified animal milk is no longer recommended because of nutritional inadequacies
(micronutrients & essential fatty acids)
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Commercial infant formula is designed to meet nutritional needs of an infant for the first 6 months of life. It
has adequate micronutrients including iron. It is an option for HIV positive mothers if the family can afford
the formula for at least 6 months and they have the water, fuel, utensils, skills, and time to prepare it.
The instructions on how to make the milk are on the tin. The milk is mixed with cooled boiled
water. Using too much milk powder and a little water is dangerous because the infant cannot
handle the big amount of nutrients. Adding too much water is not good because the infant will
not get enough nutrients and can get malnutrition.
NB. Dried skimmed milk sweetened condensed milk, cereal feed, juices, and teas are not suitable for infant
feeding in the first 6 months.
Preparation of breast-milk substitutes
Mothers, who choose not to breastfeed, need to know how to feed their infants effectively and safely.
It is, therefore, important for a CBV to assist such women to prepare and give replacement feeds safely.
This will reduce risks of illness associated with replacement feeding. To reduce the risks of malnutrition or
overfeeding, the instructions on how to prepare and give milk feed should be strictly followed.
Mothers should be advised to clean their hands, utensils, and the place where the preparation of the feed
will take place.
• Help mothers to learn how to measure the formula or any other feed, carefully mixing and cooling
it.
• Mothers should be encouraged to feed infants from the cup, because it is easier to clean than a
feeding bottle.
• Left-over milk should not be kept.
• A fresh feed must be prepared.
• Help mothers who know their HIV status and are breastfeeding their infants, to feed them safely
when they have problems such as sore or cracked nipples, engorged breast, mastitis, and oral thrush.
• For information, on this, refer to common problems associated with breastfeeding.
2. From 6 months up to 12 months of age commercial or home prepared formula should be

continued if possible. Milk provides protein and calcium. Therefore, it is very important for the baby.
Complementary feeding starts at 6 months.
3. From 12 months up to 2 years of age children develop very rapidly and are at the risk of malnutrition
if they do not eat enough food.
Expressed and heat-treated expressed breast milk.
The mother who is HIV positive may wish to give her baby her own milk. Heat treatment kills HIV virus
and is better for the baby than formula milk and other milk. The heat kills some of the substances in the
milk that protect the baby from illness. The mother needs to effectively express her milk and boil it for 30
minutes. The milk should then be fed by cup to the infant. Expressing and heating milk takes a lot of time
and mothers should be counselled on this difficulty.
Wet Nursing
In some parts of Zambia, there is a tradition that a member of the family may breastfeed a baby in the
place of the mother. This relative is called a wet nurse. Wet nursing should be considered only when:
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• The volunteer wet nurse should be told that there is a risk of getting HIV from the baby who is born
to an HIV positive mother.
• The wet nurse should be offered HIV counselling and testing; she must volunteer to have an HIV test;
and the test result should be negative.
• The wet nurse should be given information on practicing safe sex so that she remains HIV negative
while she is breast feeding the baby.
SECTION 5: COMPLEMENTARY FEEDING
Explain that complementary feeding is the introduction of other foods to the baby. Incorrect feeding
practices are among the major causes of malnutrition in Zambia for children under the age of 5 years.
Children should be breastfed exclusively from birth up to 6 months of age and thereafter be introduced
to other foods. At six months of age, the baby has grown up and the nutrients in the mother’s milk are
not enough. Breast milk is still rich in nutrients and will continue to provide protection against childhood
diseases as the baby gets older. Start the baby on light foods and then increase the thickness slowly to
help the baby’s body to learn to digest the new food. Ensure that the baby’s food is clean. The baby has a
small stomach which can only take little food at a time. Feed the baby frequently, at least three times if the
child is breastfeeding or five times if the baby is not breastfeeding.
Recommended feeding practices for children
From birth up to 6 months
It is important to Breastfeed exclusively at least 8 times in 24 hours. Do not give water, traditional
medicines glucose, gripe water, other milks, porridge, or any other liquids foods unless told to do so by
health personnel. Replacement feeding can be discussed in three stages according to the age of the child:
6 months up to 12 months
• Continue breastfeeding at least 8 times a day (both day and night).
• Feed at least 3 times a day if the baby is breastfed and 5 times a day if the baby is not breastfed.
• Give about 3/4 cup (150-200mls) per meal. The meal should be thick porridge enriched with sugar,
oil, pounded groundnuts, soya flour, milk, sour milk, beans, kapenta, dry caterpillars, mashed green
leafy vegetables or avocado.
OR
Nshima (or rice or mashed potatoes) with mashed relish that is cooked in oil or groundnuts. The soup by
itself is not enough. Between the main meals, give other foods such as mashed banana, pawpaw, avocado,
mango or orange juice, milk, bread, munkoyo, chibwantu, chikanda, mashed pumpkins, beans, cassava or
boiled sweet potatoes. Enrich cassava, sweet potatoes and pumpkin with pounded groundnuts or sugar,
milk, or oil. Where possible, mash these foods and feed the child.
12 months up to 2 years
• Continue breastfeeding as often as child wants.
• Feed the child with the food which the rest of the family is eating 3 times a day. Give 2 snacks in
between the main meals (see the above list).
• Serve at least one cup of the family food (e.g., nshima with mashed relish) per meal.
• Serve the child’s food on a separate plate from the other older children and make sure the child
finishes the meal (an older responsible child or adult can supervise the young child’s meal).
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2 years or older
• Feed family meals such as nshima with relish at least 3 time a day.
• 2 times a day between family meals, give fruits (such as banana, orange, mango, pawpaw, guava),
sump, fried sweet potatoes, bread or rice with sugar or oil.
• When counselling mothers about Complementary Feeding consider:
The food itself, is it nutritious, could it be improved?
How often the child is fed?
How much food the child is given?
Locally available food that can be used for complementary feeding
Examples of some locally available foods that can be used for complementary feeding are: - § Mealie meal
for porridge or nshima: Maize, millet, sorghum, and cassava.
 Foods added to porridge: Milk, sugar, cooking oil, mashed or pounded relish such as beans, fish,
kapenta, beef or green leafy vegetables.
 Food given in between main meals: Fruits such as bananas, mangoes, oranges, mashed beans boiled
or fried cassava or sweet potatoes, chikanda.
 Fluids that can be given to children: Water, chibwantu, munkoyo, milk and fruit juices (mango and
oranges).
How to feed a child who is not feeding well during or after illness
Advice caretakers to follow these instructions on how to feed a child who is not feeding well during or
after illness:
• If the child is still breastfeeding, give the breast more often, for a longer time, day, and night.
• Give the child small feeds more often than usual.
• Give the child soft foods and foods that they like. Try not to feed the child with the same food.
• Encourage the child and assist them to eat.
• For one week after the illness is over, increase the amount of food and encourage the child to eat as
much as possible.
Finding out about a caretaker’s feeding practices
To give correct advice to the caretaker, the CBV needs to find out caretaker’s feeding practices of children.
Below are questions the CBV should ask about feeding practices.
1. Do you breastfeed your child?
If yes
a. How many times during the day?
b. How many times during the night?
2. Does the child take any foods or fluids other than breast milk?
If yes, ask
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a. What foods or fluids?
b. How many times per day?
c. Do you use a plate/cup and a spoon to feed the child?
If the child has very low weight for age, ask
d. How large are the servings?
e. Does the child receive his or her own serving?
f. Who feeds the child and how?
3. During this illness, has the child’s feeding changed?
If yes, ask
g. What are these changes?
Giving correct advice for the child’s age
Explain to participants that its important after finding out the child’s feeding practice, the CBV should
analyse the information and come up with specific feeding recommendations appropriate to the child’s
age and nutritional situation. Discuss with the participants the nutrition recommendations as indicated
below.
NUTRITION RECOMMENDATIONS
Table 8.2: Nutrition Recommendation
IF AND RECOMMENDATIONS
The child is being giv-
The child is less than 6 en water porridge or Advise mother to stop water, porridge, or other
months old other liquid or food liquids or food and to exclusively feed the baby
The child being

The child is less than 6 breastfed fewer than 8 Encourage mother to breastfeed at least 8 times
months old times per day per day
The child is at least

6 months old The child is being given
thin porridge Advise caretaker to thicken child’s porridge with
more mealie meal
The child is being Advise caretaker to enrich the child’s porridge with
The child is at least 6 one or more of these foods: pounded kapenta or
given plain porridge groundnuts, mashed avocado, pear, beans, cooking
months old
oil, sugar, milk, or Soya flour
The child is being given
The child is at least 6 nshima with soup alone Advise caretaker to give the child mashed relish
months old cooked in oil or groundnuts
The child is at least 12 The child is being given Advise to give the child food at least 5 times a day
months old food fewer than 5 times
a day
The child is sick and has Advise the caretaker to give small, frequent meals,
no appetite The child is being fed including some of the child’s favourite foods
less than usual
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SECTION 6: MICRONUTRIENTS DEFICIENCIES
Explain that micronutrients are substances in foods that the body needs in small amounts but are essential
for good health. Examples of important micronutrients needed by the body are Vitamin A, iron, and iodine.
When these micronutrients are lacking, people suffer from micronutrient deficiencies.
Groups which are at risk of micronutrient deficiencies
Tell the participants that certain groups of the population are at high risk of suffering from micronutrient
deficiencies of their high needs. These groups are:
i Breastfeeding women
ii Children under six months who are not breastfed
iii Children under six years
iv Children who are suffering from diarrhoea, malnutrition, measles and acute respiratory infection
Types of Micronutrient Deficiencies
Discuss the micronutrient deficiencies as indicated below
Vitamin A Deficiency (VAD)
Vitamin A is good for healthy eyes and helps the body to fight diseases like measles, diarrhoea, and
malnutrition. One of the most common signs of Vitamin A deficiency is night blindness.
Iron Deficiency Anaemia (IDA)
Lack of iron causes anaemia (weak blood). This is common in children under five years of age and in women
of childbearing age. However, it can also affect anyone in the community.
Iodine Deficiency Disorders (IDD)
Lack of iodine causes goitre. This is common in women of childbearing age but can affect anyone in the
community. Use of iodized salt is one way of ensuring control of iodine deficiency disorders.
Prevention of micronutrient deficiencies
There are a number of ways in which micronutrient deficiencies can be prevented.
1. Consumption of food rich in micronutrients
Both plant and animal food are good sources of micronutrients
• Plant sources of vitamin A include Yellow and orange foods such as pumpkins, carrots, mangoes,
oranges tomatoes, paw paws, sweet potatoes.
Green vegetables such as pumpkin leaves, spinach, cassava leaves, sweet potato leaves (kalembula),
ibondwe.
• Animal sources of iron include Eggs, meat, chicken, fish, liver, kapenta, caterpillar, inswa.
• Other sources of micronutrients include Fortified foods such as iodized salt and sugar fortified
with Vitamin A.
NB. Breast milk is also an important source of micronutrients
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2. Eating foods to which micronutrients have been added
Fortification is the addition of nutrients to foods. For example, iodine is added to salt to prevent
iodine deficiency disorders such as goitre. Vitamin A is added to sugar.
3. Supplementation
Supplementation is to give additional micronutrients to a person.
Vitamin A supplement is given to:
• Children under six months who do not breastfeed
• Children between 6 months and 6 years (every 6 months)
• Breast feeding mothers within four weeks of delivery
• Sick children with diarrhoea measles, malnutrition, and acute respiratory infection.
Iron/folate supplement is given to:
• Pregnant women at antenatal clinics
• Children who have weak blood (anaemia).
SECTION 7: MATERNAL NUTRITION
Explain that good nutrition is important for the prevention of disease and death in women of child-
bearing age. It is important to advise women to eat enough and a variety of foods before, during and after
pregnancy.
Add that during this unit, the participants will learn about some of the nutritional problems women may
have during pregnancy and breastfeeding, as well as advice to give women who are having problems.
Ask participants whether they have seen some women have difficulty during pregnancy. If so, ask what
kind of trouble.
Explain that one reason a woman may have problems in pregnancy is that she may not eat enough food.
A woman needs to increase how much she eats when he is pregnant, and she also needs to eat a variety
of foods, to able to provide for her growing baby’s needs as well as her own.
Ask what participants think happens to a woman who does not eat enough food and a variety of food
when pregnant.
Ask what participants think happens to the baby growing inside when the mother does not eat enough
food or variety of foods.
Ask participants what advice they would then give about nutrition to a pregnant or Breastfeeding woman.
Then ask participants to think for a moment about some of the reasons why it might be hard for a woman
to follow that advice, and to share with the group some of those reasons.
Ask participants what suggestions they have as to how to solve those problems. And ask them how they
as CBVs will be able to help pregnant and Breastfeeding women, as well as their families, solve these
problems.
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Summarize using the information below.
What happens when pregnant and breastfeeding women do not eat enough of the right kind of
foods
Women who do not eat enough foods:
• will use their own food stores to provide for the baby’s growth. · are likely to suffer from anaemia
(weak blood).
• are generally weak and unwell and may suffer from malnutrition.
Factors that place pregnant and breastfeeding women at risk of under nutrition include:
• Pregnancies with little space time in between them. Increased need for energy and protein during
pregnancy and breastfeeding.
• Increased need for micronutrients such as vitamin A, iron/folate, and iodine.
• Working very hard during pregnancy and lactation and not having enough food and rest.
• Many pregnancies with little space in between
Pregnant and breastfeeding woman who do not eat enough good foods are likely to:
• Use their own food store to provide for the baby.
• Suffer from anaemia and general body weakness (weak blood).
• Be unwell and may suffer from malnutrition.
Babies of undernourished women who do not eat enough of the right foods during pregnancy are
likely to:
• Be too small at birth. These babies are not strong and can suffer from illnesses soon after they are
born.
• Suffer from more diseases and infection which are serious.
• May die in the womb.
• May die shortly after birth.
Advice on Maternal Nutrition during Pregnancy
Women should be advised to eat a variety of good foods during pregnancy for:
• Their health and for the growth of the baby.
• Building food stores for breast milk production.
Advise a woman to eat a variety of foods to ensure that she gets different types of nutrients. A
variety of foods is good for:
• Her own health · The growth of the baby
• The production of milk.
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Other information on pregnancy and breastfeeding that support positive outcomes:
• Pregnant women should be encouraged to start attending antenatal clinics as soon as they know
they are pregnant.
• Pregnant women should take their iron/folate tablets which are given at antenatal clinics.
• Pregnant women should also be encouraged to get enough rest during pregnancy and
breastfeeding.
• After delivery, a woman should begin breastfeeding within 30 minutes.
• After delivery women should exclusively breastfeed for 6 months and thereafter introduce other
foods with continued breastfeeding up to two years or beyond.
• Pregnant women should receive a Vitamin A supplement within 4 weeks after delivery.
SECTION 8: MALNUTRITION
Ask participants to define malnutrition. Summarise with the information given below.
Explain that malnutrition is a condition that arises when a person does not get sufficient food to meet his
or her body’s requirements.
Add that in this session, participants will learn about some of the causes, signs, and symptoms of
malnutrition, as well as the preventive measures they can promote in their communities.
Ask participants what they think are the causes of malnutrition.
Discuss the causes as indicated below.
Causes of Malnutrition
1. Not eating enough
When the body receives fewer foods, it will not be able to grow, repair itself and replace the parts
that are wearing out.
2. Infection and diseases
Infections and diseases such as diarrhoea, measles, and acute respiratory infections (ARI) can
prevent a child from getting and using the nutrients that they need. Sickness also can reduce a
child’s appetite.
3. Poverty
Poverty may keep a family from being able to get enough food and the right kinds of foods.
4. Mother’s ignorance about proper feeding practices
Mothers may not know how to feed their young children.
5. Lack of child spacing
When a mother has her children too close together, she is not able to continue breastfeeding
the older child. She will also not be able to give the older child the needed care. This can result in
malnutrition in the older child.
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Signs and Symptoms of Malnutrition
Ask the participants to mention signs and symptoms of malnutrition, then summarize with the
information below
There are 2 types of severe malnutrition:
• One type causes swelling of the body of the child. This is called oedema.
• The other type causes the baby to be very thin. This is called wasting.
The following Table 8.3 shows the signs and symptoms of the two types:
Table 8.3: Types of Malnutrition
Malnutrition with oedema (swelling) Malnutrition with wasting

• Loss of appetite • They have very low weight for their
age
• They are miserable looking • They have less fat which makes the
skin appear loose
• Swelling mainly of the feet, legs, arms, and face
• They may have an old person’s face
• They have pale and peeling skin • They seem to have only skin and
bones
• They have pale and sparse hair which is easily pulled out • Even though the stomach is big the
• They look fat because they are swollen with water, when buttocks are small
they are weighed, they have low weight for their age
Explain that many children who are malnourished do not have all these signs. The first sign that shows
that there is a problem is that the child is not growing well. That is why it is important to weigh children
regularly to catch those who are not growing well and feed them better before they show signs of
malnutrition.
Measures to prevent malnutrition
Lead a discussion on how malnutrition can be prevented and summarise with the information
below.
Malnutrition can be prevented in the following ways:
• Correct breastfeeding practices – encourage mothers to breastfeed their children.
• Correct complimentary feeding practices – encourage caretakers to introduce other foods to the
child beginning at 6 months of age while still breastfeeding.
• Adequate intake of foods rich in micronutrients.
• Children should be given foods rich in micronutrients. Even when they are receiving foods rich in
micronutrients, they still need to be supplemented with important micronutrients such as Vitamin A.
• Use of iodized salt in foods and use of sugar fortified with vitamin A should also be encouraged.
Promote good nutrition in the mother
Encourage pregnant women to eat as well as they can! Healthy mothers will give birth to healthy babies
who will be less prone to infections and disease.
Correct complimentary feeding practices are important for child’s proper growth.
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CHAPTER 13:
HEALTH PROMOTION: (A) IN CHILDREN
Learning Objectives
• Define Health Promotion
• Explain the principles of health promotion
• Explain the strategies of health promotion
• Explain Health Promotion at community level
Duration:
45 minutes
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
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Definition of Health Promotion
Health promotion is a process of empowering people to increase control over and to improve their health.
Health promotion emphasizes community actions to change behaviour; it aims at mass behaviour change.
Explain the difference between health education and health promotion. Explain that Health Education
is communication activity that influences knowledge, beliefs, attitudes, and behaviour in community
and those in power. It emphasizes individual behaviour change while Health promotion emphasizes
community actions to change behaviour; it aims at mass behaviour change.
The principles of health promotion
 Involve whole population rather than the at risk
 Directs actions on determinants of health (Income, education, food supply, water supply, sanitation
conditions, etc)
 Combined approach (method) and complementary e.g., communication and education)
 Promotes public participation to create a sense of ownership
 Enables CBVs to have an important role in the health and social fields
Strategies of Health Promotion
 Biding health public policy
 Creating supportive environment
 Strengthening community actions
 Developing personal well- being skills
 Re-orienting health services (reforming the system)
HEALTH PROMOTION AT COMMUNITY LEVEL
Explain that Health promotion at community level should enhance implementation of Community IMCI.
Community IMCI is defined as an integrated childcare approach that aims at improving key family and
community practices that are likely to have the greatest impact on child survival, growth, and development
THE 16 KEY FAMILY PRACTICES
Tell the participants that Key family practices for promotion of growth and development are grouped into
four areas:
1. Promotion of growth and development
2. Disease prevention
3. Appropriate care at home
4. Health care-seeking outside the home
Divide participants into 4 groups and assign each group to one of the four areas and come up with
key family practices. After plenary summarise the discussion with the information below.
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SECTION 1: PROMOTION OF GROWTH AND DEVELOPMENT
1. Exclusive Breastfeeding of Children up to 6 Months.
2. Complementary feeding of Children from 6 Months while continuing Breastfeeding up to 2 years

or longer.
3. Micronutrient supplementation of children either in their diet or through supplementation e.g.,

Vitamin A and Iron.
4. Promotion of Mental and Social Development by responding to a Child’s needs for care and playing,
talking, and providing a stimulating environment.
SECTION 2: DISEASE PREVENTION
5. Dispose of all faeces safely, Wash hands after defecation, before preparing meals and before feeding
children
6. Protect Children in malaria endemic areas by ensuring that they sleep under ITNs
7. Provide appropriate care for HIV/AIDS affected people, especially orphans and take action to
prevent further HIV infections.
SECTION 3: APPROPRIATE CARE AT HOME
8. Continue to feed and offer more fluids, including breast milk to children when they are sick.
9. Give sick children appropriate home treatment for infection.
10. Protect children from injury and accident and provide treatment when necessary
11. Prevent child abuse and neglect and take action when it does occur.
12. Involve fathers in the care of the family.
SECTION 4: HEALTH CARE-SEEKING OUTSIDE THE HOME
13. Recognise when sick children need treatment outside the home and seek care from appropriate
providers.
14. Take children to complete a full course of immunisation before their first birthday.
15. Follow the Health Provider’s advice on treatment, follow-up, and referral.
16. Ensure that every pregnant woman has adequate antenatal care and seeks care at the time of
delivery and afterwards.
Explain to participants the importance of the key family practices by giving the information below
DOCUMENTED EVIDENCE ON THE IMPACT OF KEY FAMILY PRACTICES
• Improving Breastfeeding could reduce diarrhoea mortality by 24-27% and morbidity by 8-20% in
infants aged 0-5 months.
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• Improving complementary feeding can prevent more than 10% of deaths due to diarrhoea and
acute respiratory infections (ARI), while malnutrition can be reduced by 20%.
• Improved sanitation could reduce diarrhoea morbidity by 26% and overall mortality by 55%
• Vitamin A Supplementation can reduce mortality by 23% among children Six months to Five years.
It also reduces severe morbidity.
• Hand washing interventions can reduce Diarrhoea incidence by 35%.
• Appropriate care seeking reduces Pneumonia deaths by 20%.
• Home treatment of Diarrhoea prevents 1.2 million deaths per year Globally.
• Widespread use of ITNs can reduce childhood mortality by 17%.
Explain that Zambia first started implementing six (6) key priority practices for child survival, growth
development as a starting point as highlighted below, add that all communities are encouraged
implement all 16 key practices enhance maximum good health for our children.
SIX (6) KEY PRIORITY PRACTICES FOR CHILD SURVIVAL, GROWTH AND DEVELOPMENT (PROMOTED
IN THE 2006-2009 C-IMCI STRATEGIC PLAN)
CBVs are expected to educate community members on the following six (6) key priority practices for child
survival, growth, and development in their communities:
• Breastfeed exclusively up to 6 months (taking into account recommendations on HIV and

unfaithful feeding)
• Starting at six months of age, provide complementary feeds, while continuing to breast feed up to
2 years or longer
• Providing < children with Vitamin A, Deworming tablets, and monitoring of growth
• Ensuring that all children complete their full course of immunization as scheduled before all of one
year.
• Ensure that all <5 children and pregnant women, and PLWAA with sleep under an insecticide
treated net every night.
• Providing health education on appropriate home management of sick children and prompt
referral to health facility.
SECTION 6: COMMON PREVENTABLE CHILDHOOD DISEASES IN COMMUNITIES
Emphasize that Community Based Volunteers are expected to assist in preventing common childhood
diseases by promoting immunizations in their communities. In order to advise community members on
the immunization schedule, to identify defaulters and assist with outreach immunizations, it is important
that CBVs are able to recognize immunizable diseases and take appropriate action.
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CHAPTER 14:
HEALTH PROMOTION: (B) GENERAL

Learning Objectives
• Explain the purpose of health promotion
• Explain the general strategies of health promotion
• Explain Health Promotion at community level

Duration:
1 hour
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
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Purpose of Health promotion
Explain to participants that the purpose of health promotion is to strengthen the ability and skills of
individuals and groups in society, so that they act individually and collectively to take control of factors
that affect their health. It leads to changes in knowledge, attitudes, and practices, and all other factors that
have a bearing on health. For this reason, health promotion cuts across all factors.
Strategies for Health Promotion
• Information, Education, and communication (IEC)

• Social mobilization
• Advocacy
Tell the participants that these strategies aim to support health policies, increase partnerships, and change
knowledge, attitudes, and behaviour.
Information, Education and Communication (IEC)
There are 3 approaches for IEC:

• Individual approaches, such as counselling or consultation
• Group approaches e.g., focus group discussions (FGDs), role play, or drama
• Mass approaches, such as campaigns, rallies, parades, etc
For IEC to be effective, use participatory approaches and multiple settings (community welfare hall,
schools, cultural events e.g., traditional ceremonies, local shops, workplace, health centre, etc).
How can you plan an IEC activity?
Lead a discussion with the participants on how IE C activity can be planned then reinforce with the
information below.
Planning IEC activities
IEC should be based on a clear knowledge of the needs and perceptions of target audiences and must
always be linked to available products and services.
Careful planning and vigorous implementation are essential to effective communication.
Basic elements of an effective IEC plans
1. Document the health status and factors influencing the health problems seen in the community
(with participation of other stakeholders).
2. Select practices (risk factors) for intervention
3. Select target audiences
4. Select communication channels
5. Develop communication objectives; position messages so as to communicate benefit
6. Develop strategies and activities
7. Develop messages
8. monitor the programmes
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Step 1: Documentation
• Collect information on the community’s health status-establish the magnitude of the problem
(s), who is affected, in what circumstances these health events occur, and their geographical
distribution in the community.
• Document the key factors influencing the health status of the community, including knowledge,
attitudes and practices and other factors (e.g., community members may not know the association
between unprotected sex and HIV infection. They may associate HIV/AIDS with witchcraft or drug
use).
• This step and the following steps should be done with the involvement of key stakeholders
(including members of the key audience groups).
Step 2: Select practices for intervention
• List all the health problems identified
• Prioritize the problems
• Look for important behaviours that bring about the selected priority problems
• Remember that what people know, and think is important to health programmes, but it is what
they do or fail to do that is of utmost importance to effective IEC.
• Select 1 to 3 behaviours, which can be changed through health education using available resources,
liaise with relevant stakeholders (government sector, traditional leaders, DHMT or Health centre)
for behaviours that might be difficult to change and may require additional resources.
Step 3: Select target audiences
• Stakeholders or participants in an IEC programme or activity may be involved as either target

audiences, partners, or allies
• Analyse the audience for the problem identified, e.g., mothers, who do not take their children for
vaccinations
• It may be appropriate to further subdivide target audiences by religion, marital status, age,
education level, or geographical location to help focus on specific messages.
Step 4: Select communication channels
• Continually identify where the people seek information from on health in the community, and
why they seek information from such sources.
• Incorporate these sources in the IEC effort.
• Identify and analyse structures through which messages can be communicated to reach target
audiences. Such structures may include neighbourhood health committees (NHCs) and other
community-based organizations (CBOs), non-governmental organizations (NGOs), football clubs,
farmers associations, parent-teacher associations (PTAs), Community Based Volunteers (CBVs),
community distributors, scouts or girl guides, district councils, schools, churches, women’s
organizations, traditional healers, and politicians.
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• Identify the medium of communication, e.g., television, radio, print media, or drama groups. If the
audience you intend to reach do not have access to television or radio, it is pointless to use such
methods. Likewise, if your intended audience is largely illiterate, it is pointless to use the print
media. In each case, the choice of medium must be appropriate for the intended audience.
Step 5: Develop communication objectives
• The desired end result in an IEC programme is to change from problem behaviour to a desired
behaviour.
• Objectives should therefore address actions, not knowledge, or attitudes
- Objectives should therefore be SMART, i.e., specific, measurable, achievable, relevant and timely
- An example of a well written objective- “by the end of the year 2009, 75% of infants in community X
will have been fully immunized by the time they reach 12 months of age”
Step 6: Develop strategies and activities
Decide on the general strategy to be used. Break this down into specific activities or actions. For each
determine:
• Who is responsible
• When the activities need to be accomplished
• What resources are needed
• Which partners are expected to be involved
Step 7: Develop messages
• Key to communication activities are the messages to be achieved. · Develop messages that:
• Reinforce positive factors
• Respond to misunderstandings and areas of insufficient knowledge
• Address attitudes
• Explain the benefits of behaviours promoted
• Urge specific action
• State where to find the services being promoted and any help that may be needed
• Address barriers to action
Step 8: Monitoring
The main aims of monitoring are to:
• Find strength and build on it
• Find a problem and fix it
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Choose appropriate indicators (based on the chosen objectives/ activities) and develop a detailed
monitoring plan as part of the initial planning process. Results of monitoring during the execution of your
activities will provide information to help you make necessary changes to your intervention and achieve
better results.
What is social mobilization?
Lead a discussion with participants and reinforce the discussion with the information below.
Social Mobilization
• The community is an equal and important partner whose ideas should be expected.
Social mobilization is involving communities in designing interventions or programmes and taking

action that benefits them. This can be done in programmes, such as national immunization days,
child health weeks, disease outbreaks, reproductive health activities, school feeding programmes,
HIV/AIDS and TB campaigns, national commemoration days, and rehabilitation etc
• For social mobilization to be effective, the community needs to be well represented and have a
clear understanding and appreciation of the issue at hand.
Strategies
• Identify and bring together all potential skills, resources, and stakeholders in the community
• Form a social mobilization committee, through the facilitation of an expert, which will act as a
forum for local communities to participate in community-based health promotion activities and
co-ordination and sharing of ideas and experiences.
• There is a need to establish the criteria for selection of members and develop the roles and
responsibilities. Partnerships should be based on shared vision, transparency, equality, and
consensus.
• Initiation of health promotion activities using health or health related issues prevalent in the area.
The community should have the major say in the selection.
• Empower the community with skills to set priorities, make decisions, plan, implement, and evaluate
the activities or intervention.
• Identify specific settings, such as schools, workplaces, or marketplaces to carry out the task.
• Encourage the use of various methods to address the issues. Selection of methods should be done
using an interactive participatory process.
• Monitor and evaluate programmes with the target audience using participatory methods.
Participatory methods
The following methods can be used to mobilize community action:
Group discussions
• Prepare the place for discussion well in advance, place people in their peer groups e.g., by age,
social status, or sex
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• Set agenda for discussion and objectives
• Build confidence in every member to ensure that everyone participates freely without feeling
embarrassed.
• Control members who dominate the group
• Maintain relevance
• Help the team to keep on track
• Talk less, listen more, and
• Keep time
Role plays
Collect information about a situation
• Analyse the issues
• Devise messages to be acted upon
• Avoid details
• Select people to do the role play
• Explain what they are to do
• Allow them to practice for a while
• During the play, the audience should observe and listen carefully, noting the skills and issue · After
the play, ensure that the role players resume their normal behaviour.
• Facilitate a discussion around the issues raised as they affect real life situation
Advocacy
Advocacy has become an unavoidable activity of health promotion; It is time consuming and therefore
potentially costly. Advocacy can enhance or damage your reputation or that of the health post. It is
therefore wise to ensure that there is a strong case for advocating for a selected issue. You should carefully
plan your advocacy campaign.
Before beginning an advocacy campaign, you need to answer five questions:
• What is the problem and its significance?
• Can it be easily changed?
• Are the benefits greater than the cost?
• Is there acceptance of the activities?
• What actions are recommended?
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Your advocacy is likely to be successfully, if in presenting your arguments you:
• Are clear about the problem
• Know the causes
• Put across workable solutions
• Provide evidence
• Create more people following in support of your idea
• Act firmly to improve the situation
• Revisit and adapt your arguments
For an effective advocacy programmes, you should ensure that you take the following steps:
• Identify the issues
• Reach consensus with different stakeholders on the issue
• Focus on an issue that has achievable goals, has high impact solutions, and is easily understood
and felt by many.
• Assess needs and be clear about what you expect to achieve
• State what you want to change by how much, by whom, and when
• Identify target audiences and analyse their perceptions
• Shape messages in such a way that they are easily understood
Deliver the messages at the right time, by the right person in the right place, and through the right media.
• State exactly in a few words what you want to say and why.
• Ensure a mass of supporters. Advocacy thrives on numbers.
• Use techniques and channels appropriate to the target audiences and setting · Assign clear
responsibilities to stakeholders.
• Implement strategy
• Provide feedback at each stage of the campaign · Evaluate strategy used and adapt where
necessary.
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CHAPTER 15:
INTEGRATED REPRODUCTIVE HEALTH
Objectives:
At the end of the session, the participants should be able to:
1. Describe the advice given to pregnant women and their families on hygiene, good nutrition, and
importance of attending antenatal clinics.
2. Describe the minor disorders and danger signs during pregnancy, labour and postnatal.
3. State the reasons for referring a pregnant woman or postnatal mother to a health facility
Duration:
32 hours
Teaching Materials
- Flip chart
- Flip Chart stand
- Markers
Teaching Methods
- Lecture
- Discussion
- Role plays
Explain that in Zambia most births take place in the homes, hence the need for safe motherhood and
family planning programmes to aim at promoting health and preventing illnesses for the mother, unborn
baby, new-born, and the subsequent children. This unit presents the basic elements of safe motherhood
needed for the Community Based Volunteer, so as to equip him/her with necessary knowledge/skills which
should enable him/her to advise women, their families, and the rest of the communities in which they live.
What is Safe Motherhood?
Explain what safe motherhood is to the participants.
Explain to the participants that they will be hearing the term “antenatal” during this training and perhaps
when dealing with health centre staff. Ask whether anyone can say what “antenatal” means.
Definition of Antenatal Care (ANC)
ANC is the care given to pregnant women from conception up to the beginning of labour. The
purpose of ANC is to prepare the woman and her family for pregnancy, labour, post-delivery care,
breastfeeding, and care of the new-born baby.
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Explain that although most pregnancies are normal, sometimes problems do happen, and a good for a
pregnant woman to know some of those problems before they become too big or serious is for her to visit
health centre for check-ups.
Ask participants whether they can think of other good reasons why a pregnant woman might want to see
the health centre for “antenatal visits.”
Explain that Safe motherhood focuses on:
- Antenatal Care
- STI/HIV Care and Prevention
- Essential Obstetric Care
- Newborn Care
- Post Abortion care
- Post Natal Care
- Family Planning
Antenatal Care
Activity
Group discussion on benefits of ANC for 10 minutes
Benefits of Antenatal Care
- Identifying conditions in the mother and the baby that are threatening.
- Advise on minor disorders of pregnancy.
- Advise on good nutrition during pregnancy avoiding drinking alcohol and smoking during
pregnancy.
- Explain the importance of tetanus toxoid vaccination during pregnancy.
- Explain to women the importance of breastfeeding and personal hygiene.
- Explain to the mother what happens during labour and delivery.
- Screening for STDs
Suggest that CBVs advise pregnant women to try to avoid taking medicines, because they might affect the
unborn child, and to try to follow the simple suggestions that you have discussed.
Role play
Divide the participants into small groups
Ask the members of each small group to take turns role – playing a pregnant woman and CBV. A pregnant
woman is consulting about a problem that she is having. Suggest that the “pregnant women” select for
themselves the problem(s) they are having either serious or not, from the list that they have all generated,
and that the other members of the group give feedback and suggestion to the “CBV” about the advice that
she gives in response.
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Tell the participants that they have 45 minutes to practice and ask them to begin.
After 45 minutes, call all participants together and ask for comments, observations, and suggestions. Ask,
for example, whether the advice to be given in each case seems realistic as in something that a woman
really could do.
Recommended Antenatal Schedule
Ask the participants how often a pregnant woman visits the health facility for a check – up during her
pregnancy. (This is not how often she should, but how often women generally do.)
Explain to participants the recommended schedule, as outlined below. Ask participants to turn to their
Handbook to see the schedule.
1st visit 16 weeks (by the end of 4 months)

2nd visit 24 to 28 weeks (6 to 7 months)
3rd visit 32 weeks (8 months)
4th visit 36 weeks (9 months)
Lead a discussion about how easy or how difficult it may be for a woman to keep to this schedule.
Ask the participants to think about some of the ways that they as CBVs might help make it possible for
women to follow this schedule.
Point out that the schedule is slightly different for “high risk” women. Ask what would make a pregnant
woman be thought of as “high risk.”
Find out if alcohol and smoking are believed to have an effect on the unborn child. Then list and discuss
some of the effects of alcohol and smoking during pregnancy
Effects of alcohol and smoking on the unborn child.
Alcohol
- Failure to grow in the womb.
- May be born before the time for birth is reached.
- Baby may be slow in growing and development.
- Some parts of the baby’s may be abnormal.
Smoking
- Failure to grow in the womb.
- Baby may die in the womb.
- May be born before term (preterm baby).
- May be born at term but may be small.
- May be even an abortion.
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Show the participants a TT card and explain the schedule. CBVs should advise women on the importance
of having tetanus toxoid vaccination during pregnancy e.g., to prevent infection in the woman as well as
in the baby after delivery especially if the cord is not managed properly at birth as well as in the first week
after delivery. Management is by good hygiene, during labour, delivery and postnatal.
Refer to the unit on Nutrition on advising women, their families, and the rest of the members of the
community on the importance of good nutrition during pregnancy and breast feeding.
Danger signs in pregnancy
Explain that during antenatal care it is important to educate women on danger signs and advise them on
the importance of seeking health services should they experience any.
Danger signs that put a pregnant woman at risk
- Bleeding from the private parts
- Severe headache
- Swelling of the feet and hands
- Body hotness or feeling cold
- Severe stomach pains
- Baby not moving or moving less
- Discharge or sore on private parts
- Getting tired easily or looking very pale.
- Fits during pregnancy
- High blood pressure
- Dizziness and blurred vision
Explain that during pregnancy however, a woman may also have minor problems. Add that as CBVs, they
will be able to help pregnant women decide on the problems for which they need medical attention and
which ones can be solved with fairly easy home care.
Ask the participants to name some of the common problems that women develop when pregnant. Start
by just identifying the problems, perhaps writing them on the board or on large sheets of paper. If one
of the problems listed below is not mentioned, bring it up. Look at each problem together and ask the
participants to suggest ways that pregnant women can deal with. If the suggestions in the list below are
not made, make them.
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Problem Advice
- Eat nuts, sweet potatoes, cassava, or little porridge upon waking
up in the morning
Nausea and Vomiting - Get up slowly from the bed upon waking up
- Eat small but frequent meals

- Drink lots of fluids
- Eat a lot of vegetables and fruits like (rape, spinach, pumpkin

Constipation
leaves cassava leaves, kalembula, bananas oranges)
- Take walks or move around

- Eat small but frequent meals
Heart Burn - Drink milk
. - Avoid eating spicy foods
- Avoid going to sleep immediately after eating

- Elevates legs when sitting
- Walk and try to move around and avoid standing for long
Leg Cramps periods
- East foods rich in calcium like sour milk, eggs, milk, and fish and
kapenta
- Elevate legs when sitting
Varicose Veins - Apply crepe bandage
- Eat a lot of vegetables and fruits to avoid lots of fluids

- Avoid long periods of sitting
Piles (Haemorrhoids) - Avoid straining when moving bowels

- Apply warm compresses
- Avoid carrying heavy loads

Backache
- sleep on a firm bed/reed mat
Section 2: STI/HIV Care and Prevention
Refer to STI and HIV chapter 15
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Section 3: Essential Obstetric Care
Explain to CBV that in order to ensure the safety of both mother and baby they should encourage pregnant
women, their families and community to seek the services of trained health workers.
Definitions of labour and delivery
Labour
This is when a pregnant woman experiences pain which results in the delivery of a baby, placenta, and
membranes.
Labour Identification
Regular pains increasing in nature.
Slippery mucus mixed with blood coming out.
Delivery
This is when the baby is born, and the placenta and membrane come out of the birth canal. Seeking
the services of trained personnel, the CBV should advise women on the following:
- Prevention of infection during delivery – by washing hands before attending to delivery and
using clean materials for the delivery (see material below).
- Recognising problems such as prolonged labour, vaginal bleeding during labour.
Prolonged Labour
Labour is said to be prolonged in a woman who has never delivered before if the duration of labour
takes more than 18 hours. In a woman who has had a delivery before duration of labour lasting for
more than 12 hours is prolonged labour.
Ask participants to list some of the complications which can arise during labour, delivery and after delivery.
Complications that may arise during labour

- Baby passing stool while still in the womb.
- Cord prolapses.
- Retained placenta.
- Recognising a tear after delivery.
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Ask participants about the minimum requirements needed for delivery.
Minimum requirements for a pregnant woman in readiness for delivery

- A piece of soap.
- A new razor blades.
- Cotton string which must be boiled or soaked in methylated spirit– used to tie the cord or cord
clump
- Clean wrapper/chitenge for delivery.
- Clean cloth or Nappies (2-4) for baby.
- Cotton wool or pads.
- Plastic sheeting
- Baby clothes, booties, head soak
- Mother’s clothes to change after delivery
Discuss with participants the importance of having a new razor blade for cutting the cord.
Ask the participants why the string for tying the cord should be boiled or soaked in methylated spirit
before use.
Section 4: new-born Care
Explain that care of the new-born is intended to give babies a health start to life and to reduce the
number of deaths of new-born. The participants will learn about the proper care of the new-born. Ask the
participants to describe the care that they think a new-born should receive. When they have finished, ask
them to turn to the handbook, and go over with them the recommendations listed there.
How to care for the baby after birth
- Always wash hands before touching the baby.

- Dry the baby soon after birth by wiping it clean with a dry cloth and keep it warm.
- Babies should not be exposed to cold because they can easily get sick.
- Use a new, unused blade to cut the cord.
- Keep the baby close to your skin to keep it warm. Skin to skin contact is best.
- Do not bath the baby immediately after birth for the first 24 hours.
Discuss vaccination at birth and briefly touch on the subsequent immunization and care (refer to unit on
immunization).
Remind the participants about the benefits of exclusive breast feeding the baby (refer to unit on
breastfeeding).
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Discuss any suggestions that they may have made that are not listed there, if some important suggestions
have been left out and you and the participants decide whether they should be included.
Emphasize the importance of recognizing the signs for referring the new-born for medical attention
immediately. Ask the participants what these danger signs after delivery are.
Section 5: Post Abortion Care
Explain that all clients with signs or history of abortion or miscarriage should be referred to the health
centre.
Section 6: Post Natal Care
Explain that appropriate care given to a mother and her new-born baby after delivery can help promote
health behaviours and identification of problems when they arise.
Explain that “Postnatal” is the term used to refer to the time after a woman has given birth. Add that
“postnatal care” is the care given to the mother from childbirth up to 6 weeks after delivery.
Ask participants why it is important to do post-natal care. What is to be gained?
Lead a brief discussion and guide participants towards forming one list. Write that list on large paper and
paste on the wall.
Remind participants that one of the things to do during post-natal care is to recognize danger signs and
refer those who present with any of the signs.
Abnormal Post Natal
Review the danger signs over with the participants
Danger signs after delivery

Baby Mother
• breathing difficulties, or not breathing fits • severe headache
• yellowness of the skin or eyes • body hotness or feeling cold
• increasingly severe stomach pain or pain in the
• fever, chills, rash private parts
• poor sucking or feeding problems vomiting • heavy bleeding
not active • breast sores, cracked nipples, redness or
swelling of breasts
• diarrhoea or constipation red, swollen eyes • bad smelling discharge from private parts
redness, pus, or blood from the umbilical
• Fits.
stump.
Find out whether any of the participants ever saw some of the danger signs in their community or family.
If they ever saw them what happened?
Ask the participants what they could do if they come across a woman with any of the abnormal signs?
Explain that a woman should make a postnatal visit to a health facility as soon as she notices any of the
abnormal signs. She should go to a health facility six weeks after delivery for routine examination and start
family planning, for monitoring of child’s growth and development, for a child who was born at home – to
start vaccinations.
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Section 7: Family Planning
Explain that as CBVs they will learn on how to educate their communities the benefits of family planning
and the methods that are available.
Ask participants to define “family planning.”
Definition of Family Planning

Family planning is a voluntary decision made by couples or individuals about the following: -
- The number of children they want

- How to space the births of the children
- when to start a family and when to stop.
- It also assists couples who are not fertile to achieve pregnancy
Invite participants who have had some experience with using family planning methods and who are
willing to talk about that experience with the group to do so. It might be interesting to hear what has
worked for people and what has not.
Divide the participants into small groups and ask each group to come up with a list of as many of the
benefits of family planning as they can. Tell them that they have 15 minutes to work and ask them to
begin. After 15 minutes, call everyone together and ask that one member of each group report on the
work of that group.
Benefits of Family Planning

Health benefits
- Women are less likely to have anaemia.
- A mother has time to improve her nutrition status and remain healthy.
- Less risk of abortions resulting from unplanned/unwanted pregnancies.
- Children have more chances of survival.
Socio-economic Benefits
Mother and father have time to give proper care to each child.
- Couples will enjoy sex without fear of pregnancy.
- Parents are able to give support to their children at school and to have time for each individual
member of the family.
- Parents, through savings, are able to provide basic needs for the family (e.g., shelter and
clothing).
Ask the participants how they feel about describing the benefits of family planning to their fellow
community members. What will be difficult? What will be easy?
Encourage the participants to share with each other some strategies that may work or that have indeed
worked in promoting the use of family planning methods in their communities.
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Participants
Ask participants to name the common family planning methods available in Zambia.
Common family planning methods available in Zambia
Common Family Planning Methods:
- The oral pills

- Natural family planning
- Condoms (Male and Female)
- Intra-Uterine Contraceptive Device (available at health facilities)
- Injectables (available at health facilities)
- Sterilization – both male and female. These are available at hospitals.
Using the Family chart review the items/methods shown, pointing out methods available in the community
and which must be gotten from a health facility.
Go through the list, item by item, asking the participants to describe how each item or method is used.
When participants are not familiar with an item or method, explain its use.
Using the penile model and any other examples available show the correct method of putting a condom
on a penis and have participants practice doing this demonstration.
During the demonstrations, encourage the participants to talk about how they think people feel about
using the various methods for family planning. Discuss some ways to help people feel more comfortable
with using the methods.
Role play
Divide participants into small groups. Ask the members of each group to take turns playing the CBV and
the community member in a series of role plays.
Ask that in each role play the “community member” approach the CBV to ask for help and advice about
family planning.
Suggest that the “community member” choose what to ask, such as what methods are available, how does
a particular method work, where can I get this item to use, etc.
Tell the small groups that they have 45 minutes to practice and ask them to begin.
To motivate men and women for family planning and refer them to the CBD agent or health centre.
After 45 minutes, call all the participants together and ask for reactions, comments, and questions. When
there are questions, first try to have the participants answer them. If they cannot, answer them yourself.
But if you do not know an answer, say so, but promise to get the answer for them as soon as possible. And
then do so.
Thank them for their participation in the role plays.
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CHAPTER 16:
MALARIA
This is chapter 13 in the participants’ handbook
At the end of this session the participants should be able to:
• Explain the five steps to malaria transmission
• Cite the four factors affecting malaria transmission
• Say which groups of persons in the community are at highest risk
Duration:
3 hours
Teaching Materials
- Flip charts
- Markers
- Bostik
Teaching Methods
- Lecture
- Discussion
- Demonstration
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Explain that malaria is the most common cause of illness and death among children under 5 years of age in
Zambia. Most of the visits and admissions to health facilities are due to malaria. Malaria can be prevented
and cured. In this unit Community Based Volunteers (CBVs) will learn how to care for adults and children
with malaria and therefore to reduce the number of deaths due to malaria.
Malaria transmission
Ask the participants why it is important to learn how malaria is passed from person to person. Explain that
this is called “transmission.” Encourage everyone to share their ideas. Review the 5 steps to transmission
with participants
Five steps of malaria transmission

Step One:
A malaria mosquito lands on a person who is already sick with malaria. The person who is sick with
malaria has malaria parasites in their blood. A parasite is a small kind of germ.
Step Two:
The malaria mosquito bites the sick person. When it does, it sucks the sick person’s blood and
parasites into its own body.
Step Three:
The parasites grow in the mosquito for 10-14 days.
Step Four:
The malaria mosquito bites a well person. The mosquito injects the parasites from the sick person
into the blood of the well person.
Step Five:
Once in the blood, the malaria parasite multiplies. From the time of the bite, it takes from 7 to 14
days for the person to feel sick from so many parasites in their blood.
Malaria is a disease people get when a mosquito carrying the malaria parasite bites them and injects
the parasite into their body. Not all mosquitoes carry malaria. The mosquitoes that make noise do
not carry malaria. Malaria mosquitoes do not make noise. The types of mosquitoes that can carry
malaria bite late at night, usually from 22:00 hours to 04:00 hours.
How much water does a malaria mosquito need to breed?
Explain that a small amount, as small as footprint
Important facts about malaria mosquitoes and person to person transmission

- Malaria can occur throughout the year, but it is most common during the rainy season.
- Many mosquitoes come out at night and are bothersome, but not all mosquitoes transmit malaria.
- Mosquitoes which make noise are not malaria mosquitoes. Malaria mosquitoes are silent.
- Malaria mosquitoes come out mainly late at night (20:00hrs) to early in the morning, (02:00hrs).
Not as much in the early evening.
- Malaria mosquitoes can fly as far as 7 km away from the community.
- Malaria mosquitoes can breed even in small amounts of water such as a footprint in the rainy
season.
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People at highest risk
Ask which people in the community are most at risk of illness and death from malaria.
People in the community who are at highest risk of illness and death from malaria infection
The most vulnerable to malaria are:
- Pregnant women
- Children under Five years of age
- People with chronic illnesses
It is important to know who these people are since they need special protection from malaria.
Families and communities should take special care to ensure that these people do not get infected
with malaria.
Recognizing the Signs and Symptoms of Malaria
Malaria is a serious illness that can cause death if it goes untreated. Therefore, it is very important that the
community learns how to recognize when someone in the community may be sick with malaria. Early
recognition of malaria and early treatment can prevent serious illness and death.
Signs and Symptoms of Malaria
Ask participants to describe what it is like to have malaria.
Ask participants whether children who have malaria show any different signs of the disease than adults.
Signs and symptoms of malaria
- Fever (body hotness)
- Feeling cold and shivering
- A lot of sweating
- Sick to the stomach and vomiting
- Headache
- Painful joints
- General body weakness
If the sick person is a child, they may also have:
- Restlessness
- Loss of interest in the surroundings
- Loss of interest in food or breast milk
- Convulsions
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MALARIA TESTING, TREATMENT, AND REFERRAL
Goal Agenda
Time: 60 Minutes
Method: Interactive plenary session, presentation
Goal
To teach participants how to test for malaria.
Objectives
By the end of this session, participants should be to:
1. Demonstrate how to use RDTs for malaria and provide treatment, including testing, correct drug dosage and
channel for referral cases.
• Describe how malaria testing is done.
• Demonstrate malaria testing using a rapid diagnostic test (RDT).
• Properly read and record RDT results.
2. Explain malaria treatment.
• Explain malaria treatment guidelines for simple malaria.
• Treat malaria patients correctly.
3. Identify patients that should be referred.
• Identify patients that should not be treated but referred.
4. Explain pre-referral treatment of eligible children.
5. Show how to fill in a referral note.
• Correctly give pre-referral treatment to demonstration activity, case study eligible children using rectal
artesunate.
• Correctly complete the referral note.
Preparation/materials:
- Flip charts, markers (two different colors), visual cards, projector, and screen.
- Ensure that each participant has a copy of the visual card displaying the malaria life cycle diagram or
is able to see the projection clearly
(i) Demonstrate how to use RDTs for malaria testing
Explain that before providing malaria treatment to a person, it is important to confirm the presence
of malaria parasites in the body. Testing or diagnosis of malaria cases cannot be done by observing
signs and symptoms only because other diseases like flu share the same signs and symptoms with
malaria.
WHO defines a case of malaria as one that has been confirmed through detection of malaria parasites
by using a scientific test such as a rapid diagnostic test (RDT)or microscopy.
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Explain that these two tests—rapid diagnostic tests or microscopy—are the two common methods of
malaria diagnosis and that community health workers ONLY test using rapid diagnostic tests.
Preparing for rapid diagnostic testing
Explain to participants that, before doing anything, it is important to observe the following:
1. Take time to explain to the patient what you are going to do.
2. Read product instructions carefully.
3. Prepare the following materials:
• RDT (new unopened test device, alcohol swab, buffer)
• New, unopened lancet
• Disposable gloves
• Timer or watch
• Cotton, alcohol (if swab not supplied with the RDT)
• Box/containers for used lancet/sharps and other infectious waste
• Pencil or marker for labelling the RDT
• Record book and pen for recording the results 4. Check expiration date of the RDT and colour
of desiccant.
DO NOT use an expired or damaged RDT or an RDT showing signs of exposure to humidity
Note: Exposure to humidity can be observed:
• By shaking the desiccant; if the granules shake then there has been no exposure but if granules have
solidified then there was exposure.
• OR by checking the colour of the desiccant as follows:
1. RDT not exposed to humidity desiccant granules remain the original colour of the desiccant (Yellow
or White).
2. RDT exposed to humidity desiccant granules change from yellow to green.
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NB: Do not use rapid diagnostic test which is expired as it may give you false results
Rapid diagnostic testing procedure
As participants observe, demonstrate the process of performing a rapid diagnostic test:
Ask two participants from the group to demonstrate the process in front of the class to see whether they
have understood. One should play the role of the CHW and the other the role of a patient.
Reading RDT results
An important part of malaria diagnosis is to be able to read, interpret and record results correctly. There
are three possible results in an RDT test. These are positive, negative, or invalid.
• The test is positive if the malaria parasites are found in the patient’s blood.
• The test is negative if there are no malaria parasites in the patient’s blood. This means that further
investigation is required to determine the cause of the fever.
• The test is invalid if it shows no defined reading of being either a positive or negative result. This can
occur when the test is not done correctly or when the RDT is damaged.
135
The images below show how RDT results are read:
Positive: lines appear in both the “control or C” window and the “Test or T”.
Note: The test is positive even if the line on “Test or T” is faint. As indicated below
Negative: Only one line appears in the “Control or C” window. There must be no lines in the “T” window”.
Invalid result: If there is no line in the “C” window (or there are no lines at all), then the test is invalid
Note: Results must always be written in the register
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Activity
RDT result reading (practical)
Now that participants understand how to administer an RDT, it is important for them to practice how to
read and record results correctly.
1. Collect used RDTs and line them systematically on a table.
2. Divide participants into small groups. Allow participants in each group to do the following:
• Write their name on a piece of paper.
• Carefully observe the RDTs displayed on the table.
• Read, interpret, and record result of each labeled RDT cassette on their piece of paper.
3. Collect the pieces of paper, grade, and tabulate results. Conclude the activity by emphasizing the
following key points.
Key points to remember for RDT use
• Follow RDT instructions strictly.
• Keep a copy of the product insert handy.
• Do not use expired or damaged RDTs.
• Do not use the RDT if the pouch/packet is punctured or damaged or the desiccant has
changed colour.
• Do not mix buffers, cassettes of different RDT brands.
• Open the RDT pouch just before using it.
• Avoid prolonged exposure to humidity during RDT preparation.
• Store RDTs in a shady, cool place.
• Read and interpret test results after or within the time specified by the manufacturer.
• Do not re-use RDTs.
• Always observe blood safety practices.
(ii) Explain malaria treatment
In the previous discussion, participants will have learned how to diagnose and test for malaria. We
now focus on what treatment should be given once the patient has been tested and found to have
malaria.
Treatment of malaria by a community health worker
CHWs can only treat simple malaria in children with a body weight over 5kg and in non-pregnant
individuals at all ages. All other cases of malaria MUST be referred. Zambia uses artemisinin
combination therapies (ACTs) for treatment of uncomplicated or simple malaria.
Artemether-lumefantrine (AL) treatment for malaria
AL is the current national malaria treatment policy choice for simple malaria in adults and children
who weigh at least 5 kg. AL is a combination of two active substances, artemether and lumefantrine,
both of which work together to kill the parasites that cause malaria.
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ACT dosages:
Paracetamol dose: give every 6 hours until fever stops
Age 100mg tablet 500mg tablet

2 months up to 12 months
(6 – 10 kg) 1 ¼
12 months up to 3 year
10-15kg 1 ¼
3 years up to 5 years
15-19 kg 1½ ½
Ask the participants whether people in their area generally give paracetamol to children. If so, for what
reasons do they give it? If not, what, if anything, do they do relieve the discomfort of children when they
are sick?
Explain that although CBVs may not have Paracetamol in their CBVs kits, they will be expected to teach
caregivers the correct amount of Paracetamol to give a child who has fever.
Do a brief demonstration of how to determine how much Paracetamol to give a child and how to give it.
Prevention of Malaria
It is important to learn how to prevent people from getting malaria. Prevention is much better than getting
sick and then hoping to find a cure.
Training methods
Explain to the participants that malaria prevention is an important community activity. Add that CBVs
should be able to advise community members on how they can prevent malaria in their communities.
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Ask the participants to list the reasons why it is important to prevent malaria. Reinforce prevention rather
than cure
Reasons why it is important for families and communities to prevent malaria
- Prevention keeps people well

- Prevention keeps people from dying
- Prevention is less expensive than treatment
- Prevention keeps the family happy, but sickness and death make everyone sad
Ask participants to list ways in which malaria can be prevented. Facilitator to divide responses into the 3
categories: A) Most cost-effective (ITNs). B) Other ways. C) Expensive or less effective ways.
Present the methods of malaria prevention to the participants. Stress that some methods are better and
cost less than others.
Malaria is prevented by protecting ourselves from mosquito bites. That is the only way we can be sure that
we will not get sick from malaria. Some ways of preventing malaria are more effective than others.
Insecticide-treated mosquito nets
The very best way to prevent bites from the malaria mosquito is to sleep under a mosquito net every
night, especially one that has insecticide incorporated in its fibres. This is the most effective way of
protecting ourselves from malaria mosquitoes.
Other ways less effective in prevention of mosquito bites
- Wear long sleeves, long pants or skirts and cover your hands and feet in the evening to keep
mosquitoes away.
- Cover up all children, including babies on the back, in the evening to keep mosquitoes away
from their skin.
- Burn grasses or leaves to make smoke and sit where it is smoky to keep the mosquitoes away.
Expensive and less effective ways of preventing mosquito bites
- House spraying: This method is only effective if the spraying is done very often (every 6 months),
and all houses are sprayed.
- Cutting grasses: This method will keep the area clean and keep rats and snakes and other pests
away, but malaria mosquitoes do not breed in grasses.
- Emptying containers with stagnant water: This method may cut down on mosquito breeding
but cannot completely do away with malaria mosquitoes.
- Filling local dambos: this method will also cut down on mosquito breeding but cannot
completely do away with malaria mosquitoes since they can breed in just a little water and fly
from very far away.
- Use of mosquito sprays, coils, and malaria prevention drugs: These methods are expensive
for most people.
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Ask participants to discuss the various methods they use to prevent malaria.
The advantages of owning a treated net
• Simple and effective:
It is a simple way of providing effective protection against malaria. Treated nets are especially
useful in preventing malaria in infants and children. Treated nets have a big impact on reducing
severe malaria disease and deaths
• Long term, full protection:
A treated net gives protection even if it is torn, or not tucked in properly, or a part of the sleeping
person’s body is touching the net. On the other hand, an untreated net provides much less
protection. Treatment extends the useful life of the net even when it is torn. Mosquitoes are killed
up to 12 months after treatment. Some of the nets available are pre-treated with a longer lasting
insecticide These provide protection for more than 12 months.
• Reduces mosquito population:
The widespread use of treated nets helps to reduce the number of mosquitoes and transmission
of malaria. Untreated nets do not reduce the population of mosquitoes.
• Safe and easy to use:
Everyone can use treated nets; no special training is necessary. Treatment can be learnt by anyone
in the community and can even be done by households. Unlike insecticides used in spraying
campaigns, net insecticides are safe even for children, as the quantity of insecticide used is very
small.
• Cheap and long lasting:
Mosquito nets and insecticides are not very expensive to buy. If the net is carefully looked after, it
can be used for five years or above.
• Protects from all insects:
Treated nets reduce the bites of malaria mosquitoes, and other nuisance biting, crawling and flying
insects. This enables the family to sleep in comfort. A treated net also provides some protection
to those in the household who are not sleeping under it. These benefits are not present with
untreated nets.
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CHAPTER 17:
DIARRHOEA
• Define diarrhoea.
• Explain why diarrhoea is dangerous.
Duration: 1 hour.
Teaching Materials
- Flip charts
- Markers
- Bostik
Teaching Methods
- Lecture
- Discussion
- Demonstration
141
Explain that Diarrhoeal diseases have been and continue to be a major cause of death and illness in the
community, and especially among children under-5 years of age. Deaths are often caused by dehydration.
Dehydration can be treated safely and effectively by a simple method- Oral Rehydration Therapy (ORT). In
this unit, CBVs will learn about how to decide which diarrhoea may be treated safely at home and which
children with diarrhoea must receive medical attention at the health centre. In addition, CBVs will learn
proper home care of children with diarrhoea, including ORT.
Ask the participants what diarrhoea is. Lead the group discussion to create a definition similar to the one
listed below.
Definitions
Diarrhoea is the passing of loose watery stools more than three times a day. During diarrhoea, other
fluids, food, and body salts are lost, resulting in reduction of the normal body fluids (dehydration).
Diarrhoea is most common in children between 6 months to 2 years.
Dehydration is the loss of large amount of water and salts from the body.
As part of the discussion, be sure to include what diarrhoea is not (it is not simply the frequent passing of
stools or just soft stools.)
Dangers of Diarrhoea
Ask the participants whether they think diarrhoea is dangerous, and, if they do, why it is dangerous. Be
sure that most of the Dangers of Diarrhoea listed below are mentioned in the discussion.
Dangers of diarrhoea
Death from acute diarrhoea is most common and often caused by dehydration. Diarrhoea can
cause malnutrition and death.
Optional Exercise
- Fill a surgical glove with water and tie it off.
- Tell the participants that a child, like this surgical glove, should have plenty of water.
- Poke a small hole in one finger of the glove.
- Say that although some water is lost every day when a child urinates and defecates, when a child has
persistent diarrhoea, the child loses more than he or she should.
- Make the hole larger, and say that when a child has acute diarrhoea, the child loses too much water
to fast. Like the glove, the child becomes thin and wasted when he or she loses water too quickly.
Assess for diarrhoea
Refer to Chapter 6 B Sick Child on assessing for Diarrhoea.
Causes of diarrhoea
Ask participants what they believe causes diarrhoea. Write the causes that are stated on flipchart paper
and summarize their statements out loud.
If participants have stated that eating contaminated food or drinking water that is not clean can cause
diarrhoea, say that they are correct. State that there are very effective ways to make food safe to eat and
drink, and that together you will talk about them here.
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Management of Diarrhoea
All children presenting with diarrhoea and no signs of dehydration need to be treated at home Explain
that children with diarrhoea may die from dehydration therefore they will need to be assessed in order to
determine whether to refer urgently to the health facility or not. An important part of the CBV’s job is to
decide which children need medical treatment.
If the child has diarrhoea less than 14 days, with no blood in stool and no other danger sign, the family can
treat a child with diarrhoea at home. A child with diarrhoea receives ORS solution and a zinc supplement.
Below is the box on treating diarrhoea on page 2 of the recording form. The box is there to remind you
about what medicine to give and how to give it.
 If diarrhoea (less than 14  Give ORS. Help caregiver to give child ORS solution in front of
days you until child is no longer thirsty.
AND no blood is stool)  Give caregiver 2 ORS packets to take home. Advise to give
as much as the child wants, but at least 1/2 cup ORS solution
after each loose stool.
 Give zinc supplement. Give 1 dose daily for 10 days:
 Age 2 months up to 6 months 1/2 tablet (total 5 tabs)
 Age 6 months up to 5 years—1 tablet (total 10 tabs)
Help caregiver to give first dose now.
 Give ORS
A child with diarrhoea can quickly become dehydrated and may die. The body loses water and salts in
diarrhoea. These must be replaced. Giving water, breast milk, and other fluids to children with diarrhoea
helps to prevent dehydration.
However, children who are dehydrated—or are in danger of becoming dehydrated—need a mixture of
Oral Rehydration Salts (ORS) and water. The ORS solution replaces the water and salts that the child loses
in the diarrhoea. It prevents the child from getting sicker. The new, improved ORS also helps shorten the
time the child will suffer with diarrhoea.
Use every opportunity to teach caregivers how to prepare ORS solution.
Ask caregivers to begin giving ORS in front of you and give it until the
child has no more thirst. The time the child is in front of you taking
ORS helps you to see whether the child will improve. You also have a
chance to see that the caregiver is giving the ORS solution correctly
and continues to give it.
If the child does not improve, or develops a danger sign, urgently

refer the child to the health facility.
If the child improves, give the caregiver 2 packets of ORS to take

home. If diarrhoea continues, advise the caregiver to give as much
ORS solution as the child wants. But give at least 1/2 cup of a 250 ml
cup (about 125 ml) after each loose stool.
ORS mixed with water replaces the fluids and salts lost
during diarrhoea.
143
The new formulation of ORS—low osmolarity ORS—helps to reduce the
number of fluids the child loses during diarrhoea. It also helps shorten
the number of days the child is sick with diarrhoea.
(UNICEF distributes this packet of ORS to mix with 1 litre of water. A

locally produced packet will look different and may require less than 1
litre of water. Check the packet for the correct amount of water to use.)
Prepare ORS solution
1. Wash your hands with soap and water.
2.
Pour the entire contents of 1 packet of ORS into a clean

container (a mixing bowl or jar) for mixing the ORS. The
container should be large enough to hold at least 1 litre.
3. Measure 1 litre of clean water (or correct amount for

packet used). Use the cleanest drinking water available.
In your community, what are common containers

caregivers use to measure 1 litre of water?
4. Pour the water into the container. Mix well until the salts
completely dissolve.
Give ORS solution
1. Explain to the caregiver the importance of replacing fluids in a child with diarrhoea. Also explain
that the ORS solution tastes salty. Let the caregiver taste it. It might not taste good to the caregiver.
But a child who is dehydrated drinks it eagerly.
2. Ask the caregiver to start giving the child the ORS solution in front of you. Give frequent small sips
from a cup or spoon. (Use a spoon to give ORS solution to a young child.)
3. If the child vomits, advise the caregiver to wait 10 minutes before giving more ORS solution. Then
start giving the solution again, but more slowly. She should offer the child as much as the child will
take, or at least ½ cup ORS solution after each loose stool.
144
4. Check the caregiver’s understanding. For example:
• Observe to see that she is giving small sips of the

ORS solution. The child should not choke.
• Ask her: How often will you give the ORS solution?
How much will you give?
5. The child should also drink the usual fluids that the child
drinks, such as breast milk.
If the child is not exclusively breastfed, the caregiver

should offer the child clean water. Advise the caregiver
not to give very sweet drinks and juices to the child with
diarrhoea who is taking ORS.
6. How do you know when the child can go home?
A dehydrated child, who has enough strength to drink, drinks eagerly. If the child continues to
want to drink the ORS solution, have the mother continue to give the ORS solution in front of you.
If the child becomes more alert and begins to refuse to drink the ORS, it is likely that the child is
not dehydrated. If you see that the child is no longer thirsty, then the child is ready to go home.
TIP: Be ready to give ORS solution to a child with diarrhoea. Keep with your medicine kit:
• A supply of ORS packets
• A 1 litre bottle or other measuring container
• A container and spoon for mixing the ORS solution
• A cup and small spoon for giving ORS
• A jar or bottle with a cover, to send ORS solution with the caregiver on the trip to health facility
or home.
Put the extra ORS solution in a container and give it to the caregiver for the trip home (or to the health
facility if the child needs to be referred). Advise caregivers to bring a closed container for extra ORS solution
when they come to see you next time.
8. Give the caregiver 2 extra packets of ORS to take home in case she needs to prepare more.
Encourage the caregiver to continue to give ORS solution as often as the child will take it. She
should try to give at least ½ cup after each loose stool.
Store ORS solution
1. Keep ORS solution in a clean, covered container.
2. Ask the caregiver to make fresh
ORS solution when needed. Do not keep the mixed ORS solution for more than 24 hours. It can lose its
effectiveness.
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ZINC Tablet
Zinc is an important part of treatment of diarrhoea. Zinc helps to lessen the amount of fluids lost during
diarrhoea so that the diarrhoea is less severe. Zinc shortens the number of days for diarrhoea. It increases
the appetite and makes a child stronger.
Zinc also prevents diarrhoea. Giving Zinc for the full fourteen can help prevent diarrhoea for up to the next
three months. For these reasons zinc is now given to children with diarrhoea
Home Treatment of Diarrhoea
Explain that all children presenting with diarrhoea and no signs of dehydration (in other words, the danger
signs that were talked about in the last unit) should be cared for at home.
Add that part of their responsibilities as CBVs will be to teach the caretakers of those children with
diarrhoea some things they can do to help their children get better quickly and to keep their children
from becoming dehydrated.
Ask why it is important to increase fluids.
Ask the learners what kinds of fluids would be good to give the child.
Types of fluids
- Breastmilk
- Plain clean water – best boiled
- Maize/samp water
- Rice water
- Sour milk
- Fresh munkoyo and chibwantu
- Oral rehydration salts (ORS)
- Fresh fruits juices
Tell the learners the several suggested fluids are listed in their Handbook.
Ask the learners why it is important also to feed the child.
Ask them what kind of foods the caretaker should feed a child who has diarrhoea.
Thank the learners for all their suggestions as to food and drink for the child with diarrhoea. Tell them that
many of the suggestions they have made about food and drink for the child with diarrhoea are listed in
their Handbook.
Explain that caretakers also need in mind that even when they give extra fluids and continue to feed the
child with diarrhoea, sometimes the child will get worse and will need medical treatment.
Ask the learners what they know about Oral Rehydration Solution, or ORS.
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SECTION 7: PREVENTION OF DIARRHOEA
One of the most important jobs for CBVs is to help community members adopt certain preventive practices
and continue to practice them in order to prevent diarrhoea (refer to chapter on water and sanitation).
Go over the pictures one-by-one as a review of some of the ways that people can prevent diarrhoea. For
example, the following format may be used:
Trainer: What do you see in this picture?

Participants: (Description of pictures)
Trainer: How does this help prevent diarrhoea?
Participants: (Reasons given)
Trainer: (Trainer agrees or, if necessary, asks other learners for their ideas.)
Go through with the participants the recommended preventive practices below:
Recommended preventive practices
Breastfeeding: Children exclusively breastfed up to 6 months and continue breastfeeding up to 2 years

have less diarrhoea.
Improved complementary feeding practices
Children should be introduced to new foods at the age of 6 months to meet their daily requirements for
growth. Caretakers are advised to take extra care in the preparation of weaning food, since this is the time
when children are likely to develop diarrhoea. Caretakers must observe the following food preparation
practices:
• Wash hands before preparing and feeding the baby
• Use clean utensils to prepare weaning foods · Give freshly prepared food to the baby
• Keep baby’s food well covered in a clean place
• Never use feeding bottles to feed the baby, use a cup
Use of plenty of clean water
If water is too little or is dirty, it is a good source of disease. Do the following to prevent diarrhoea:
• Collect water from the cleanest available source.
• Treat your water with Chlorine Home Water Purification Solution. Chlorine can be found in health
clinics, pharmacies, drug stores, shops, and supermarkets throughout Zambia for a very small
price. Refer to the Section on Water and Sanitation, dosing instructions on Chlorine.
• Store your drinking water in a closed container. Do not scoop water out of the container with your
hands or a cup as this might contaminate the water again.
• Drinking water should be boiled or left to stand for 24 hours in a covered container before drinking
• Protect water sources from animals and away from latrines.
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Hand washing
Family members should wash hands:
• Before eating or feeding a child after defecation
• After disposing of a child’s faeces.
• Caretakers should wash the hands of young children all the time.
Use of latrines
Emphasize that all families should have clean latrines that should be used by family members who are
old enough to use them. The latrine must be kept clean by regular washing of dirty surfaces. If there
is no latrine, family members should defecate a distance away from the house, paths, or areas where
children play and at least 10 metres from the water source and bury the faeces. Avoid going barefoot to
the defecating area. Do not allow children to visit the defecating area alone.
Bury the stools of young children. Quickly collect the stools of a young child or baby, wrap it in a lead
or newspaper and bury it or put in the latrine. Young children should be assisted to defecate in a place
where faeces can easily be collected and disposed of. Children should be cleaned, and hands washed
immediately after defecation.
148
CHAPTER 18:
ACUTE RESPIRATORY TRACT INFECTION (ARI)
• Define “cough or cold.”
• Define pneumonia
• Explain why it is important to get medical treatment for a young infant or child who has pneumonia.
• Explain the referral procedure of sick children
Duration:
1 hour.
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
149
Explain that respiratory infections occur in any area of the airway including the nose, throat, voice box,
air passage and lungs. Acute Respiratory Infections (ARI) are one of the major outpatient attendance,
admission, and deaths in Zambia.
SECTION 1: COUGH, COLDS AND PNEUMONIA
Explain that many times when a child has a cough or a cold (often called “flue”), that child can be taken
care of at home. Home care may be enough to help the child get better.
A child that has a runny or blocked nose is said to have a cold. Sometimes the child also has a cough. The
parents or caretakers may treat a child with a cold or cough at home.
Definition of pneumonia
Explain that pneumonia is an infection of the lungs. Pneumonia is a common cause of death in children,
and especially in young children. A child that has pneumonia should be taken to the health centre to
receive medical treatment as quickly as possible. – Remind participants to refer also to chapter 6 (B)
Assessment of Sick Child in their handbook)
SECTION 2: SIGNS OF PNEUMONIA
Explain that a child with cough or cold may develop a more serious infection of the lungs called pneumonia.
When a child has a cough or cold, the caretaker should watch for signs of pneumonia. The signs that show
that the child has developed pneumonia are fast breathing, difficult breathing, and chest in-drawing.
Assessing the child with cough or difficult breathing and treatment refer to Chapter 9 (B) Sick Child
- assessing for cough or difficult breathing and treatment for pneumonia.
For a child who has been given medicine at the health facility to take home:
Tell the caretaker to continue feeding and offering the child more fluids together with breast milk, as well
as keeping the child warm. Soothe or relieve any pain that the child has on the throat with warm water or
tea + honey/sugar (+ lemon). Remind the caretaker to take the child to the health facility on the day they
have been given or if the child is not improving.
Prevention
• Immunisations help prevent some respiratory infection Ensure that the child is kept warm.
• Avoid overcrowding
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SECTION 4: REFERRAL PROCEDURES
Tell the participants that it is important to refer the child with pneumonia if you cannot treat the child with
an antibiotic at home or if the child has severe pneumonia or danger sign as discussed in chapter 9 (B)
Explain that there are four steps to take when you refer a child to the health facility these are:
1. Explain to the caretaker that the child is very sick and must be taken to the nearest health centre
for treatment.
2. When explaining this to the caretaker, give examples of children with similar illness who have
recovered after treatment in the health centre or hospital.
3. Give clear and specific instructions to caretakers regarding the care of the child on the way. That
advice should include the following:
• Keep the infant warm.
• Clear secretions if nose is blocked.
• Continue breastfeeding the infant and increase fluids for the older child.
Write a referral note about the sick child (see example in the Appendix). Give the note to the caretaker,
who should carry it to the health worker at the health centre.
Explain that when a child has received treatment at a health facility, sometimes the caretaker is given
medicine to give the child at home. The caretaker is given advice on when to return immediately. The
CBV should also advise caretakers on when to quickly go back to the health facility. The points below are
a guide to advising the caretaker to return to the health facility immediately. The caretaker should return
immediately if the child:
1. Is not able to drink or breastfeed or
2. Becomes sicker or
3. Develops a fever
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CHAPTER 19:
WATER AND SANITATION
• Define “safe water sources”
• Describe and demonstrate two common water sources available in the community.
• Pro mote the use of safe water sources in the community.
• Explain two steps that may be taken to make and keep water sources safe.
• Explain the importance of using pit latrines.
• State the important of considerations to keep in mind during the sitting of a latrine.
• State the benefits of appropriate human waste management.
• List two common types of latrines.
• Explain the difference between a traditional pit latrine and a ventilated improved pit latrine
• Identify common pests found at household level
• State the benefits of pest control
• Establish control measures against household common pests.
Duration:
4 hours.
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
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Ask participants what some of the determinants of health are (Income, Education, Food supply,
Water supply, Good sanitary conditions, Environment, Justice, Peace, Economic opportunity, etc).
Acknowledge all responses. hopefully, someone will mention “clean water.”
Explain that in this part of the chapter you would like to talk about clean water and ask why clean water
is important (Answer: People need clean water to be healthy. Drinking dirty or contaminated water can
cause several illnesses).
Explain that safe drinking water and healthful sanitation practices are essential to life. Shortage of water,
inadequate sanitation and poor hygienic practices cause common diseases that affect our daily lives. A
number of studies done in Zambia suggest that less than 40% of households have access to adequate water
and sanitary services. In this country, water and sanitation related problems are major causes of hospital
admissions and deaths. The major diseases arising from poor water supply and sanitary conditions are
diarrhoeal diseases such as dysentery, cholera, typhoid, and acute diarrhoea. Other water and sanitation
related diseases include worm infestations, eye, and skin infections.
Section 1 : Water sources
Tell the participants that this section deals with the common sources from which people draw their water
for everyday use. Water affects heath in many ways. It may carry germs of specific diseases called, water-
borne diseases. Shortage of water and inadequate personal hygiene may result in increased transmission
of a water-borne disease.
Explain that because people need access to safe water sources if they are to be healthy and able to prosper,
every community must be able to offer its members safe water.
Add that the CBV can help his/her community establish and maintain safe water sources.
Say that in this session, participants will learn what some of the common water sources in communities
are, how to keep those sources safe, and how to promote the use and maintenance of water sources
Ask participants to define safe water, safe water source and protected water source. Reinforce the
responses given and summarize by giving the definition below.
Definition of safe water
Safe water can be defined as water drawn from protected sources which is free from suspended impurities
and harmful substances and organisms.
Definition of safe water source
These are water sources, which are protected and have less chance of spreading water-borne diseases.
Definition of protected water sources
Water source is protected when it is prevented from contamination by human and animal waste, refuse,
and bathing and! or washing.
Examples of safe water sources
• Deep protected well
• Protected spring
• Deep well-bore hole
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Methods of protecting water sources
• Fencing of water point
• Fencing offspring/digging a drainage system
• Bore-holing
• Zoning of water source
• Provision of drainage system
• Lining of water sources
Hold up a clear container of water (perhaps a tall glass of water) and ask the participants something like
the following: “How can you tell whether water is clean and safe to drink?” (Answer: You cannot tell by
looking at it, but you can be sure always to draw your water from a
“safe” water source. Or you can test it in a laboratory).
If someone has mentioned the idea of a safe water source, ask what that is. If no one has, bring it up and
ask what it is.
Ask participants to name or to describe some safe water sources.
For each source named, ask participants to state why it is a safe source. (Answer: Each source is protected
from contamination by human and animal waste, refuse, and bathing and/or washing. The protection is
often provided by fences)
Ask participants what water sources they have where they live.
Explain that you will now lead the participants through the “water ladder” exercise, which is an exercise
that they may want to use with their communities to help the members discover just how safe their water
supplies are and whether changes need to be made.
The Water Ladder
Explain that this is a set of 18 pictures (each on separate page) each depicting particular water
source, including traditional water sources and commonly used pumps.
The Water Ladder
This is a set of 18 pictures, each depicting a particular water source. These pictures include
traditional water sources and common pumps used. When using the ladder, always check that
the group understands and can interpret each picture in their own context. The basic principle
of water ladder is that the water sources can be ranked through sequence of being poor or good.
This will tell a lot about the existing knowledge and hygiene practices and water source situation
in a given community.
Go over all the pictures with the participants, checking to be sure that everyone understands and can
interpret each picture.
Divide participants into small groups. Give each group a complete set of water ladder images.
Ask each group to work together to arrange the pictures in order from the safest water source to
the least safe.
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Add that each group should be prepared to explain why they have chosen to place the pictures in that
particular order.
Say that they have 30 minutes to work and ask them to begin. After 30 minutes, call all participants
together and ask one group to present to everyone else how they have arranged their images.
When they have finished, ask whether another group has a different arrangements and explain why they
have made the choices they have made.
Ask whether they are other arrangements from other groups. Invite them to share theirs and
explain their choices.
Lead a discussion about the differences between the groups the groups’ arrangements. Try to come up
with one arrangement together.
Explain that the basic principle of the water ladder is that the water sources can be ranked through a
sequence of poor to good.
Add that the way that community members rank the water sources tells a lot about the existing knowledge
and hygiene practices and the water source situation in that community.
Ask participants how they can use the water ladders in their work as CBVs in their communities.
Encourage them to be specific as to how and when they could use them.
COMMON WATER SOURCES
Surface Water Sources
Surface water sources include rivers, streams ponds and lakes.
Protected Water Sources
Explain that protected water sources are those water sources which are protected from the entry of disease-
causing germs. This includes lined wells with concrete rings and fitted with wind lasses or hand pumps,
boreholes and springs provided with pipes and water collection boxes. Protection means preventing
entry of disease-causing germs. The picture later shows a protected well.
How Water Becomes Contaminated (Polluted, Dirty, Unsafe)
Explain that water is clean when it comes from the sky as rain or out of earth as a spring. Humans and
animals that come in contact with it contaminate it. Water can be contaminated by:
• People passing urine and stool near water source.
• The rain or run overs carry the human waste into the water source if it is not protected.
• People wash their bodies and clothes in the water source.
• People put dirty containers in the water source.
• Animals pass urine and stool in the water or near the water source.
How to Protect Water Sources
Discuss with participants how water can be protected and summarize with the information below.
Rivers and Streams
Explain that if people draw water from a river or stream for drinking and cooking, they should do so up-
river away from the place where they wash their clothes and bodies and away from where animals are
allowed to drink. Animals should drink downstream at a distance from where people stay.
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Emphasize that where possible a fence should surround the place where drinking water is fetched.
Note: Water drawn directly from a river or stream may be polluted. If there is no other source of water the
community must boil their water before drinking it if they are to remain healthy.
Springs
A spring can be protected using the following steps:
i A ditch should be dug about 1,5m uphill from the spring to divert water away from the catchment.
This is to prevent the spring from being made dirty by surface or stream water.
ii A collection box should be built at the spot where the water comes out of the ground to keep the
water from being fouled.
iii The collection box should have an outlet for collecting the water.
iv There should be a manhole cover over the collection box to limit or prevent dirt from getting into
the water.
Shallow Wells
Explain that building a lining of concrete blocks and providing a concrete apron and a cover well can
protect a shallow well. Only one bucket and rope should be used to draw water.
Wells
Explain to participants that a well should be situated away from pit latrines and other sources. A well
should not be constructed downhill from a pit latrine. (All sources of water should be located at least 10
meters away from pit latrines, animals, or rubbish pits.)
SECTION 2 : METHODS FOR MAKING AND KEEPING WATER CLEAN AND SAFE
Lead a discussion with participants on methods for making and keeping water clean and safe and
summarize with the information below
Water that is of good quality water is described as follows:
• It should be clear and free from suspended materials
• It should taste good
• It should not cause any harm to the person who drinks it.
Water can be made safe by:
• Boiling
• Direct sunlight
• The two-pot method.

Boiling
Materials Needed
• Large pot
• Fresh water
• Source of heat to boil water
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Method
• Collect water in a pot
• Boil water for at least 5 minutes
• Cover and cool the water
• Store water in a clean covered container
• Scoop water out with a clean container or a narrow-mouthed container to prevent contamination
or a narrow-mouthed container to prevent people from putting a contaminated cup or their
hands in the water container. This means that the water must be poured.
This is the best method for making and keeping water clean and safe to drink!
Direct Sunlight
Materials Needed
• 6 hours of full sunlight
Method
• Collect fresh water in clean covered transparent containers
• Place the covered containers in direct sunlight
• Keep them in direct sunlight for 6 hours
• After 6 hours most of the germs in the water will be killed. Cool and store the water in clean
covered containers.
Two-Pot Method
Materials Needed
• Clean covered container
Method
• Collect freshwater m a clean covered container
• Leave it to stand for 1 full day. During that time most of the dirt in the water will settle at the
bottom of container.
• The next day transfer the clear water from the top part of the container into a narrow-necked
container using a clean cup or gourd.
• Store the water in a clean covered container.
• Scoop water out with a clean container (only water which has been stored from the day before is
used for drinking).
Note: This method helps make water clear and free of visible dirt but does not kill germs that may
be in the water. Boiling the water for 15 minutes after transferring it to the second containers will
kill the germs.
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Treating water with chlorine water purification solution
• Chlorine is a water treatment solution for homes. It should be used to disinfect your water for
drinking, washing fruits and vegetables, and washing cooking and eating utensils.
• Chlorine can help prevent diarrhoea and other water-borne diseases, such as cholera. Chlorine is
the cheapest way to make your water safe to drink. It is much cheaper and safer than boiling your
water.
• Water can have germs that cause disease at any time. Even water that looks clear can have germs.
Use chlorine all year long.
• Chlorine can be found in a health centre, pharmacies, drug stores, shops, and supermarkets
throughout Zambia for a very small price.
• Store your drinking water in a closed container (narrow mouth container) with a lid.
Water stored in closed containers does not get re-contaminated as easily as water stored in open buckets.
Method
• Fill your closed container with water.
• Measure the correct amount of chlorine for your containers by using the lid of the chlorine bottle.
• For a 20-litre container, fill the centre of the chlorine lid once and pour it into the container with
the water.
• For a 5-litre container, fill the out rim of the chlorine lid twice.
• For a 2.5 litre container fill the outer rim of the chlorine lid once.
• After adding chlorine, shake the container and then wait for 30 minutes before drinking the water.
• When you want to use it, pour the water out of the water container. Do not scoop water out of the
container with hands or a cup as this might re-contaminate the water.
Section 3 : Hand washing methods
Explain that washing hands with soap and water or ash and water can prevent some illnesses. The next
two sections describe hand washing methods and when to wash hands. Fingers and hands are used to do
lots of things, such as preparing and eating food, scratching, etc. This puts fingers and hands in contact
with germs that can cause disease. No germs can be seen with the naked eye, but they can be washed
away with proper hand washing method.
• Each person uses different water. The water is pored over the hands from the container
• Each person washes hands with soap or ash at all times rinsing enough to remove the soap or ash.
When many people wash their hands in the same water in a basin, they pass dirt and germs from
one person to another.
Proper hand-washing practices are important for the following reasons
• Germs on a person’s hands particularly after a visit to the toilet are easily transferred to the person’s
mouth or to other people if hands are not washed.
• Diseases such as cholera are easily spread if hands are not washed or are poorly washed.
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Section 4: Hand washing times
Lead a discussion with participants on when washing of hands should be done. Summarise with the
information below.
There are times when it is very important to wash hands. These times are:
• After using the pit latrine or toilet (after defecating and passing urine)
• After handling the faeces of a child
• After working in the field
• Before handling, preparing, or eating food and water
Germs that cause disease can be passed on to other people when proper hand washing methods and
hand washing times are not observed.
To avoid getting these germs and passing them on to others hand washing is very important.
Section 5: Management of household rubbish
Lead a discussion with participants on management of household rubbish. Summarise with the
information below.
Explain that that rubbish or refuse is any waste matter or material that is no longer useful, and which
should be thrown away. Common types of refuse are household sweepings, leftover food, used wrapping
paper and plastic.
There are problems associated with poor refuse disposal, these are:
i Unwanted pests, such as rats, flies and cockroaches are attracted to refuse and breed in it if it is left
in the open
ii Refuse that is left in the open smells bad
Common Methods of Household Refuse Disposal
• Burying the refuse
• Burning the refuse
Burying the refuse
• Refuse pits should be situated away from the house (preferably on the side of the house which is
away from the wind)
• They should be sited 60 meters away from any water source and at least 20 meters from the kitchen
or food preparation area.
• One method that can be used is to dig a trench about 5 meters in length one meter deep and one
meter wide. The waste is dumped at one end of the trench and the soil used to cover it is taken
from the other end. This allows the trench to be used for a longer time.
Burning the Refuse
• It is best to bum dry refuse in a large metal container such as a 55-gallon drum
• Place a heavy screen on top of the drum during burning to keep ashes from flying around
• Drill holes (5 cm wide) around the bottom of the drum to allow air to enter the drum and therefore
help the fire burn.
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Section 6: Human waste disposal
Disposing of human waste including children’s faeces safely
Explain that it is important to dispose of human waste safely because it is a source of disease. Many
illnesses especially diarrhoea come from germs which are in faeces. People can swallow these germs
through water, food, dirty hands or when they use dirty utensils. If faeces are left exposed where flies can
come into contact with them, diseases easily spread. Flies can carry diseases from contaminated faeces to
food and water.
Explain that household should be encouraged to build, use, and maintain latrines/toilets properly, because
the use of latrines helps reduce the spread of common diarrhoeal diseases.
Add that in this session, you and the participants will talk about two different kinds of latrines and some
important factors to keep in mind when building a latrine
Ask participants why we should be concerned about what happens to human stool and urine.
Ask how household can get rid of human waste and urine safely.
Review with participants the two types of latrines, the issues involved in siting a latrine, and the construction
of latrines.
In some communities in Zambia, people still use the bush or stream to pass stool. One responsibility of the
CBV is to improve this situation by explaining the need for and the construction of cheap simple latrines.
Children as well as adults should be encouraged to use latrines.
Discuss with participants the advantages of using a Latrine.
Advantages of Using a Latrine
• There is privacy
• It keeps flies and other insects away from faeces · It protects the user from rain, wind, etc.
• It can be built or constructed from cheap and locally available materials
• It can be constructed by local communities with minimum help. (The CBV may ask an Environmental
Health Technician or other health worker for helps on how to build a latrine.)
Ask participants to mention the types of latrines they know, Summarise with the information below.
Types of Latrines
i Traditional pit latrine
ii Ventilated Improved Pit Latrine (VIP)
Traditional Pit Latrine
Where to build the latrine
• It should be down-hill, away from any water source
• It should be on the side of the house which is sheltered from the wind
• It should be 10 meters away from the house and 10 metres from any well or spring or any source of
water supply
Lead a discussion on how to construct latrines, then summarise with the information below.
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Construction
A good pit latrine should have:
• A rectangular or square or round pit
• A hole big enough to allow faeces to pass through but small enough to prevent
• accidents (such as children falling in)
• A hole cover or lid to keep away flies and smells
• A strong floor that is easy to clean
Ventilated Improved Pit Latrine (VIP)
• Where to build the VIP (the same guidelines as for a Traditional Pit Latrine)
• Construction
The VIP Latrine is built much like the traditional pit latrine only that a good VIP Latrine should have the
following:
• A rectangular or square pit
• A hole big enough to allow faeces to pass through but small enough to prevent accidents (such as
children falling in)
• A hole cover or lid to keep away flies and smells
• A strong floor that is easy to clean
• A door and a roof
• A ventilation pipe
Difference between a VIP Latrine and a Traditional Pit Latrine
Explain that the difference between the VIP and the Traditional Pit Latrine is that the VIP has a vent pipe
which has gauze on top (see illustration above). Flies that may enter the pit of the latrine cannot escape
through the hole of the latrine if it is covered. They go up the vent and are trapped by the gauze at the top
of the vent. Smells also escape through the vent.
Advantages of the VIP Latrine over the Traditional Pit Latrine
• The VIP latrine reduces or eliminate smells
• The VIP latrine reduces flies
Note: The VIP is more expensive to build than the Traditional Pit Latrine. It is suitable for schools’ health
centres and public places.)
Construction of a Pit Latrine
The pit latrine is constructed using the following steps:
• Dig a pit 1 to 5 meters deep (and at least 2m above the water table).
• In unstable soil (sand) line the pit with bricks or concrete blocks where available.
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• Make the slab by laying logs over the pit and applying soil to cover the logs. Leave a hole in the
middle. Make a concrete slab where concrete is available.
• Construct a “super structure” of pole and dagga over the slab. Where available make walls of bricks.
• Put a roof made of thatch on the structure. Where available iron sheets or asbestos sheets may be
used.
Note: When building a VIP latrine include a vent pipe that opens into the pit and ends a foot or so above
the roof.
Water and sanitation ladders analysis
The exercise can be undertaken at the same time. Each group assigned to work either on water or
sanitation ladders. The size of the groups will depend on the total number of participants. If it is a large
group of participants (20) divide them into small 4 groups and allow 2 groups to work on water and the
other 2 on sanitation ladders.
Instructions for the exercise
• Split participants into small groups (5-8 persons)
• Give a set of sanitation ladders and water ladders
• Let the group discuss what they see in the pictures
• The group sort out pictures into an order starling with least desirable situation Use a single dot,
voting group considers where the community is in terms of the common human waste disposal in the
given community (current situation).
Section 7 : Household pest control
Explain that Community Based Volunteers have responsibility of teaching members of the community on
how to control household pests. Most of these household pests can cause diseases and some of them a
mere nuisance to the members of the community.
Ask participants the disadvantages of poor management of household rubbish (session 5) and poor
excreta disposal (session 6). Hopefully, someone will mention nuisances by pests.
Explain that in this session you would like to talk about pests found at household level and their control
introduced at this time, the objectives of this session (see above.)
Ask participants to quote common pests found at household level. (Answer: flies, mosquitoes, cockroaches,
bedbugs, ants, mice, and rats).
Common household pests

· Flies
· Mosquitoes
· Cockroaches
· Bedbugs
· Ants
· Fleas
· Mice
· Rats
For each group of pests, ask participants where to find them frequently at home, why they are harmful,
and how to control them.
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House Flies
They are mostly found in warm organic rubbish, i.e., manure, faeces or decaying vegetable matter or
rubbish. Their body and legs can carry microbes; they can contaminate our food with microbes derived
from excreta. Flies can spread diarrhoeal diseases.
To control them, destroy all breeding places:
• Keep latrines clean
• Bury all food wastes or cover with soil in a compost heap.
• Remove all faeces (human and animal) from the compound — use latrines
• All rubbish should be buried, burned, or put into a bin.
All food should be covered or kept safely
Cockroaches
They breed in cracks in warm places, e.g., near the fireplace, and come out at night.
They contaminate food and can transit diarrhoeal diseases. To control them:
• clean regularly the kitchen
• Plaster of cracks and holes in the walls
• Use if possible simple insecticides found in the market.
Bedbugs
They also breed in the cracks of walls, floors, wood, beds. They come out at night to suck blood and cause
great irritation and loss of sleep.
To control them:
- Plaster of cracks in the walls the CBV should consult the EHT for an appropriate insecticide.
Ants
These are attracted by sugar and food that is left lying about. General cleanliness is essential
Fleas
Fleas are dangerous because they are the link between rat and man and can transit diseases (e.g., plague).
Its habitant is of animal it bites — rats fleas develop in rat burrows, human fleas on the floors of dirty
houses. They are mostly caused by lack of hygiene and the presence of domestic animals, so domestic
cleanliness is the best preventive measure. CBV should liaise with the EHT for use of insecticides.
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Mice and rats
They destroy woodwork and material; they can infect food and cause diseases; they cat grain, root
crops and they carry diseases.
To Control them:
• strict cleanliness
• good grain storage
• plastering hole in the walls and scaling of floors
• burial or composting of food wastes
• The CBV can also consult the Environmental Health Technician (EHT) for an appropriate rationale
if necessary. And how to use rat poison.
Mosquitoes (see Chapter on malaria)
Ask them what they have learnt as origin or cause of pests. (Answer in general: lack of hygiene).
Summary:
Trainer or participant summarizes the main points of the session.
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CHAPTER 20:
SEXUALLY TRANSMITTED INFECTIONS (STIs); HIV AND AIDS
This is chapter 17 in participants Handbook
Learning Objectives
• State a simple definition of STDs.
• Identify community perceptions about STDs.
• Explain the impact STDs on the individual, family, and community.
• Discuss risk sexual behaviours found in the communities.
• State a simple definition of HIV
• State a simple definition of AIDS
• Identify community perceptions about HIV/AIDS
• Explain the impact of HIV/AIDS on the individual, family, and community.
Duration:
3 hours
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
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SECTION 1: SEXUALLY TRANSMITTED INFECTIONS (STIs)
What are Sexually Transmitted Infections?
Divide the participants into 3 groups.
Ask each group to define STIs; discuss risk sexual behaviours found in the communities and explain the
impact STDs on the individual, family, and community.
Let them get back to plenary and let each group present their responses to the assignment.
Discuss as a group what the responses mean and agree on what is the right definition.
Definition of STIs
Sexually transmitted Infections (STIs) are diseases that are acquired and passed on through sexual
intercourse. They are spread through vaginal, anal, and oral sex. Some STIs, including HIV, can be
spread by other ways including razor blades in tattooing, and reusing needles and syringes. Some
medical and local names for some common STIs include chancroid (bola bola), gonorrhoea (leaking,
Kaswende), herpes, syphilis (akasele), warts (bamukolwe, nkombola) and HIV.
Check your notes in the handbook and reinforce their findings. Encourage participants to refer to the
notes in their handbook in addition to their group findings.
Explain that these diseases can be grouped together according to the signs they present and that these
signs can be seen on the genital parts of both females and males. Say that people in the community may
not come to see the CBV and show them the signs. See below.
Classification of STIs
· Sores on the genital organs
· Discharge from the genital organs
· Swellings in the groin.
Remind them that they need to identify these signs and refer the patient to the health centre for treatment.
They should also encourage the patients to take with them their partners for treatment
Common signs and symptoms of STIs

· Bumps, sores, warts or small growths near the genitals, anus, or mouth.
· Stinging or burning when passing urine.
· Urinating more frequently.
· Swelling or redness near the genitals
· Fever, chills, aches, and pain, yellowing of the skin.
· A strange discharge or smell from the vagina or penis.
· Vaginal bleeding other than a menstrual period.
· Deep vaginal pain when having sex.
· Pain between the hips and genitals in women.
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You should use some visual aids such as slides on STDs or picture codes with STDs for them to see. Let
them say what they see on the slides or pictures and discuss briefly among themselves whether they often
see these things.
Ask participants to discuss how STD can be identified (signs and symptoms) in group work. Let them come
together in plenary and present their findings. Discuss and compare al responses from the groups. Write
on a separate piece of paper all the findings that the groups agree on. Discuss further on those which they
have doubts about with reasons why they doubt it. Take note of strong feelings on findings they do not
agree as a group. Let them compare each response on the group list with those given in their handbook.
Summary
Trainer or participant summarizes the main points of the session. Explain that in the next session, the
participants will look at HIV/AIDS.
SECTION 2: WHAT IS HIV AND AIDS?
Part 1: Definition
Ask participants to define HIV and AIDS, reinforce the responses with the information definition
below
HIV is a virus that can get into your body through contact with blood or body fluids of an infected person.
HIV makes it difficult for the body to fight other diseases by weakening the immune defence system,
leading to development of AIDS. The body fluids containing HIV include blood (including menstrual
blood), semen, vaginal secretions, and breast milk.
Explain to participants the facts about HIV and AIDS as indicated below
Part 2: Facts about HIV and AIDS
• HIV stands for Human Immuno-deficiency Virus.
• When a person becomes infected with HIV, that person becomes “HIV positive” and will always be
HIV positive. Over time, HIV disease infects and kills white blood cells called CD4 lymphocytes (or
“T cells”) and can make the body unable to fight off certain kinds of infections and cancers.
• AIDS stands for Acquired Immune Deficiency Syndrome and is caused by HIV. The names HIV and
AIDS can be confusing because both terms describe the same disease. Think of AIDS as advanced
HIV disease. A person with AIDS has an immune system so weakened by HIV that the person
usually becomes sick from one of several opportunistic infections or cancers such as PCP (a type
of pneumonia) or KS (Kaposi sarcoma), wasting syndrome (involuntary weight loss), memory
impairment, or tuberculosis.
Ask participants to mention signs and symptoms of HIV and AIDS. Summarize the responses with
the information below.
Part 3: Signs and Symptoms of HIV and AIDS
Emphasize that there is no way one would know for sure if someone else has HIV. Many people with HIV
look perfectly healthy. Other people who are sick with HIV may have symptoms that are identical to other
common illnesses. You cannot tell by looking whether someone is HIV positive. The only way to know
for sure is if someone tests HIV positive. It is important to consider how well you know someone and
how much you trust them when talking about sex and HIV. The following signs of illness may appear in a
person who has been infected with HIV:
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• Prolonged fever
• Cough
• Breathing problems
• Headache
• Mouth problems such as white sores
• Difficulty in swallowing
• Night sweats
• Swollen glands
• Diarrhoea
• Weight loss
• Failure to thrive (in children)
• Rashes
• Vomiting
• Tiredness
SECTION 3: TRANSMISSION OF HIV AND STDS
Remind the participants that this lesson is a continuation of the previous one.
Explain that many people are confused as to how a person gets HIV/AIDS and that community members
need true, clear information to make good decisions about what behaviours are safe and which are risky.
Get a big piece of paper and ask the participants to give as many ways as they can about the transmission
of HIV/AIDS. Encourage everyone to give what they know.
List all the responses on the paper. Allow participants to discuss the responses given and cross out the
wrong ones. Write on a separate piece of paper those responses which the group agrees as correct and a
separate list for the wrong ones. Compare it with the list in the notes on the left. Explain why the wrong
ones are wrong.
One important way that a CBV can help his or her community is by providing correct information about
how an individual can become infected with HIV/AIDS and STDs. By explaining how HIV and STDs are
passed from one person to another the CBVs can help their community members recognize what are safe
behaviours and what are risky behaviours.
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Part 1: Transmission of HIV and STDs
Explain the methods of transmission as indicated below
HIV is spread in the following ways:
• By having sexual intercourse without a condom with a person who is HIV positive. This is the most
common way of transmission.
• Through mother to child transmission (MTCT). An HIV positive woman can transmit HIV through
pregnancy, labour, or breastfeeding.
• Through use of contaminated instruments. Re-usable medical tools, needles and razor blades can
spread HIV if they are not properly cleaned.
• By transmission of infected blood or blood products.
Part 2: Types of HIV transmission
The sexual behaviours that can transmit HIV
• Vaginal sex (penis in the vagina)
• Anal sex (penis in the anus) involving either men or women
• Oral sex (mouth on the penis or vagina)
• The risk of transmitting HIV is greatly reduced by using a condom.
• Sexual cleansing as practiced by many communities when a spouse dies. This is a practice where a
person whose husband or wife has died is required to have sexual intercourse with a relative of the
dead person to get rid of the dead person’s spirit, this practice should be discouraged.
• Dry sex where women are encouraged to insert medicines or herbs into their vaginas to make
them tight and warm makes the vagina develop sores easily during intercourse allowing for the
transmission of HIV. This should be discouraged. In many traditional practices this is very common
among women.
Mother to child transmission of HIV
HIV transmission from mothers to infants occurs during pregnancy, at the time of labour and delivery, and
postnatal through breastfeeding. Out of 100 babies born to HIV-positive mothers:
• About 63 may not be infected with HIV.
• About 7 may be infected during pregnancy.
• About 15 may be infected during labour and delivery.
• About 15 may be infected through breastfeeding if the babies breastfeed for 2 years.
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Discuss with participants how HIV is transmitted from a mother to the child using the information
below:
During Pregnancy
If a mother is infected with HIV, the virus can pass from a mother to her unborn baby in the womb and
can be due to:
• Inconsistent condom use during pregnancy.
• Having multiple sexual partners puts the pregnant woman at risk of contracting HIV.
• Poor diet weakens her blood and immune system which may in turn expose the pregnant woman
to infection.
• Poor antenatal care for early detection of sexually transmitted diseases may expose the pregnant
woman to greater risk of HIV.
During labour and delivery
Explain that during this time, infection is passed on to the baby through direct contact between the
mother’s blood or vaginal fluids and the baby’s blood due to:
• Delayed and prolonged labour may expose you to other infections which may give way to HIV. ·
Tears and cuts of the birth canal may cause the mother’s infected blood to mix with their baby’s.
• Home deliveries that are risky are likely to expose the mother to tears.
• Too many vaginal examinations with unskilled birth attendants.
During breastfeeding
Infection can also be passed on to a baby through breastfeeding if the mother is HIV positive through:
• Breast milk.
• Poor breastfeeding methods may cause cracked nipples which may bleed during breastfeeding.
• Swollen breasts can leak infection into the breast milk. Irregular feeding can cause swelling of
breasts.
Discuss the other ways of HIV transmission
• Home tattooing and body piercing: accidental needle sticks, blood transfusions
• Reuse of injection equipment
Explain that it is important to remember that HIV is NOT transmitted through the following ways:
• Saliva, tears, sweat, faces, or urine
• Hugging Kissing Massage Shaking hands Insect bites Living in the same house with someone who
has HIV Sharing showers or toilets with someone with HIV
• Witchcraft
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Ask participants to mention some false statements or myths about HIV transmission
A sample of false statements or myths about how a person can get HIV/AIDS
• HIV/AIDS is an illness only for prostitutes.
• HIV/AIDS is a punishment from God.
SECTION 4: PREVENTION OF HIV/AIDS AND STIs
Explain that HIV/AIDS can be prevented although it cannot be cured, therefore communities must have
the right information about HIV/AIDS. It is not enough to just talk about it but practice safer sex methods
that will prevent transmission of the disease. The community must identify factors that put them at risk of
contracting HIV/AIDS and see or plan how they can change those behaviours.
Methods of preventing STDs and HIV/AIDS
Discuss with the participants how their communities are currently managing the cases of STD and HIV/
AIDS and who provides the counsel and treatment.
Provide information on the methods of prevention
Explain that the Community Based Volunteer should be able to talk about STIs and HIV/AIDS and also
provide information on the 5 Cs namely:
i Counsel community members and those infected about how to prevent further spread of the
infection and take care of themselves.
ii Promote and educate on the right use of condoms for the prevention of STIs and HI V/AIDS. iii
Maintain confidentiality of the clients who report about their being infected or seeking counsel.
iv A CBV must be able to keep information from his/her client or patients confidential. v Follow up
sexual partners of infected clients seeking counsel from them. This called contact tracing of sexual
partners.
vi Patients having STIs should be encouraged to comply to treatment advise given to them in order to
have effective treatment and cure of the treatable STIs.
Do condom demonstrations and let the participant’s practice.
Discuss issues or barriers that may hinder the community being able to use the condoms.
Summary
Trainer or participant summarizes the main points of the session.
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Explain other methods of preventing HIV/AIDS and STIs as indicated below
People may use the following methods to protect themselves from getting both HIV/AIDS and STIs and
emphasis should be put on behavioural change that includes the ABC:
• Abstinence from all sexual intercourse (i.e., vaginal, anal etc, and oral)
• Being completely faithful to one sexual partner who is completely faithful to you.
• Use of condoms, either male or female, for every sexual act.
People may also use the following methods to protect themselves from getting HIV/AIDS:
• Correct sterilization of all medical instruments prior to use.
• Use of new or sterilized razor blades to perform any cutting and not sharing razors for shaving.
• Correct screening of blood prior to transfusion (to be done by health staff in hospital).
Early detection and treatment efforts can be strengthened by:
• Increasing awareness of types and prevalence of STIs.
• Helping individuals recognize signs and symptoms.
• Encouraging individuals to seek without delay medical care from healthcare providers especially if
signs or symptoms are present.
Abstinence from all sexual intercourse
These detection and treatment efforts can be further improved by:
• Reinforcing prevention behaviours among people already infected with STIs.
• Encouraging people infected with a sexually acquired infection to notify their partners and refer
them for treatment.
Prevention of Mother to child transmission of HIV (PMTCT)
• HIV Counselling and Testing
Women and their partners should know if they have HIV by going for voluntary counselling and
testing (VCT). Couple counselling must be encouraged to empower the couple to make joint
decisions.
• Prevention of new HIV infections during pregnancy
Women who are newly infected in pregnancy are at increased risk of transmitting infection to their
babies because the amount of virus in the blood stream. All HIV positive pregnant women should
go for antenatal advice and care early in the first trimester.
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• Screening and treatment of sexually transmitted diseases
STIs are associated with increased risk of MTCT. Prevention of STIs as well as the early detection and
treatment of both partners can reduce MTCT.
• Antiretroviral therapy
All couples should be helped in making sure that the antiretroviral drugs (ARVs) are taken as advised by
the doctor. ARVs have been proven to reduce mother to child transmission of HIV.
SECTION 5: SHARING INFORMATION ABOUT HIV/AIDS AND STDS WITH COMMUNITY
Explain that it can be difficult for people to believe new information and to adopt new practices. One
challenge for every CBV is how to discuss with the client at the same time respect his/her fellow community
members’ beliefs, myths, and customs and also to share new information and to promote new behaviours
with them.
Tell the participants that one big challenge for a CBV is to find ways to share the new information that s/
he has learned – in training such as this and in supervisory visits by health centre staff – with the rest of
the community.
Explain that in this session, participants will be able to help each other explore some ways to do that.
Before the session, write the following heading on a large sheet of paper or on the board.
Ask participants what they think are the messages about HIV/AIDS and STDs that should be shared within
their communities. Write the messages they propose on the large paper or on the board without comment.
When participants have no more messages to propose, go over each of the suggested messages. Some of
the following questions may be helpful in doing this review.
• How clear is message, can somebody explain?
• Are these the words/ideas that people will understand, how good are these words/ideas?
• How does (the action proposed in the message) help people keep from getting HIV/AIDS or STDs?
When you and the participants are satisfied with the messages, remind participants of the following
statement that was made earlier: those community members need true, clear information to make good
decision about which behaviours are safe and which are risky.
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Ask participants to listen to a short tale about a CBV in another area and his experiences in trying to share
“true, clear information” with his fellow community members. Tell the story found at left. (Give the CBV a
locally appropriate name and supply a location that would make sense.)
When the story is over, ask participants what the CBV did well and what he could have done better. For
example:
Done well: He went to spot where people gather Could have done better:
• Chosen a less “social” time.
• Asked just one message at a time and willing to talk about health topics right there.
• Present just one message at a time and perhaps as a follow-on to a consultation about other
problems.
Remind participants about the CBV in the role play that was done earlier and ask how he used his friend’s
question about whether she/he had HIV/AIDS to start talking about how to prevent HIV/AIDS.
Divide participants into small groups and ask the members of each group to share with each other some
ideas about when and how they should pass messages to their fellow community members.
Suggest that if any group wishes to create a short role play demonstrating one of their ideas, they may do
so and share it with the rest of the participants when they are all together again.
Tell them they have 30 minutes and ask them to begin. After 30 minutes, ask the groups to share their
results. If any group has a role play, invite the group to ask other participants to give them feedback, such
as what they did well and what they could do better next time.
When all groups have reported, thank them for their efforts and encourage them to continue to share
ideas about how to deliver messages to their communities in helpful and appropriate ways.
Summarize the messages to Give the Community as indicated below
Messages to Give the Community
These are some of the messages that CBVs can pass on to their fellow community members:
• Practice monogamy; be faithful to only one faithful sexual partner.
• Use condoms properly during every sex act.
• Use sterile or brand-new razor for tattooing.
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COMMON TRADITIONAL RISKY PRACTICES
Sexual cleansing
This practice requires that a person who has lost a husband or wife should have sexual intercourse with
a relative of the dead person to get rid of the spirit or ghost of the dead person. Therefore, if either the
surviving spouse or the relative has HIV/AIDS she/he can also infect the other. This practice should be
discouraged through a dialog among the community members.
Polygamy
Some traditions encourage men to marry more than one wife. Having more than one sexual partner helps
spread HIV/AIDS. For instance, one of the women may be infected. She can infect the husband who will in
turn infect the other women. The women should be informed.
Dry sex
Dry sex is the use of certain substances in order to dry the vagina before having sex. Engaging in this
practice, however, makes it more likely that a woman’s vaginal wall will become damaged during sex. The
damage or injury caused to the woman’s vagina can allow HIV/AIDS to infect the woman through broken
skin. This practice also should be discouraged through a dialog in the community.
Tattoos
People may use tattoos for a number of reasons. Young people for example may use tattooing as a way
of introducing some “Juju” or herbs into their bodies to make them strong and able to win rights (i.e., peer
rivalry). The use of tattooing by traditional healers in some areas, as a way of introducing medicines in their
patients, is also dangerous. HIV/AIDS can be transmitted from one person to another, if the same Razor
blade has been used first by an infected person.
Circumcision
Circumcision is the tradition of cutting the boy’s foreskin of the penis. If the same blade is used on a boy
who is infected with HIV/AIDS and on another boy who does not, the second boy can then be infected.
Not all communities practice circumcision in Zambia. Where it is done, however, practitioners would be
encouraged to use a sterile (preferably brand new) instrument to make cuts.
Part 2: Treatment of HIV/AIDS
Explain to participants that currently patients with HIV/AIDS may benefit from antiretroviral drugs (ARVs).
Although ARVs do not treat HIV/AIDS, the drugs improve the quality of life, and reduce opportunistic
infections and mortality. Add that it is the role of CBVs to encourage all patients with HIV/AIDS to see
health workers at health facilities in order for them to be assessed for possible commencement of ARVs.
The health workers will examine the patient and conduct laboratory tests to determine if the patient is
eligible for ARVs. Treatment with ARVs is lifetime. ARV therapy requires a long-term commitment from the
patient. Adherence is the most important factor in successful ARV therapy. Correct and consistent use is
required for the drugs to be effective and the effect to last. The CBVs must encourage the patients to take
all the drugs as advised by the health workers.
Once patients start responding to ARVs they have mild or no reported side effects; improved clinical
status; improved growth, no new AIDS defining illness or fewer inter-current illnesses. All patients on ARVs
should be encouraged to feed on nutritious foods, avoid raw foods and maintain good personal hygiene.
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CHAPTER 21:
TUBERCULOSIS
Learning Objectives
• State a simple definition of TB
• Describe how TB is spread
• Name at least two signs and symptoms of TB.
• Explain how to tell whether a person has TB.
• Name at least two ways to help control TB.
Duration: 3 hours
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
- Role play
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SECTION 1: DEFINITION AND HOW TUBERCULOSIS IS SPREAD
Explain that tuberculosis is a very common health problem in Zambia. Many people suffer from TB, and
many people die from the disease.
Ask participants what TB is. Help them develop a definition of TB and write it up on large paper or on the
board.
Definition of TB
Tuberculosis (TB) is an illness that mainly affects the lungs, but it can also affect other parts of the
body, such as brain, bones, glands, etc. TB is caused by the germs which spread through the air
when the infected persons cough or sneeze. TB is easily spread in crowded housing conditions,
particularly when the living areas are not well – ventilated.
Ask participants how a person gets TB.
Ask participants what people in their communities believe about TB – what it is and what causes it. List
community beliefs on large paper or on the board.
Ask participants why it might be important for them to understand what other community members
believe about TB and its causes. How will knowing these beliefs help them in their work?
SECTION 2: SIGNS AND SYMPTOMS OF TB
Explain that it is very important for a CBV to recognise early signs and symptoms of TB so that he can refer
the patient to get prompt care and treatment.
Ask participants how they would know that a person has TB. Write their answers on large paper or on the
board.
Lead a discussion using the list and ask participants whether having the signs/symptoms indicates
presence of TB. Guide the discussion towards agreement that the best way to know whether a person has
TB is for person to have a test done at the health centre or hospital.
Ask participants to open their handbook. Together, compare their list with the list in the handbook and
make any additions necessary to either list.
Signs and symptoms of TB

Besides coughing, the other symptoms of TB are:
• Fever, especially rising in the evening
• Pain in the chest
• Loss of weight
• Loss of appetite
• Coughing up of blood.
• Failure to thrive (in children)
• Difficult breathing,
• Tiredness and general weakness
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SECTION 3: TREATMENT OF TB
Explain that TB can be fully cured if the full course of the prescribed drugs is taken regularly, and without
interruption. This is crucial. TB germs are very stubborn; so, drugs must be taken for at least six months (in
children) and eight months (in adults). If the full course of medicines is not taken regularly as prescribed,
the bacteria will develop resistance to the TB drugs, or a serious form of TB may develop. Cough, fever,
and chest pain will go away quickly by taking TB medicines, but TB is not cured yet. The patient should
continue taking medicines as prescribed. Follow-up sputum examinations are important and must be
done to check progress.
Ask participants to describe the treatment given for a person who has TB.
Treatment of TB
The treatment of TB of the lungs takes about 6 months in children to 8 months (in adults) to
complete. Some other types of TB e.g., Tuberculous Meningitis it will take 12 months. The only
effective way to cure TB is through Directly Observed Treatment, Short course (DOTS). DOTS
ensure that TB patients take the full course of the prescribed TB medicines. Drugs should be taken
under the observation of a health worker or a caretaker. TB can be fully cured if the full course
of the prescribed drugs is taken because it is a very successful approach. All patients should be
encouraged to have a variety of nutritious foods available in the community.
Explain the following information on to participants to reinforce on DOTS
• Watch the patient swallow the right TB drugs each time.
• Mark the TB treatment card each time the patient takes the TB drugs.
• Encourage patient to continue TB treatment.
• Make sure there is always a supply of drugs available for the patient.
• Refer the patient to the health facility if there are problems. If possible, take the patient to the
health centre. If patient is not able, arrange for the sputum to be taken at the health centre.
• Make sure the patient goes to the health facility when a follow-up sputum exam is due.
Ask why it is important to complete treatment. What will happen if treatment is not completed?
Invite other participants to comment on or add to what has been suggested.
Ask a volunteer to describe in his/her own words the treatment given for TB. Invite other participants to
comment on the description, perhaps by adding to it or changing what has been said.
Point out to participants that it is very important for a person who has TB to follow the entire course of
treatment, and not to stop taking the medicine when she/he begins to feel better.
The TB drugs may have side effects. Discuss side effects so that the patient can tell you if any of these signs
appear:
• If the person has nausea and no desire to eat, reassure and try giving drugs with food or porridge.
• If orange/red urine appears, reassure the patient that this is a normal effect of the drug. Nothing
needs to be done.
Remember to emphasis on avoiding the spread of TB to other family and community members.
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Seek the help of a trained health worker if patient has joint pain or a burning sensation in the feet. If a new
skin rash, itching, yellow skin or eyes, repeated vomiting, deafness, dizziness, or eyesight problems occur,
STOP treatments immediately and then seek help from a trained health worker or take the patient to the
health facility.
How the suspected person should be treated?
First, before giving any drugs, the suspected person should be evaluated to confirm whether she or he has
TB. The best way to diagnose lung TB is by examining the sputum under a microscope. Germs of TB can be
seen with a microscope. Three samples of sputum should be examined for accurate diagnosis. Remember
that for TB diagnosis X-ray is more expensive and less accurate than sputum examination. X-ray may be
necessary in the case of some patients.
SECTION 4: PREVENTION OF TB
Ask participants how they think TB can be prevented. Write their ideas on large paper or on the board. Ask
how other community members think that TB can be prevented. Make a separate list.
Ask participants to open the Handbook. Invite them to compare their list of ways to prevent TB with the
list included there.
Methods of Preventing TB
· Making sure that sick people commence prompt and complete treatment
· People who have stopped taking medicines to be encouraged to re-start taking medicines
· Good nutrition
· Improvement of ventilation
· Giving BCG and other immunizations to young children
· Preventing HIV infection
Also invite them to compare the list of ways that community members believe TB can be prevented with
the list in the Handbook.
Remind participants about the role they described for themselves in the treatment of TB and ask them
now to describe what they see as their role in the prevention of TB. Write their ideas on large paper or on
the board without comment.
When they have no more suggestions to add to the list, invite all participants to comment on the list. Are
the actions included there practical? Would the participants feel comfortable doing them? (Add other
questions, as needed.)
Explain to participants that TB can not only be treated and prevented, but also controlled. Ask them to
open their Handbook and to read over with you the methods listed there for controlling TB.
Methods of Controlling TB
· Starting treatment early

· Completing treatment
· Tracing of people who have stopped taking treatment
· Examining TB patients and family members for TB
· Providing Home Care, including good nutrition.
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Summary
Remind participants that they have already looked at how they as CBVs can help their fellow community
members in the treatment of TB, as well as in its prevention. Explain that in the next session, you would
like them to demonstrate how they as CBVs can help their communities in the treatment prevention and
control of TB.
SECTION 5: ROLE OF CBVs IN THE PREVENTION AND CONTROL OF TB
Let CBVs discuss what they think will be their main activities in the community in as far as prevention of
T.B. is concerned. Write these activities on board or large sheet of paper.
Ask participants/CBVs to list the categories of people they are likely to involve in these activities.
Divide participants into small groups (5 – 6 people). Ask each small group to do a short role play in which
one member plays a CBV, who is visiting a family in the community. Give the following details to get the
groups started:
First role play
The family has one member who has just gotten back from the health centre the day before. The Health
Workers there told him that he has TB and they have explained his treatment to him. The person who
has TB is not sure that he really understands and might not follow the treatment they have given to
him. The CBV has come to visit, because she/he was the one who referred this person to the health
centre in the first place. The CBV suspected the person had TB and is now coming to see what he
found out. Early recognition of T.B. patients.
The participants should have the CBV, the person who has TB, and the family all act out their parts in
a way that seems as close to real life as possible.
Second Role Play
The patient has been on treatment for 3 weeks felt better and stopped treatment. Ask the person who
portrays patient to be difficult and give excuses why they should not continue with treatment. The
CBV to encourage patient to continue treatment. CBV to involve members of the family to observe the
patient take treatment.
Practice
Tell them they have 30 minutes to prepare the role play and ask them to begin. After 30 minutes, call
all participants together and ask one group to present its role play.
When that group has finished, ask the other participants to give feedback by saying what was done
well and what could be improved.
Invite another group to present its role play and to receive feedback. Repeat this process until all
groups have had a chance to present their work and to receive feedback.
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Briefly summarize the main points that have been made by the groups in their role plays, such as the
following:
• The CBV can help a TB patient and his/her family understand the treatment that she/he needs
to follow.
• The CBV can check in with the patient and family regular to make sure that the treatment is
being followed.
• The CBV can help the patient and his/her family understand how important it is to them, as
well as to the rest of the community, that the patient finish the whole course of treatment.
Summary
Participant summarizes the main points of the session. Explain that in the next session, participants
will learn about the relationship between TB and HIV/AIDS.
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CHAPTER 22:
LEPROSY
Learning Objectives
At the end of this session, participants will be able to:
• Define what Leprosy is · Describe the signs of leprosy
• Describe the treatment of leprosy.
• Describe the diagnosis of leprosy.
• Explain the reasons for delay in care seeking by patients.
Duration: 3 hours
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
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SECTION 1: DEFINITION AND SIGNS OF LEPROSY
Ask the participants to tell you what they know about leprosy.
Emphasize the definition below after participants have finished giving their responses.
Leprosy is a disease of the skin and the nerves caused by a small germ that mainly infects the
skin and nerves leading to disabilities. Untreated leprosy sufferer sneezes or coughs many leprosy
germs that spread the disease. Most people have a natural resistance to the leprosy germ and
cannot get the disease.
Tell the participants to read about the signs and symptoms of leprosy in their CBV handbook.
When everybody is finished reading, conduct a discussion on the signs and symptoms of leprosy ensuring
that all the signs below are mentioned.
Signs of leprosy
• Skin patches lighter in colour than surrounding skin — one or more, any size, any
place on the body.
• Skin patches with little or no feeling.
• Thickening of the skin or lumps, especially on the face and ears.
• Pain, tenderness and/or thickening of a nerve (usually near the joints).
• Loss of feeling or weakness of fingers and/or toes.
• Painless injuries, burns and blisters on hands and feet.
• Single, lighter colour flat patch: These patches may have lost feeling. Person may not
have any other complaints.
• Patch is similar to ringworm; towards the centre skin is lighter in colour. The edges are
raised, loss of feeling; May have no other complaints.
• Flat light-coloured patches with loss of feeling; May complain of loss of feeling and or
weakness in fingers and toes.
• Lighter patches with raised edges with slight loss of feeling; Person may complain of
loss of feeling of hands and feet.
• Pimple-like lumps on face, ears, and hands; Person may complain of nose bleeding
and blocked nose.
• Loss of feeling and weakness of hands and feet; Bigger lumps on skin and ears; loss of
eyebrows, complains of nose bleeding and nose blocks.
• Thickening of skin, face, and earlobes; Loss of feeling and weakness in hands and feet.
Blocked nose, nose bleeding and loss of eyebrows.
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SECTION 2: TREATMENT AND PREVENTION OF LEPROSY
Explain the treatment of leprosy to the participants ensuring that everyone understands. Refer to the
handbook and the information on treatment below.
Treatment of leprosy
Treatment of leprosy usually lasts between 6 months to 12 months, depending on how severely
a person is affected.
The best time to start treatment is as soon as the signs of leprosy appear. Treatment reduces the
risk of the person spreading leprosy. Treatment reduces the person’s risk of getting disabilities.
Ask the participants about the importance of people with leprosy reporting to the nearest health centre
as soon as possible. Lead the discussion with reference to the information in the CBV handbook on early
diagnosis and reasons for delay in care seeking among people with leprosy.
Summarize with participants the information on leprosy as indicated below
Can leprosy be treated?
Yes, leprosy can be successfully treated. Treatment usually lasts between 6 months to 12 months,
depending on how severely a person is affected.
• The best tune to start treatment is as soon as the signs of leprosy appear. · Treatment reduces the
risk of the person spreading leprosy.
• Treatment reduces the person’s risk of getting disabilities.
Early diagnosis and treatment can prevent deformities
• When the community accepts the disease and gives people the necessary support and motivation
to seek help.
• When it is detected early.
• When a person receives regular treatment.
• When a person comes for regular check-ups.
• Nerve damage can result in clawing of fingers.
• Nerve damage may lead to eyelids that cannot close properly and the person being unable to
blink the eyes.
• Nerve damage can result in injuries to hands and feet.
Reasons why people delay seeking help
• They are afraid to show they have the disease

· They may not be aware of the signs of the disease
· They may feel rejected and socially stigmatized.
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SECTION 3: THE ROLE OF THE COMMUNITY BASED VOLUNTEER
Explain the role of Community Based Volunteer on Leprosy prevention and control as indicated
below
To educate the community on.
• The truth about leprosy
• The signs of leprosy
• The possible complications/disabilities that can occur as a result of leprosy.
• To refer people whom, you suspect might have leprosy or any other skin disease to the leprosy
clinic.
• To support a person with leprosy by.
- Motivating client to take treatment correctly. - Caring for existing disabilities.
• To support patients and their families in overcoming their fears and shame about the disease. · To
support the family of a person with leprosy by.
- Informing them how to help the patient
- Giving them more information about the disease.
• To help the family overcome social and emotional obstacles that they are facing.
SECTION 4: COMMUNITY AWARENESS
Divide the participants in two groups. Let them to discuss the roles of Community Based Volunteers
in the following topics:
• What should the community know about leprosy?
• How should a CBV support a person on treatment?
Call the groups to make presentations during the plenary meeting and ensure that the points in the
handbook are mentioned.
185
Summarise with the following information below
Your message to the community
• Leprosy can be cured.
• Do not fear it.
• Treat it.
• Leprosy is not the result of a curse or ancestral spirit.
• There is no need to isolate a person with leprosy.
• People with leprosy that go untreated run a greater risk of getting disabilities.
• Leprosy is not highly infectious.
• People with leprosy can stay with their families and remain active members of their communities.
How should a Community Based Volunteer support a person on treatment?
• Motivate the person to take treatment daily.
• Encourage the person to collect treatment regularly on the given return date.
• Tell the person not to stop treatment unless instructed by health worker in charge of the leprosy
programme!
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CHAPTER 23:
MENTAL HEALTH PROMOTION AND SUBSTANCE ABUSE
PREVENTION
Learning Objectives
• List at least four major activities of normal life.
• Explain the meaning of mental health.
• Explain the meaning of mental illness.
• Explain how to handle a mentally ill person in the community.
• Identify key network organisations that would assist in management of mentally ill in the community.
• List factors that may contribute to the cause of mental illness.
• List at least 10 common signs and symptoms of mental illness.
• Describe the causes and consequences of alcohol, drugs, and tobacco use
• Explain how to prevent substance abuse in communities
Duration:
2 hours 30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
187
SECTION 1: MEANING OF MENTAL HEALTH- WHAT IS MENTAL HEALTH?
Explain that activities of normal life vary. Thereafter, ask participants to break into groups of four to five
and list down major activities of normal life that they know.
Let participants explain in their own words the meaning of mental health after having outlined major
activities of normal life.
What is the meaning of mental illness? (Answer: Illness of the mind leading to failure to maintain to normal
behaviour)
The World Health Organization defines mental health as
“a state of well-being in which the individual realizes his or her own abilities, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her
community (WHO 2002)
Mental health is the foundation for well-being and effective functioning for an individual and for a
community.
How would you manage a mentally disturbed person in the community?
Summarize discussion outlining main points discussed. In summary form give the following as answers for
the major activities of life, mental health, and illness:
Major activities of life
• Growing and having food in the home
• Maintaining good interpersonal relationships (management of social contracts)
• Finding time for resting · Adaptation to the work situation
• Adjust to the other sex.
Mental health is the ability of an individual to live in harmony with his or her environment. In
so doing, he or she maintains good interpersonal relationships and is considered normal by the
community.
Mental illness is sickness of the mind leading to an individual failing to work, maintain his or her
interpersonal and social contacts, talks nonsense, refuses to take care of his/her personal hygiene
and wanders about aimlessly.
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Explain that mental health is an important part of the general health of a community. At some point in
your work experience as Community Based Volunteers, you are going to be confronted with mental health
problems affecting individuals, families, and the community at large. As a Community Based Volunteer, you
need to be familiar with the management of mental disorders at a community because mental illnesses,
such as anxiety and depression, are common in people who attend your clinics. You need to:
• Provide basic treatment and care for people with a mental illness who may not be able to see a
specialist.
• Provide a long-term follow-up and support for mentally ill patients at the community.
Policy Statement
To increase the life expectancy of Zambians through effective promotive, preventive, curative, and
rehabilitation programmes for both communicable and non-communicable diseases, including mental
health.
The Magnitude of Problem
Explain that Zambia is yet to compile country specific information concerning the incidence and prevalence
of mental disorders. It has been estimated that 19% are attributed to mental and neurological disorders
in Africa region (2008). The growing number of non-communicable diseases, mental illnesses, and injuries
which in 2002 accounted for 27% of the total disease burden in the region shows that mental illness is a
priority public health problem in our communities.
The common mental conditions are anxiety and depression, which occur at a rate of 2030% among the
population, and up to 40% among those who attend general outpatient clinics.
Lead a discussion with participants what an individual in a good state of mental health is expected to do
in the community, summarise with the information below.
• To adapt to changing situations of life and achieve some autonomy (freedom).
• To work productively to contribute to their own fulfilment and to the well-being of their community
• To acknowledge their successes and address their failures
• To avoid resorting to violence, reckless sexuality, and harmful use of psychoactive substances.
Explain that a person’s mental health status is reflected in behaviour. Add that this is because behaviour is
believed to be the working of the mind that arises from the cognitive functions which result in observable
conducts or activities that people can judge one about.
Explain further that there are a number of factors that determine and influence behaviour throughout the
different stages of life. These are: genetic (inherited), physiological, emotional, and psychological which
depends on the social context and environment, and combine with happiness, stress, or difficult situation
to bring about either mental health or mental disorder
Mental health, therefore, is important as an essential element of health and for shaping personality.
189
SECTION 2: ACTIVITIES OF NORMAL LIFE AND MEANING OF MENTAL HEALTH ILLNESS
Explain that as stated earlier, mental health is an essential part of health services at community level. It is
therefore expected that Community Based Volunteers should acquire information to appreciate what are
termed activities of normal life and the meaning of mental health and illness.
Mental Health therefore means the ability of an individual to live in harmony with his/her environment.
Mental illness may mean sickness of the mind where an individual fails to work, maintain his interpersonal
and social contacts, talks nonsense, refuses to take care of his/her personal hygiene and wanders about
aimlessly.
SECTION 3: CAUSES OF MENTAL ILLNESS
State that causes mental illness are many. (In order for them to understand a little further about this
subject, it is essential that they discuss what they may observe in the following short play)
Ask one participant to play role of husband, one participant to play role of wife. This is a family of 5, i.e.,
husband, wife and 3 children – 2 boys and a girl.
The scenario is that the husband is impossible. He always comes home drunk. In the presence of children,
he insults the wife and sometimes beats her up. Other times, he insults the Neighbourhood and accuses
people of being jealousy of him. The resultant effect is that children run away from home and wonder
aimlessly. Most of the time they are caught stealing. The girl later turns out to be a sex worker.
Discuss in groups reasons for the children’s behaviour.
Ask participants possible causes of mental illness that they know.
Presents the following information to summarise
Factors contributing to cause of mental illness
• Living conditions – For instance shortage of basic requirements in the home such as food
and clothing
• Family relationships – Where family members quarrel and fight amongst themselves most
of the time.
• Interpersonal relationships outside home – Inability to get on with anyone · Occupational

adjustment – Inability to cope with work.
• Infections (e.g., Malaria, Meningitis, HIV) – these conditions when severe do affect the brain.
• Influences during child growth – For instance where a child learns that violence, stealing
and use of abusive language is normal.
• Damage to the brain (injuries) through road traffic accidents, falling from heights etc.
• Drug abuse including dagga smoking, petrol and glue sniffing and smoking human excre-
ta (especially among street kids) etc.
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SECTION 4: FEATURES OF A MENTALLY ILL PERSON
State that signs and symptoms of mental illness come in various forms. The important thing is that CBVs
should be able to identify these symptoms in afflicted individuals in the community.
Ask one participant to play the role of a mentally ill person in all categories i.e., in dress, talk and
behaviour.
In groups, ask participants to discuss what they observed in the role play. Allow participants to discuss
other signs and symptoms of mental illness that they know.
In their group presentations, ask participants to list down at least 10 signs and symptoms of mental illness
that they may know.
Summarize with the following points.

• Extreme untidiness in a person not talking properly.
• Refusing to bath.
• Talking very fast continuously despite the appeal to the reason of the individual doing that.
• Extreme cheerfulness usually unsubstantial.
• Laughing and crying for no apparent reason.
• Extreme sadness of mood.
• Self-blame for no apparent reason.
• Extreme shyness.
• Inability to acknowledge time, place, and person.
• Standing in one place for a long time.
• Suspiciousness of people and the environment around.
• Hearing strange voices that other people cannot hear.
• Unexplained worry.
• Expressionless face in the face of all types of provocations.
• Talking nonsense.
• Fatuous (silly smiles).
• Fixed beliefs that cannot be changed despite the appeal to the reason of person entertaining them:
“I am Jesus Christ.” · Undressing and moving naked.
• Destroying property.
• Keeping away from others (isolation).
• Failing to sleep - either as a result of disturbed thing or worry or elation of mood.
• Looking confused.
• Loss of sexual appetite.
• Lying in bed continuously and helplessly and failing to respond to stimuli.
• Wanting to kill oneself (suicidal).
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SECTION 5: MANAGEMENT OF MENTAL PATIENTS IN THE HOME AND COMMUNITY
Explain to the participants that mental patients are a part of society and therefore must be involved
in community activities. It is important to explore needs and rehabilitation of mental patients in the
community.
Divided participants into groups of 3 – 5 and let them discuss that needs and rehabilitation of mental
patients in the community. They will be expected to report back into plenary.
Give the groups the following questions:
• What are the basic needs of a mentally ill person in the community?
• Assess the needs listed above required to enable the mentally ill in normal society.
• Discuss the need to rehabilitate the mentally ill.
• Is there room for developing further the mentally ill through rehabilitation?
• What advice would you give to families living with the mentally ill?
• What should you check for when you visit a mentally ill person at home in your catchment area?
• What should you do when you realise that a mentally ill person in your catchment area needs
treatment? (Refer to the nearest health centre).
• What should you do when you detect the following side-effects:
• Feeling sleepy, dryness of the mouth,
• Excessive salivation and restlessness,
• Person cannot speak properly with a tongue protruded,
• stiff neck etc?
(Refer to the nearest health centre)
Summarize by giving possible responses to the above questions.
Basic needs
- Food
- Shelter
- Clothing
- Work / education
- Treatment
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Assessment of family patient interaction.
Advice to families living with the mentally ill
- Ensure patient takes medication
- Ensure that patient is properly advised in the context of above-mentioned basic needs
- Inform family that mental illness is like any other illness
Importance of rehabilitation of mentally ill
It helps in restoration of patients to their previous levels of functioning. They are able to maintain their
dignity and self-esteem.
CBVs ensure that patients work for their living interact well with family, comply to medication whilst at
home etc.
Things to check for when a CBV visits a mentally ill person at home.
- Appetite
- Sleep
- Hygiene
- Manner of talk and the way the patient is dressed
- Interpersonal relations
- Feelings of family / friends on illness and their observations
- Whether patient is taking medication
- Involvement in work.
1. `What should be done when a mentally ill person is unmanageable at home?
Refer to the nearest health centre
2. The person taking psychiatric drug may have the following: feeling sleepy, dryness of mouth,
excessive salivation, restlessness, difficulties in speaking, muscle rigidity, rolling of eyes, protrusion
of tongue.
What to do when patient has side effects?
- Refer to the nearest health centre.
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Community Based Rehabilitation (CBR)
Explain that community-based rehabilitation is the restoration, with the community ‘active involvement,
of the individual’s ability to function adequately as a member of the community. Community Based
Volunteers need to support community-based rehabilitation by:
• Liaising with other sectors dealing with community-based rehabilitation, such as the
• Catholic Secretariat and other church organizations
• Identifying possible community group activities in which those affected by mental illness could
participate.
• Facilitating the entry of the mentally ill into appropriate community groups to ensure that group
members understand the situation and they are willing to make efforts to provide support.
• Passing information to the mentally ill individuals and their families about opportunities for the
patient’s involvement
Social support groups
Explain that the social support groups are groups of people who share a common problem and who can
therefore share experiences, understand the experiences of the other members, and can provide both
psychological and practical help and support.
SECTION 6: SUBSTANCE ABUSE: ALCOHOL, SMOKING, & DRUG
Tell the participants that there is a growing concern in Zambia, like in many other countries in Africa, that
substance abuse intake of alcohol, smoking, and drug such as cannabis or marijuana - ‘mbanje, ibange,
Chamba,’ cocaine or heroin, has become a serious public health problem. Faced with challenges of lifestyles
and in traditional values, and with social and health problems, individuals, families, and communities are
at a greater vulnerability to substance abuse and an increase in consumption, with severe risk effects on
health.
Explain that the World Health Organization (2007) reported the estimates of total deaths attributed to
alcohol consumption show an important burden of 2.1 % in 2000 and 2.2 % in 2002 for Africa region only.
With limited data in Zambia, this situation makes no difference from other countries in Africa.
Lead a discussion with participants on alcohol use, causes and consequences of alcohol consumption,
summarise with the information below
Alcohol Use
Alcohol is a drug and common practice of young people in Zambia. Alcohol consumption of alcoholic
drinks by young men and women aged 16-27 years is 20% (WHO 1993) Its consumption has increased in
quantity and frequency. The age at which drinking starts has declined.
194
Causes
• Poverty
• Unemployment
• Violence
• Social exclusion- broken families, lack of education, marital disputes, poor relationships at home and
at school- turn to drink for emotional relief. · Peer pressure- plays a major role in sustaining drinking
• Heavy drinking by parents- · Maturity
• Reduce anxiety
• Socio-cultural values- view drinking by young men as reinforcing the male image of toughness and
maturity, but women’s drinking is seen differently. The woman who drinks too many bears a social
stigma and as a result may try to hide her difficulties instead of seeking help.
Consequences of alcohol consumption
• Become aggressive
• Many commit crime
• Suicidal behaviour
• Physical disability
• Disfigurement and death in youth
• Health problems:
- Heavy drinkers are great risk of cancer
- Ulcers
- Heart disease
- Muscle wastage
- Malnutrition
- Cirrhosis of the liver (liver disease), a leading cause of death
- In pregnant women- cause risk of brain damage, growth deficiency and mental retardation as a
result of high level of alcohol in bloodstream to unborn child
Lead a discussion with participants on drug use, Smoking or Tobacco use, causes and consequences,
summarise with the information below.
195
Drug Use
Explain that drug use is a health hazard with particular relevance to young people. While drugs, such as
cannabis or marijuana, cocaine or heroin have been used throughout history by adults, in recent decades
drug-taking has become particularly associated with the counterculture of the young, rebelling and
seeking new experiences. In Zambia, the proportion of young people 16-17 years who use cannabis is
25%, the third highest among 18 countries surveyed globally. It shows that Zambia is the one of victim
countries for drug use among the young people.
Causes
• Availability of such drugs
• Peer pressure
• Curiosity
• Poverty
• Unemployment
• Homelessness
• Social disintegration or family problems
• Reduce anxiety and emotional relief
• Physical energy in men
Consequences
• Dependence or addiction
• Overdose
• Accidents
• Physical & psychological (mental) damage, or mental disorder
• Death
• In women- premature birth, stillbirth or low birth weight among children born from drug users.
196
Smoking or Tobacco Use
Tell the participants that although smoking is quite low in Zambia and in many parts of Africa, it is one of
the forms of behaviour most damaging in the long term to the health of the young people.
Consequences
• Long term tobacco consumption causes:
• Lung cancer
• All cancer deaths
• Respiratory or chest infections as chronic bronchitis and emphysema
• Heart disease
• Diseases of the teeth and gums, and cancer of the mouth
Community Management of Alcohol, Drug and Tobacco Abuse
Discuss with the participants Community Management of Alcohol, Drug and Tobacco Abuse as
indicated below.
• Sensitization of communities, schools, individuals, and families on dangers of substance abuse need
reinforcement- IEC is important through media, drama, and other health promotion channels for
behaviour change.
• Law enforcement, especially among young people should be intensified at community level
• counselling of victims
• Social support and rehabilitation of victims (refer to community-based rehabilitation and social
support sections of this Chapter)
• Referral of substance abuse cases to a health facility for screening, counselling, and treatment
197
CHAPTER 24:
NON-COMMUNICABLE DISEASES (CHRONIC DISEASES)
Learning Objectives
• To define diabetes mellitus, heart diseases. high blood pressure, stroke, and obesity
• To describe the causes of diabetes mellitus heart diseases. high blood pressure stroke and obesity
• To describe the signs and symptoms of diabetes mellitus heart diseases. high blood pressure stroke
and obesity
Duration:
1 hour 30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
198
Explain that non communicable diseases, such as diabetes mellitus, heart diseases, high blood pressure
(hypertension), and strokes are becoming a major public health problems in Zambia. This chapter presents
these as key facts for community awareness and the need for prevention, and to seek early medical care
are essential element to prevent strokes and death among the population in communities.
SECTION 1: DIABETES MELLITUS
Explain that diabetes is an abnormality in the body’s handling of sugar. It is a common disease in Zambia
and affects all ages. It can be inherited or acquired.
Ask participants to mention the causes of diabetes mellitus. Summarise with the information given
below.
Causes
Sugar, in form in of glucose, is the basic fuel of the body for energy, obtained from carbohydrates (bread,
Nshima, and starch) or made within the body by a complex biochemical pathway, which is “insulin.” It
circulates within the blood stream to all body cells.
Close biomedical control ensures the quantity of sugar in the blood matches the body’s needs. Too little
blood sugar leads to light- headedness and tiredness.
Too much sugar in blood is diabetes.
A constant high sugar intake in the diet contributes to diabetes. Blood sugar can remain constantly high,
and the person becomes diabetes
Insulin- lack of insulin causes little sugar to be absorbed by most cells thereby reducing energy in the
body. Insulin is the hormone switch that tells cells to let sugar in. It is produced by the pancreas gland and
released into the blood stream in response to the body’s needs for energy.
Disease of the pancreas causes little production of insulin leading to high levels of blood sugar
Ask participants to mention the signs and symptoms of diabetes mellitus. Summarise with the
information given below.
Signs and symptoms
• Excess urine output and increased thirst
• Tiredness
• Weight loss
• Infections- bacteria feed on sugar causing thrush (fungal infection of the groin, armpits, and vagina),
boils and abscesses
• Blindness
• Leg ulcers
• Kidney failure, and
• Stroke
199
Explain how diabetes mellitus can detection as indicated below
The urine can be checked for sugar by urine examination
Blood test is conducted for blood sugar
If sugar is found in urine and high in blood, the person has diabetes
Treatment
Explain that the aim of treatment is to keep blood sugar levels as close to normal as possible. This is done
by reducing sugar intake with a balanced diet and by using drugs or insulin.
Diet
Emphasize that a diet with balanced amounts of fat, protein and sugar is important for diabetes. The sugar
should be in a natural, unrefined form, as in fruit and vegetable.
Diabetes should aim to lose excess weight. Diet alone will give good control in adult diabetes.
Drugs
Tell the participants that drugs are used where diet is insufficient and also used to stimulate pancreas
Insulin
Explain that Insulin is provided to those with severe diabetes especially for young people with acute
diabetes.
Quality Control
Discuss the following points under quality control
• The aim is to keep blood sugar levels within a fairly narrow normal band.
• It is checked by taking finger-prick samples of blood for analysis or testing
• Regular medical checks are important to control the disease and avoid complication
• Diabetic patients are forbidden smocking.
200
Complications
Tell the participants that if diabetes mellitus is not controlled it can result into the following
complications:
• Blindness
• Kidney failure
• Heart failure
• High blood pressure
• Strokes
• Death
Role of Community Based Volunteers
Emphasize that role of Community Based Volunteers as indicated below
• Education of communities and individuals about the disease, consequences, and the need for
medical checks
• Referrals to medical care
201
SECTION 2: HEART DISEASES
Explain that Heart disease, also commonly known as heart failure, is the inefficiency of the pumping action
of the heart because of some underlying disease or problem. Heart disease is one of the causes of death
in Zambia.
Ask participants to mention the causes of heart disease. Summarise with the information given
below.
Causes
Explain that the heart is made of tough, durable, specialized muscle which beats for a lifetime. Most causes
are:
• Heart attack due to reduced blood supply to the heart
• Congenital defects of the heart
Ask participants to mention the signs and symptoms of heart disease. Summarise with the
Signs and Symptoms
• Feeling of tiredness
• Breathlessness- due to fluid building up in the lungs, especially when lying flat
• Swelling of ankles
• Coughing frothy dry cough –due to poorly oxygenated blood
Detection
Explain how heart failure is detected with the following points
• Heart failure is diagnosed on examination by a medical doctor
• Chest X-ray
• Heart machine examination (ECC, Echo)
202
Treatment
Explain how heart failure is managed with the information below
• Patients are put-on long-term treatment of drugs
• Treat cause of heart
• Periodic checks
• Operation on the tubes of the heart if affected
Role of CBVs
Emphasize the roles of CBVs in control and prevention of heart diseases using the following points
below
Referral of cases to medical check up
• Education of community
• Follow –up through home visits to assess chronic cases and advice on the need for taking regular
medication
203
SECTION 3: HIGH BLOOD PRESSURE
Explain that high blood pressure is the condition of abnormally raised pressure within the blood vessels-
arterial system, also called hypertension. It is one of the most common chronic health problems among
adult people.
Ask participants to mention the causes of high blood pressure. Summarise with the information given
below.
Causes
• Stress- due to excessive workload, worry
• Diet
• Obesity-over weight
• High alcohol intake
• High blood pressure also runs in families
• Kidney problems or disease
• Hormones
• Abnormality of blood vessel (aorta)
• High blood calcium
• Pregnancy complications
• Some cases remain unknown
Ask participants to mention the signs and symptoms of high blood pressure. Summarise with the
Signs and symptoms
• Blood pressure is measured by a blood pressure machine.
• If it becomes high, then the person is said to have blood pressure
Treatment
Explain how high blood pressure is managed with the information below
Self-help measures:
• Reduce salt in take
• Reduce weight- control diet
• Nutritional therapy- eat whole foods, plenty of fruit and vegetables, oily fish.
Strictly ration fatty, salty, and sugary foods
Relaxation through medication
• No smocking and excessive alcohol
• Regular blood pressure and other medical examination checks
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Drugs:
Tell participants that drugs for high blood pressure are given in health facilities
• Patients are given drugs to reduce blood pressure
Complications
Discuss the following complications that may occur if high blood pressure is not controlled.
• Heart failure
• Strokes
• Kidney problem
• Death
Role of CBVs
Emphasize the roles of CBVs in control and prevention of high blood pressure using the following
points below
• Education of community about causes, dangers, and importance of taking treatment for those
affected by the disease
• Referral
• Home visiting for support and care of chronically ill cases
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SECTION 4: STROKE
Explain that stroke is a brain injury occurring as the result of some kind of interference with blood flow
within the brain.
Discuss causes of stroke with participants
Causes
Explain that the brain relies on a constant flow of oxygen-rich blood through the great carotid arteries
(blood vessels) in the sides of the neck and the vertebral arteries (back blood vessels) up the back of the
neck. The following are some of the cause of stroke:
• Disruption or damage leads to giddiness and blackouts; loss of blood flow for couple of minutes;
and death of nerve cells and result in stroke.
• Brain tumour
• Raised cholesterol
• Smocking
• Age, especially old age
• Excessive heat, but rare
Signs and symptoms
Discuss the signs and symptoms of stroke with the participants
• Paralysis of muscles, for example, sudden loss of use of an arm, or a leg or both, drooping of half
the face
• Slurred speech
• Difficult in swallowing
• Changes in senses, e.g., blindness, inability to feel part of the body
• Loss of balance
• Giddiness
• Loss of emotional control and confusion
• The most serious strokes cause sudden unconsciousness, then death
• Others lead to chronic ill health with immobility, incontinence (no control of urine or faeces), and
increased risk of chest infections
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Treatment
Discuss the treatment of stroke with the participants
• After stroke, the treatment is to provide skilled nursing care
• Aspirin is given to reduce blood to clot and so lessens the risk of a future strokes
• Rehabilitation through physical exercises (physiotherapy)
Role of CBVs
Explain the participants the roles of the CBVs in prevention of stroke using the following points.
• Education of community
• Home based nursing care
• Home visiting and rehabilitation of patients
• Referral of serious cases to rule out other causes and treat infections
207
SECTION 6: OBESITY
Explain that obesity is excess weight gain in relation to your body build and height
Ask participants to mention the causes of obesity. Summarise with the information given below.
Causes
• Overeating- excessive calories intake- taking foods containing sugar, large quantities of fat –
enriched cakes, chocolates, biscuits, and salt
• Heredity-runs in families
• Depression
Ask participants to mention the signs and symptoms of obesity. Summarise with the information
given below.
Signs and symptoms
• Excessive weight gain beyond a normal weight gain
• Breathlessness
Treatment
Explain how obesity is managed with the information below
• Special dieting- need for food values –meat, fish, eggs, milk fruit and vegetables- reduced salt,
sugar, and fat enriched foods
• Physical exercises for weight loss
Complications
Discuss the following complications that may occur if obesity is not controlled.
• Joint pains
• Breast cancer
• Gall stones-stones in the kidneys
• Constipation
• Bowel cancer
• Stomach cancer
• Tooth decay due to sugar
Role of CBVs
Explain the participants the roles of the CBVs in prevention of obesity using the following points.
• Education on the causes and consequences of obesity · Rehabilitation of those affected.
• Referral for special rehabilitation on dieting and physical exercises
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CHAPTER 25:
EMERGENCIES AND OTHER CONDITIONS
Learning Objectives
• Describe signs and symptoms of eye infection.
• Describe causes and prevention of common eye infection.
• Describe signs and symptoms of worm infestation.
• Explain types of worm infestation.
• Describe prevention of worm infestation.
• Describe the common skin infections.
• Explain how to prevent skin infection.
• Describe types of bites.
• Explain on dangers of insect, snake, or animal bites.
• Describe management and prevention of common accidents
• Define unconsciousness, convulsions, and Shock
• Describe management of unconsciousness and convulsions
• Describe management and prevention of shock

Duration:
3hours 30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
209
Explain that CBVs must also have accurate knowledge and skills on certain emergencies and other
conditions that could be managed at community level or referred to the health workers. CBV should also
provide health information to community members on prevention of these common ailments.
SECTION 1: EYE INFECTIONS
Introduce the topic by discussing the importance of sight.
Ask the participants to brainstorm the common eye problems they see in their community.
After brainstorming, divide the participant into groups and let them discuss the following: signs and
symptoms of eye infections, causes, prevention, and referral. Let them refer to the CBV handbook during
the exercise.
During the plenary session, make sure that all participants are active. Give appropriate emphasis and
explanations where need arises.
Show the correct way to clean the eyes and apply eye ointment as instructed below. Do not demonstrate
on any of the participants.
How to clean and apply eye ointment

· Wash hands thoroughly.
· Clean eyes with lean cotton wool or cloth soaked in mild salty water. To clean appropriately;
gently place the soaked, cotton wool or cloth in the inner part of the eye and move gently to
outer part of the eye.
· Apply eye ointment on lower eyelid and ask patient to close the eyes for some time and
protect the eye from sunlight.
Summarize all the points with reference to the learning objectives. Refer to the CBV handbook. Indicators
of achievement of the objectives include participants should be able to list signs and symptoms of “red
eyes.” Participants should be able to state preventive measures of red eyes and discuss treatment of mild
infection.
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SECTION 2: WORM INFESTATIONS AND COMMON SKIN CONDITION
Discuss with the participants that worm infestation is a common condition among children below 5 years
of age. Worm infestations are acquired through close contact with contaminated soil (soil into mouth).
Show the participants the posters with types of worms. Describe which of these are round, hook, thread,
or tape worms.
Divide the participants into groups to discuss the signs and symptoms of worm infestation. After group
work let them make presentations and discuss the findings. Compare their lists and ensure that all the
signs below are mentioned in the discussion.
Signs and symptoms of worm infestation
· Pain or discomfort in the stomach,

· Itching around the anus especially at night,
· Passing of worms with stools,
· Vomiting of worms,
· Anaemia,
· Nausea (feeling like vomiting),
· Chronic diarrhoea,
· General body weakness
Discuss the prevention and treatment of worm infestation. Emphasize the importance of all caretakers
attending Child Health Weeks for deworming. Mention the points below for prevention.
Prevention of worm infestation

· Emphasis should be put on personal hygiene.
· Hand washing after passing stool and before handling or eating food.
· Proper disposal of stool.
· Avoiding eating soil.
· Food must be cooked well.
· Wash vegetables and fruits thoroughly.
· Treatment of all infected persons in the family to avoid re-infection.
Summarizes by asking the participants about the types of worms, signs, and symptoms of worm infestation,
refer to CBV handbook.
Part 2: SKIN CONDITIONS
Introduce the session by saying that common skin infections are mostly seen in children. They cause
discomfort and may sometimes be very painful and or itching. The purpose of this session is to provide
the CBV with knowledge and skills to be able to identify, provide preventive care, treat, and refer severe
skin infections.
Ask the participants to describe the examples of common skin conditions seen in their communities.
211
Summarize by mentioning scabies, ringworms, and leprosy. Remind them that they had already learnt
about leprosy.
Describe scabies as an itchy skin condition which spreads through skin contact, clothing, and bed linen.
The main areas that are affected are the folds of the skin between lingers, wrists, elbows, and buttocks.
Allow the participants to participate in the discussion by giving examples on their experiences.
Conduct group work discussions on the signs and symptoms of scabies.
Signs and Symptoms of scabies
· Itchy swelling and rash.

· Scratching is more pronounced at night.
· Common sites for lesions are between fingers, wrists, elbows, armpits, trunk, buttocks, and
genital area.
· The face and scalp are usually spared.
Discuss treatment and prevention of scabies by asking the participants to refer to their CBV handbook.
Treatment of Scabies
· Wash body thoroughly and apply benzyl benzoate.
· House members to follow preventive measures.
· Boiling of all clothing and iron them if possible.
· Dry clothes in direct sun light.
Prevention of Scabies
· Encourage body bath at least once a day.
· Wash clothes regularly.
Ringworms
Inform the participants that the infection usually affects the scalp and are more common in children. The
infection is contracted through skin contact and sharing clothing and beddings.
Let the participants describe the signs and symptoms.
Signs and Symptoms
· Coin shaped patches on scalp with broken hairs (ring worm of scalp).
· Itchy circular or ringed patches on the body (body ring worm) with raised or active edges.
· Itchy in between toes.
Discuss treatment and prevention of ring worms by asking the participants to refer to their CBV handbook.
212
Treatment
• For scalp ring worm treatment should be done at a health centre because the infection
takes long to resolve i.e., the infection is in the hair follicle.
• Hair to be cut short.
• For body ring worm apply benzoic acid (Whitfield’s ointment) twice a day until the lesions
are clear and continue one week more.
• Clean between toes thoroughly and dry, then refer to health facility.
Prevention
Avoid sharing clothing, beddings, towels, and combs, being in close contact with infected per-
son. Socks should be washed regularly.
Impetigo
Define this skin disease by saying that it spreads quickly from one person to another. The areas affected
commonly are the scalp (head), faces, upper and lower limbs.
Signs and Symptoms

· Blisters that later become sores.
· Itching in affected parts.
· Localised swelling and redness.
Management
· Washing clothing and beddings with soap and water.
· Avoid using Vaseline for the whole family as this would act as a reservoir of infection.
· Refer to health centre
Lice infestation
Discuss with the participants the types of lice and the signs and symptoms. Let the participants describe
the ways to prevent lice infestation. Explain the treatment of lice infestation.
Types lice infestation

Body (clothes) louse, Pubic louse, and Head louse
Signs and symptoms · Itching sensation as the louse moves.
• Small sores that develop through scratching as die louse bites.
• Falling of hair due to scratching of hairy areas where the mite attaches itself.
Prevention
Encourage personal hygiene e.g., daily body bath with soap, boiling of all clothes, beddings,
towels, combs, and ironing.
Treatment
• I % Lignocaine lotion application to the affected areas once at night.
• Wash body thoroughly and cut the hair where applicable.
Note: All other skin conditions should be referred to the health facility.
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SECTION 3: BITES
Make a presentation about the most common bites in the community. Discuss all approaches used by
participants in their communities to manage the bites. Inform them that the most common bites discussed
in this session are snake bites, insect bites and dog bites. Refer to the table below also available in the CBV
handbook.
Types of Signs and symptoms Management

common bites
Poisonous At the site of bite • Immobilize the bitten limb or part and put
snakes it in an elevated position. (Relax patient, tell
him not to panic).
• Pain,
• Swelling, • Tie a string or piece of cloth tightly above

the bitten site so as to prevent blood flow
• Tissue discoloration.
back to the heart but preserve the pulse to
• Tissue dies, avoid gangrene (rotting of tissue due to lack
of blood supply). (Do not make tattoos, as
• Regional lymphadenopathy, you may introduce dirt).
• Bleeding
• Clean the bitten area and give a pain killer
especially Panadol if necessary. (Do not ap-
Other signs ply traditional herbs).
• Refer patient to health centre.

• Nose bleeding,
• Bleeding from eyes and gums • Do not make patient to move fast because
poison may move quickly to other parts of
the body.
Danger signs
• Drowsiness,
• Incoherent or abnormal speech,

• A lot of saliva from the mouth,
• Difficulties in breathing
Non At the site of bite:
poisonous
• Two (2) rows of teeth mark with
snakes
no prominent marks for fangs.
• No front fangs (if snake is killed
and brought, check its mouth
properly to confirm this fact).
Dog bites Dog bites should be taken very seri- • First find out from the patient, relative or
ously as people are sometimes bitten owner of the dog if the dog was vaccinated
by mad (rabid) dogs which can trans- against rabies within the past 12 months.
mit a deadly disease called rabies. All • Clean the wound with soap and water and
animal bites are generally regarded cover it with a clean dressing.
as infectious for they introduce dirt • Refer patients to the
and germs into the wound.
214
health centre. Inform the health centre staff
if dog’s vaccination certificate is still valid.
· Observe the dog for 10 days for signs of
rabies
(e.g., abnormal behaviour among which
restlessness and fear of water are common).
if it turns mad then report to the health
centre.
· Vaccinate all the dogs in the village against

rabies. Ask the local veterinary department
to help. CBV to report to the health centre
and Veterinary department for vaccination
against rabies.
· Educate the community
to kill all stray dogs and get all pet (tamed)

dogs vaccinated against rabies where pos-
sible and scorpions.
Insect bites · Severe pain at the site of bite. · Apply cold compress at the site of bite.
Shock may occur, especially in If the patient is in shock refer immediately.
· children. Redness at the site of · Give painkiller e.g., aspirin or Panadol. Refer
bite and may be bleeding. the patient to health centre if the insect
· The bite site may be swollen. · bite is severe.
·
·
Summarize all the common types of bites and the management, refer to CBV handbook.
215
SECTION 4: COMMON ACCIDENTS
Discuss with the participants the types burns and scalds, signs, and symptoms as well as management.
Define burns as wounds caused by dry heat such as fire, explosions of stoves, petrol burns, hot metals,
electrocution etc.
Define scalds as types of injuries caused by wet heat such as boiling water, hot oil, and hot tea (fluids).
Types of Burns Signs and symptoms Management

Minor Burns Pain at the site of burns Give Panadol
These are bums that are very Put burns part of the body in cold
superficial and cover a small water.
surface of the skin.
Moderate burns Pain at the site of burns. The Give Panadol.
skin may be red or blistered.
These are burns where the Do not break the blisters because you
skin is partially destroyed The skin is partially destroyed. may introduce infection.
If blisters are broken wash the wounds

gently with soap and water.
Apply boiled and cooled Vaseline.
If no Vaseline, protect the site from
dirt, dust, flies and refer to the health
centre.
Deep Burns Burns area looks raw Patient Give Panadol

may show signs of shock e.g.
These are bums that destroy The CBV to refer such a condition
the skin and expose the raw Patient is in severe pain. immediately.
flesh and are always serious.
Summarize management of burns and scalds.
216
SESSION 6 : CONTROLLING BLEEDING
Define bleeding as a loss of blood from the body. It may result when an injury, wound, fracture or damage
to organs occur. Any bleeding must be controlled or stopped immediately
Describe the types of bleeding as nasal and wound bleeding. Explain that nasal bleeding is common and
is due to break of small vessels in the wall of the nostrils. This could be due to disease or direct impart or
force on the nose.
Explain the management of nasal bleeding as indicated below.
Controlling nasal bleeding

· Place the patient in a sitting position.
· Pinch the nose lightly for 10 minutes or until the bleeding has stopped.
· Apply cold compress or wet cloth on the bridge of the nose.
· Advise the patient to breathe through the mouth and spit any blood that may collect in the
mouth.
· If bleeding continues refer to health centre.
· Tell patient to breath using his mouth
Describe a wound as a break in the skin due to sharp edged objects e.g., knives, bullets, nails, spears etc.
Explain the management wound bleeding as indicated below.
Control of bleeding wounds

· Clean wounds and remove foreign bodies.
· Control bleeding by direct pressure on the bleeding site using clean material e.g. chitenge,
cotton wool.
· Elevate affected limb.
· Keep patient warm and give oral fluids.
· Refer patient to the health centre.
Summarize control of bleeding.
217
SESSION 7 : POISONING
Define poisoning as the introduction of a harmful substance into the body by swallowing, injecting, or
breathing in. It is common in children but can also happen in adults.
Describe the types of poisoning as chemical, food, and gas. Give examples as shown below.
CHEMICAL e.g., paraffin, chemical for spraying crops, drugs, petrol, and acids etc. FOOD e.g., some
mushrooms, some cassava and caster beans GASES e.g., from charcoal brazier (Mbaula).
Explain the management of poisoning as indicated below.
Signs and Symptoms Management of Poisoning

• Vomiting Chemical e.g., • Keep patient warm.
Paraffin
• Abdominal pains • Do not make patient vomit.
• Refer to health centre.
• Diarrhoea
• Give clay soil or pounced charcoal.
• Headache
• Dizziness
• Sweating
• Confused state
• Unable to see properly
• Too much saliva from the
mouth
Food • Bed rest.
• Keep patient warm.

• Give ORS or milk if the patient is vomiting or has
diarrhoea to prevent dehydration.
• Refer to the health centre.
Gases • Open windows and
doors for fresh air to come in and the used air to go
out.
• Remove the patient away from where the gas/air is
coming from.
• Apply artificial respiration and refer to Health
Centre if no improvement.
• Refer.
Drugs • If the patient is conscious and vomiting or has

diarrhoea give ORS/milk.
• Refer to health centre.
All poisons are emergency. Refer them urgently.
Summarizes management of poisoning.
218
SESSION 8 : SPRAINS, DISLOCATIONS, AND FRACTURES
Define dislocation as a displacement of bones in a joint following an impact or fall.
Define fracture as a crack or a break in the bone. Fractures are a common health problem in Zambia for
both children and adults. The most affected being children.
Describe the two types of fractures as: closed fracture in which there is no open wound; and open fracture
in which there is an open wound.
Explain the management of sprains, dislocations and fractures as indicated below.
Signs and symptoms Management

Fractures • Pain at the site of fracture. • If there is a wound, attend to the wound first
and control or stop bleeding.
• Swelling.
• Do not move the
• Deformity. fractured part to avoid pain and worsening
of the fracture.
• Loss of function to the • Place and support the fractured part on
injured part. plants or sticks and bandages or piece of
cloth.
• Wound and bleeding (if
open fracture). • Do not remove clothes
• Signs of shock may be to avoid further injury.
present.
Assure patient.
• Give Paracetamol or aspirin.
• Refer patients to a health centre.
Sprains/dislocation • Severe pain • Rest and support the injured part in a most
comfortable position.
• Swelling
• Deformity. • Apply cold compression and bandage.
• Signs of shock • Give aspirin or Panadol to reduce pain.
• Loss of function of the • Refer to health centre.

affected part.
• Treat for shock if present.
Carry the patient to the health centre in the most comfortable position taking into consideration the injured
part. Support the part before carrying the patient. Use hard surface when transporting the patient to the health
centre.
If you suspect fracture of spine, carry on bed or hard board
Summarize management of fractures and dislocations refer to CBV handbook.
219
SECTION 9: UNCONSCIOUSNESS
Explain to the participants that loss of consciousness is one of the important conditions a CBV will be
required to deal with in the community. If first aid treatment is not applied in time patients may lose their
life.
Define unconsciousness as the condition in which the sick or injured person cannot voluntarily control his
body activities, is not aware of the surroundings and may not respond to touch or when calling.
Explain the management of unconsciousness.
Common causes of
General signs and symptoms Management of unconsciousness
unconsciousness
Poisoning. General body weakness. Position the patient rightly
Absence of voluntary body
Drunkenness. activities. e.g., laying the patient on one side
with head titled backward to make
Not aware of the sure the airway is open.
Head injury.
surroundings.
Never give patient any food or drinks.
Heart attack.
Avoid overcrowding the patient.
Bleeding (severe) Dehydration
(severe). Diseases e.g., malaria,
Identify the cause and manage it if
meningitis possible. Refer patient immediately to
health centre.
Maintain airway, breathing circulation.
Summarize management of unconsciousness.
220
Session 10 : Convulsions and shock
Define convulsions as strange jerking body movements due to sudden loss of consciousness. Sometimes
they are called “fits.”
Define shock as a condition in which a patient has very low blood pressure. Shock usually occurs following
a severe injury, bleeding, or pain.
Explain the management of shock and convulsions as indicated below.
Common causes General signs and symptoms Management
Shock
Bleeding Pale face and lips. The management of shock takes
priority over any management except
Allergic reaction Sweat on the forehead
bleeding:
Severe dehydration Cold hands and feet
Lie patient on table or on the ground
Severe pain Shallow breathing on a sheet or blanket.
Poisoning Fast and weak heartbeat.
Keep the patient warm.
Vomiting
Stop any bleeding
Unconsciousness (at a later
stage). Fractures should be splinted, and
wounds be covered before sending
the patient to the health centre. Refer
the patient to the health centre.
Maintain airway, breathing circulation.

Convulsions
Disease e.g., malaria of the Identify the cause and manage it if
brain, meningitis, epilepsy. possible. Refer patient immediately
to the health centre. In case of high
Head injuries. fever lower the temperature by
sponging the patient. Position the
Severe dehydration. patient well not to block airways and
Poisoning. blood flow.
Summarize management of convulsions and shock, refer to CBV handbook.
221
CHAPTER 26:
DISEASE MONITORING AND CONTROL
Learning Objectives
• Describe the concept of disease surveillance to influence decision making on health care and
directions for improvement of health services.
• Define disease surveillance
• Explain purpose and importance of disease surveillance
Duration:
30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
222
Provide explanation of the definition of surveillance, purpose, and importance of disease surveillance.
Refer to the notes provided below.
Explain that disease surveillance is the collection, analysis, and interpretation of health information on
where, when, and in whom the disease occurred, and the dissemination of information to those who
need to know so that they can take appropriate action to prevent further diseases. The aims of disease
surveillance are to monitor the number of cases of illness coming into the health system and to use this
information to detect the occurrence of outbreaks and make decisions to respond appropriately on time.
It is important to analyse the data at your health post regularly and to implement measures to prevent
further disease outbreak.
Purpose of disease Surveillance:
Discuss with the participants the following points:
• Helps to monitor programme performance and the impact of interventions
• Identifies high risk populations
• Involves timely detection and response to disease outbreaks.
• Provides information for programmes planning and evaluation
• Certifies achievement of disease control and disease elimination or eradication objectives
Monitoring the Quality of Disease Surveillance
Explain the following points for monitoring the Quality of Disease Surveillance
• Timeliness of reporting: Ensure that you report to the health centre in time. The ability to effectively
control disease depends on the timeliness and appropriateness of the response to disease outbreaks.
• Completeness of reporting: Ensure that the reporting forms are completed correctly, with the
relevant information before submission to the health centre.
Reporting Data to Higher Levels and Providing Feedback to community level
Explain the following points to ensure efficiency in reporting
• Send monthly reports to the health centre by first week of each month.
• The health centre should end to the district within the first week
• The district should send reports to the province by second week of the month
• The province should send theirs by third week of the month
• Provide feedback through meetings, newsletter, and supervisory visits
223
Epidemic Preparedness and Response
Explain that the district health office is responsible for organizing a response to control epidemics
by:
• Strengthening or forming epidemic preparedness committees within the catchment area

(Community health post, health centre and district).
• Ensuring the availability of resources (medical and non-medical) for emergency preparedness and
response (EPR)
• Establishing rapid response teams (RRT) within the catchment area (district, health centre and
health post level) that can respond to outbreaks within 48 hours.
Action Needed for Different Types of Disease Outbreak
Explain the following action needed for different types of Disease Outbreak as indicated below
An ongoing outbreak:
• Needs immediate attention
• Identify population at risk
• Prevent the spread of the disease and reduce morbidity associated with the disease through
preventive, promotive, and case management interventions (i.e., Isolation, treatment, and referrals).
An outbreak that is almost over:
• Plan and implement activities to prevent future outbreaks/ cases through preventive and promotive
measures, such as health education, use of ITNs, chlorination of water, supplemental immunization,
etc
224
CHAPTER 27:
CBV ESSENTIAL DRUGS
Learning Objectives
• Describe the essential drugs management for the CBVs.
Duration:
30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
225
Ask participants to refer to CBV manual. Explain essential drugs kit for the CBVs as described below.
Explain that essential drugs are those that satisfy and support implementation of the Basic Health Care
Package and the health care needs of the majority of the population. They should, therefore, be available
at all times in adequate amounts and appropriate dosage forms.
This section lists most of the essential drugs mentioned in this manual for Community Based Volunteers
(CBVs).
Selection and Supply
The district or hospital Pharmacotherapeutic Committee (Drug and Therapeutic Committee), in

conjunction with the Zambia National Formulary Committee select the essential drugs.
Explain that essential drugs are defined depending on the level of health care and highlight the information
below:
• Community- supplied through the Community Based Volunteer’s kit
• Health centres- supplied through the health centre kit
Find out if participants know some CBVs drugs and supplies; summarise with the information below.
Community Based Volunteers essential Drugs
1. Acetylsalicylic acid tablets 300mg [aspirin] (for pains, fever, and headaches in adults only)
2. Gentian Violet crystal (for small wounds)
3. ORS (WHO-formula), sachets, powder27.9g/IL (for diarrhoea)
4. Paracetamol tablets BP 100mg [Panadol] (for fever and pain in children only)
5. Paracetamol tablets BP 500mg scored [Panadol] (for fever and pain in adults only)
6. Tetracycline eye ointment 3.5g (for bacteria eyes diseases)
7. Contraceptive pills [assorted brands] (for family planning)
8. Amoxicillin capsules (for Pneumonia)
9. Co-Artem Tablets (for Malaria)
Basic supplies:
1. Bandage, cotton W.OW. 5cm x 5m (for cleaning and dressing wounds)
2. Condoms [male & female] (for prevention of STIs/ HIV infection and family planning)
3. Diaphragm [contraceptive method for female] (for IEC on family planning)
4. Cotton wool absorbent non-sterile (for cleaning wounds)
5. Notebook pad A5 ruled 50 pages (for writing some information on diseases, others)
6. Pen ball point blue (for writing some information on diseases, others)
7. Toilet soap (for washing hands before and after seeing patients)
8. Triangular –bandage cloth 910mm sides (for use in patients with fractures/dislocations of shoulders
while referring)
226
CHAPTER 28:
MONITORING & EVALUATION
Learning Objectives
• Define monitoring
• Explain concepts monitoring and evaluation.
• Define health information system
• Define data analysis
• Describe the process of report writing
Duration:
30 minutes
Teaching Materials
- Flip charts
- Markers
Teaching Methods
- Lecture
- Discussion
227
Explain that as with all health services, community health services should be subject to quality monitoring
and evaluation. The regular and accurate collection of service statistics and regular monitoring and
evaluation at the facility level are a key to maintain and improve the quality of services delivered. They can
also help in assessing whether community health services are actually available to individuals and families.
If at the beginning of introducing health services, information has been collected including information on
illnesses and deaths from various community diseases, and if routinely and accurately kept at community
level, programmes will be able to evaluate the extent to which full access to community-based health
services reduces illnesses and deaths.
The aim of monitoring and evaluation is to share and discuss information or statistics collected with other
stakeholders in the community to make decisions about improvements to community health services.
SECTION 1: DEFINITION AND APPLICATION OF MONITORING
Part 1: Definition
Ask participants to define monitoring and reinforce with the definition below.
Explain that monitoring is overseeing the processes of implementing services, including changes over
time through supervision, routine service statistics and patient information.
Routine Monitoring should include:
• Analysis of problems in community health services according to types of services offered to

individuals or families using service statistics (information displayed in numbers) in record books
or registers. For example:
• Numbers of children, women, adolescents, and men seen, but not provided with services, Numbers
of those individuals seeking health care at a health post provide by a trained Community Based
Volunteer.
• Numbers of complications or serious problems referred to health centre
• Numbers of child immunizations by type given to children in the community
• Numbers of contraceptive methods provided by type
Regular aggregation of community data or information from community level health post and submission
of reporting forms to the health centre.
Assessment of progress to correct problems identified in routine monitoring
Discuss with participants the data sources and Indicators for Monitoring and Evaluating Community
Health Services in the table below.
Emphasize that data collection and reporting does not only provide proof that one is working but
much more it provides facts for generating information for decision making and planning
228
Table: Suggested Data Sources and Indicators for Monitoring and Evaluating Community Health Services
1. Routine Service Statistics:

Child health services
• Number of children under 5 referred to health centre for treatment by type of illnesses
(such as diarrhoeal diseases, acute respiratory infections, fevers, etc)
• Number of children received immunizations by type of immunizations given
• Number of children with HIV +ve
Safe motherhood
• Number of women currently pregnant in the community
• Number of women attending ANC at health post or at health centre in the last quarter, or year
• Number of women delivered in the last quarter of year
• Number of mothers received PNC at health centre
Family planning services

• Number of women on family planning by type of methods
• Number of community agents trained in family planning services
Communicable diseases and non-communicable

• Number of people with chronic illnesses
• HBC given by type of illness and social support care
• Number suffered from infectious diseases by type of disease
2. Periodic evaluation
• May involve participation in other communities
• Type of services offered at community level
• Assessment of quality of home-based care or quality of community health services
• Number of Community Based Volunteers trained
• Quality of adolescent health services by type
3. Patient information (kept in community register or case record or notebooks)

• Age, parity, marital status, education, occupation, head of household or village name
• Reasons for referral
• Treatment given
• Reasons for refusal
• Follow-up home visit care given
Developing integrated Monitoring Indicators and Performance Audit tool (see appendix 4)
229
Part 2: Supervision
Explain that supervision is an important part of community programme activities. It is not just a matter of
checking on work and giving instructions, but an important part of effective monitoring.
Emphasize that the best supervisor provides support without taking charge and with skill
understanding and patience
Ask participants, “Who Makes the Best Supervisor?” summarise responses as indicated below.
An important part of good supervision is trust and friendship
Ask participants, “What is Good Supervision?” reinforce responses as indicated below.
• Supervision and workers must be in a relationship of partnership.
• Shared responsibility for mutually agreed objectives and working methods.
• Good teamwork, with frequent meetings at which all viewpoints can be expressed.
• Clear and agreed job descriptions for all involved.
• The giving of praise where it is due and the opportunity for promotion or upgrading, or further
training
• Discussion of mutual progress, problems, and plans
• Realistic decision-making and planning according to the need, priorities, and available resources
• Awareness of responsibilities and possible problems in the personal lives of one another
• Reaching agreement wherever possible during discussion, or if not, agreeing to differ
• Where conflicts arise, listening patiently to all points of view separately, before trying to resolve
them together
• Avoidance of favouring some workers in preference to others
• Fair distribution of mutually agreed tasks
• Careful joint planning of the work plan with objectives that can be measured or clearly evaluated
• Giving advice and instructions that are clear, relevant, feasible and practical’
• Using the opportunity to share and learn new facts and skill.
• Providing regular opportunities for workers to meet each other, to prevent feelings of isolation
and to encourage learning
• Provision of learning materials, such as manuals (of this nature), pamphlets, newspapers, and
visual aids where possible
• Ability to compile reports and make use of available information for the field worker
• Recognition that the supervisor also learns from, and with the field workers
230
Ask participants, “How often is Supervision Needed?” reinforce responses as indicated below.
This will depend on:
• How much support the field worker normally receives from community/team/other workers, but
usually it should be monthly or quarterly.
• Distance and cost (how far it is, and what it costs for a supervisor to visit a worker or for a worker
to visit a supervisor.
• Reimbursement of costs (whether the worker is being paid for the journey and by whom, and how
long the worker is away from work)
• Seasonal factors (for example whether it is planning or harvesting time, or rainy season)
• Length of visit (whether the visit is for a few hours, overnight or longer).
• Normal workload (whether the worker needs more frequent advice or supplies, and also how
much time the supervisor has, if supervision is only a part-time activity).
231
SECTION 2: CONCEPT OF EVALUATION
Explain that evaluation is assessing the relevance, effectiveness, efficiency, sustainability, and impact of
services using service statistics from monitoring and from special investigations to assess the extent to
which programme goals or objectives are being accomplished.
Ask participants why they should evaluate?
Explain that when you ask people why they evaluate their work, different people give different answers.
For example, actual answers that may be given are as indicated below:
To help see where we are

going and if needed to change
direction
To help us Make
To see what has betther plans for
been achieved future
To measure progress
To make work
more monitoring
To to able to
improved our “Why did you
methods
evaluate?” To collect more
information
Tosee where our

strengths and
weaknesses lie
To see if our work is
costing too much and
achieving too little
To criticize our
own work
To compare the To be able to share

programme with our experiences
others who like it
Explain that from the examples of answers given above to the question “why did you evaluate?” ten key
reasons emerged. These are to do with:
Achievement: seeing what has been achieved
Measuring progress: in accordance with the objectives of the programme
Improving monitoring: for better management
Identifying strength and weaknesses: to strengthen the programme Seeing if effort was effective:
what difference has the programme made? Cost benefit: were the costs reasonable?
Collecting information: to plan and manage programme activities better.
232
Sharing experience: to prevent others making similar mistakes or to encourage them to use similar
methods.
Improving effectiveness: to have more impact
Allowing for better planning: more in line with the needs of the people at community level
Point out that some of these key reasons are easy to understand, some are more difficult. It is therefore
important to involve those who have the experience in evaluation to assist you. Use of words and meanings
that are even more simple and clear than those given above are important in the techniques of evaluation.
Explain that evaluation is a way of looking at the programme activities, human resources, material
resources, information, facts and figures in order to:
• Monitor progress and effectiveness in relation to resources being used
• Consider costs and efficiency in terms of money and time being used to achieve efficiency of work
activities.
• Show where changes are needed, and
• Help to plan more effectively for the future.
Part 1: Methods of Evaluation
Discuss that the methods of evaluation as indicated below.
These are:
• Rapid appraisal technique- involving quick methods e.g., needs assessment, community diagnosis
• Surveys
• Focus group discussion
• Record review to collect statistics
• Mapping system for creative learning
233
SECTION 3: COMMUNITY BASED HEALTH INFORMATION
Explain that in many communities, information system is still a problem. This is because of lack of
understanding of the importance of information, lack of adequate training and poor methods of data
collection. For this reason, it is still a problem getting reports from community level.
Part 1: Definition of Health Information
Explain that health information tells people about the health status of the people. It refers to either lack of
or presence of disease in the population. Proper Health Information Management should be seen in the
context of not only maintaining our records but as a means through which we can monitor and improve
the lives of our communities. Health information helps us in detection of the occurrence of an event in our
community, e.g., disease like cholera.
Part 2: Types of Health Information:
Discuss with participants the types of health information as indicated below.
Epidemiological information
• Reported sickness (morbidity)
• Deaths (mortality)
Demographic information
• Number of household
• Total population in an area
• Children under the age of 5 years
Environmental Information
• Number and types of water sources
• Number and types of Pt latrines
• Number of refuse pits
Nutrition Information
• Number of children under the age of 2 years who were brought to the weighing section
• Number of children growing well
• Number of children who did not gain enough weight
• Number of children below the lower line
234
Part 3: Reporting System
This involves the process through which data collected is transmitted from the source of collection to the
next level and back to the data collection source. It refers to the data collection instrument methods of
compilation, frequency of reporting and feedback system.
Ask participants “Who needs health information at community level?” summarize responses as
indicated below.
• Parent of young people
• Community leaders
• Health Centre Team
Explain the sources of information as indicated below
i Community Register
ii Patient Register - Nutrition
iii Register Health - Education
iv Register
v Report Form
vi Map (Catchment Area)
Discuss with participants different methods of data collection. Summarise the methods shown
below
i Reporting
ii Forms
iii Questionnaire
iv Interviews
v Direct Observations
vi Focus Group Discussions
Discuss with participants on the use of information, summarize as indicated below.
i For planning
ii For estimating supplies and logistics required
iii For monitoring health status of community members.
Emphasize to participants concerning reporting that they should:
• Get the meaning not just the numbers
• Link the results with action to be taken
235
Data Analysis
Definition
Explain that data analysis is a process where data is simplified and understood by people otherwise it will
be useless. The basic tool used when analysing data at the community level is sum.
Discuss with participants the example below:
MAI community children under 5 total population in the first quarter of 1997 was 286. In the same quarter
the CBV recorded Severe Malnutrition Cases as shown below:
Table 22.4: Severe Malnutrition Cases in MAI community
Months Cases
January 11
February 13
March 20
What is sum?
Sum is adding (putting together of the events that have occurred in the 1st quarter of 1997 in MAI
community).
The total number of severely malnourished cases is therefore:
SUM=11+13+20= 44
Interpretation
In the first quarter of 1997 MAI community had 44 children who were severely malnourished meaning
242 children were okay. Did MAI community have malnutrition problem in the 1st quarter of 1997? Yes, 44
severely malnourished cases indicate to the CBV how much work is still to be done. At a later date the CBV
can check again to see what progress has been made in terms of improving nutrition status of children.
236
Report Writing
Explain that this is one other way of keeping information on the activities that you have carried out. At the
end of each month, or every three months or every year, it is important to document all the activities you
have done in a way of a written report. The structure of the report has to include the following information:
title of the topic, who is affected, number, age group and sex, action taken and assistance resources
General Useful Points for Preparing a Written Report:
Explain to participants useful points for preparing a written reports indicate below.
Keep written report short- very long reports tend to be used less than short ones. No time to read a long
report.
• Keep it clear
• Use short sentences
• Plan spacing and layout- break contents into paragraphs or sections
• Use subheadings
• Emphasize key point
• Use a running commentary- report present the key points
• Review your report
• Submit on time
What the Report Needs to Contain:
Explain the lay out of the report to participants as indicated below.
Front cover- Title of the report; name and location of programme; names of those who took part in the
evaluation; names of those with whom the programme is linked, such as ministry of health, or donor
agencies, etc; period covered by the report; and date report compiled.
Summary- A brief one- or two-page overview of the report is useful for busy readers and those who wish
to study in it more details- Explain purposes of evaluation; for whom was it carried out; how; where, when;
major results; conclusion; and recommendations.
List of contents- A list of contents in clear, logical order will help the readers find sections of special
interest to them.
Background information- This puts the programme into perspective and shows its origin, objective, and
evolution:
Explain briefly when, why and how a programme began, who was involved by type/e/group/training/
umber etc.
Which were the priority objectives?
Which were the main activities and resources involved?
The length of this section depends on the objectives of the report.
237
Purpose of evaluation and methods chosen- Explain the purpose of the evaluation and state the
intended audiences.
Be clear about what it is not intended to do.
Briefly explain the reasons for the particular evaluation plan and the methods used to obtain the
information (e.g., focus group discussions or interviews, observations, and so on).
Include samples of these methods used in the appendix.
Mention problems of manpower, finance, physical resources, and political situation.
Outcome of using the methods- Where and how were the evaluation methods developed and tested?
How was the information collected and by whom, and which methods were sued?
How reliable and valid did they prove to be?
Include information about how staff and participants were trained to use the methods.
Results of data collection and analysis- After analysis of the facts, figures and information collected,
tables, graphs, or diagrams (see Data analysis section below), can be prepared and included.
You may also want to include typed examples from illustrations or photographs. These can convey a
particular point which cannot be expressed in any form, for example those in numbers form.
Conclusion- These may include the following:
To what extent have programme objectives been achieved?
Which aspects of the programme (such as planning, management, monitoring, training, field activities,
etc) are strong and which need to be strengthened?
Have human and material programme resources been used efficiently?
How has the programme changed with time?
What are its financial costs and benefits?
What predictions can be made for the short- and long-term future of the programme? Most important of
all, what effect or impact is the programme having?
Recommendation- On the basis of your conclusions, what courses of action are proposed?
How are these to be implemented, by whom and when?
This may be the part of the report which some people read first. It may be the only part which they read.
Identify the priority recommendations
238
Making a Verbal Report
Explain the instructions on making verbal reports as indicated below.
When preparing the presentation remember the following points:
Keep it short- Do not give people too much information- just help them to remember the main points.
Think what they need to know- Remember their own needs and interests and prepare your presentation
to suit them.
Emphasize key points- It helps to sue visual materials, posts, quotations, tables, graphs, etc
Encourage participation- Question-and- answer sessions, a panel of selected people, or social drama can
all help in the presentation and sharing of the information.
Encourage people to express their views- Discussion of results may result in conflicting views, Coping with
these is an important part of a participatory approach.
Listen and be tactful- Try to maintain a good atmosphere and good relationship between people,
especially if they have differences of opinion.
Feedback
What is Feedback?
Explain that feedback at the community level should be a two-way system. The first feedback is between
the CBV/NHC to the community. The second feedback is between the HC and CBV/NHC. This involves
sharing of information through communication either through discussions in meetings, referrals notes to
health facility, letter writing, reports and sending verbal messages.
Data storage at community level
Ask participants how data can be stored at community level. Summarise as indicated below.
Explain that data can be stored using the following methods
i Hard cover notebooks
ii Filling cabinets (Book shell)
iii A map stuck on the wall
239
Bibliography
Central Board of Health. 2002. Integrated Technical Guidelines for Frontline Health Workers, Ministry of
Health, Lusaka
Central Statistics Office., Ministry of Health., Tropical Diseases Research Centre., University of Zambia.
2009. Zambia Demographic and Health Survey 2007. Macro International Inc.Calverton
El Bindari-Hammad., Smith, D.L. 1992. Primary Health Care Reviews: Guidelines and
Methods, WHO, Geneva
Feuerstein Marie-Therese. 1986. Partners in Evaluation: Evaluating Development and Community

Programmes with Participants. MacMillan
Hart, R.H., Belsey, M.A., Tarimo, E. 1990. Integrating Maternal and Child Health Services with Primary Health
Care: Practical Considerations. WHO, Geneva
Monekosso, G.L. 1994. District Health Management: Planning, Implementing and Monitoring a minimum
health for all package from mediocrity to excellence in health care, WHO Africa. Brazaville
Ministry of Health. 2009. Standards and Guidelines for reducing unsafe abortion morbidity and mortality
in Zambia
Ministry of Health.2007. Community Safemotherhood Action Groups: Trsining guide for SMAG Trainers
Ministry of Health., WHO., Unicef. 2007. Integrated Management of Childhood Illnesses
Ministry of Health. 2006. Child Health in the Community (Community IMCI), National Strategic Plan 2006-
2009, Lusaka
Ministry of Health. 2005. National Health Strategic Plan 2006-2011, “Towards Attainment of the Millennium
Development Goals and National Health Priorities”
UNFPA and Ministry of Health. 2005. Rapid Socio-cultural Research as a Methodology for Informing Sexual
and Reproductive Health/HIV/AIDS Programme in North-Western Province, Zambia
WHO Africa. 2008. African Health Monitor: Fighting Non-Communicable Diseases: Africa’s New Silent Killers
WHO. 2007. Indicators for Assessing Infant and Young Child Feeding Practices, Geneva
WHO.2003. Safe Abortion: Technical and Policy Guidelines for Health Systems, Geneva WHO.2003.
Integrated Management of Pregnancy and Childbirth: Pregnancy, Childbirth, Postpartum and Newborn
care: A Guide for Essential Practice, Geneva
WHO. 2002. Promoting Mental Health: Concepts, Emerging Evidence, Practice. Geneva
WHO Africa and CDC.2002. Technical Guidelines for Integrated Disease Surveillance and Response in
Zambia
WHO.1993. The Health of Young People: Challenges and Promise, Geneva
240
Appendix 1 Sample of community register
Sample of Community Register
Number of households Number of Number of pit Number of

water sources latrines refuse pits
Identification of Community by Name:
____________________________________________
Date of registration (by year or month and year):
___________________________________________
Relati on Date Disabilities/

Date of marital to Head Cause
Name Age Ed. Occup. Sex of Chronic
birth status of family of death disease
death
241
Appendix 2 Referral note
Referral note
Date: ________ /______ /_____
Village/Town: _______________________________________________________________________
Area: ______________________________________________________________________________
FROM: ____________________________________________ (Name of Community Based Volunteer)
TO: STAFF ON DUTY
_______________________ Health Centre

I have requested________________________________________________________ (name) _____ (age)
to come to you for further investigations and treatment.
The patient have had the following signs and symptoms: ________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
for the past ______days.
He/she has been treated with ______________________________________________________________
for ______days with no improvement.
N.B. If space provided for signs and symptoms is not enough, please use any other paper.
242
Appendix 3 Feedback from a health facility
Feedback from a health facility
Date :______ / ________ /______
The patient _____________________________________________________________________________
who was referred to this health facility for treatment and was suffering from__________________________
______________________________________________________________________________________
______________________________________________________________________________________
has been treated with ____________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please continue supervising recovery by:
________________________________________________________________________ _______
_______________________________________________________________________________
To return/not to return for review on ___________ / __________ / ___________
Name of attending Officer _________________________________________________________________
243
Appendix 4 Sample of Community Based Agents Integrated Aggregation Form
Sample of Community Based Agents Integrated Aggregation Form
Monthly/Quarterly Form
COMMUNITY BASED AGENTS’ AGGREGATION FORM

Background Information Name of District: …………………………………
Refernce: Year………………. Quarter…………… Month……………………………. Name of H/C: ……………………………………

Date of Reporting: ……………………………………………………………………. Name of Catchment Areas/Zone:
Reporting by (Name): Catchment Population: ………………………….
……………………………………………………………….
Designation:
……………………………………………………………….
Diseases (CBV) first Growth Monitoring (CBGMP & CBVs)
attendance
Diseases (number) 0 - 5 Yrs 5+ Yrs Attendees (number) 0-12 mon 13-24 25-60 mon
mon
Malaria/Fever New
ARI Re-attendance
Sore eyes Child not gained 2 mon
Diarrhoea Below lower line
Skin infection MUAC tape Red Yellow Green
Injury New
Other Old
Referrals Home visits
No. of cases refered to health No. of TB home visits

facility
No. of cases refered to other No. of HBC home
CBAs visits
No. of effective referrals (with feedback) No. of malnutrtion home visits
Antenatal Health Care Deliveries (TBAs) Maternal Health (TBAs)

(tTBAs)
No. of new No. of live births No. of maternal deaths in the
attendees community
No. of re- No. of still births
attendees
Post Natal No. of total referrals Family planning (CBDsm EBDsm tTBAs, CBVs)
No. of effective referrals No. of new FP acceptors
No. of FP re-
attendees
Peadiatrict HIV & AIDS (HIV & AIDS in children) Commodities distributed
No. refered for No. on ARVS defaulting No. of pill cycles

PITC
No. Tested +ve No. of defultors traced No. of condoms
pieces
No. on ARVs No. on septrin No. referef other methods
water and sanitation (Sanitation Agents or CBVs) Malaria, diarrhoes, HIV (Malaria Agents or
CBVs)
Old New Supplies Received Sold/Dist.
No. of protected water sources No. of ITNs
No. of un-protected water No. of Chlorine

sources bottles
244
No. of pit No. ORS
latrines
No. of VIPs No. condoms
Health Education Talks (Peer Educators, Community Counsellors, EBAs or CBVs)
Malaria Diarrhoea HIV/AIDS STD F/ Nutrition

Planning
No. of Talks
No. of attendees
Supervisor’s report/comments (From Health Facility)

Number of CBAs Reporting
TBAs CBVs Community Counsellor CBGMP Peer Educators CBD & MA TB t/s
Comments by
CBA
Comments by Supervisor
245
Appendix 5 Pre/post-test questions
Please Tick (√) True (T) or False (F) for the following questions
T F
1. ( ) ( ) The best distance between a refuse pit and a house is at least 10m.
2. ( ) ( ) The CBV should observe the community problems and decide how he/she can best solve them
3. ( ) ( ) It is OK to drink water that is not boiled if it looks clean
4. ( ) ( ) When registering vital events, still births are not included
5. ( ) ( ) Pregnant women should gain only the weight of the baby during the pregnancy
6. ( ) ( ) Children should be fed very little while they are sick
7. ( ) ( ) It is always good if a child is fat
8. ( ) ( ) Pregnant women should not eat eggs or meat
9. ( ) ( ) Small children should be weighed once a year
10. ( ) ( ) Meat and eggs are not absolutely necessary for good health
11. ( ) ( ) Nshima alone can be a complete and health meal
12. ( ) ( ) Children are small, but they need a lot of food
13. ( ) ( ) Parents should encourage children to play and to ask questions about things, because this
is how children learn
246
14. ( ) ( ) You should never feed a child with diarrhoea
15. ( ) ( ) Diarrhoea in child which is more than 14 days is not a danger sign
16. ( ) ( ) Pregnant women do not need to go health centre until they are ready to deliver
17. ( ) ( ) Using any family planning methods can protect you from AIDS
18. ( ) ( ) Every baby should eat only breastmilk until 6 months of age.
19. ( ) ( ) It does not matter what age children get immunized.
20. ( ) ( ) Having only one faithful sexual partner can help prevent HIV/AIDS
21. ( ) ( ) Young children should be kept warm and well covered to prevent them from getting
coughs and colds
22. ( ) ( ) Children with diarrhoea should not be given a lot of fluids as it will worsen the diarrhoea
23. ( ) ( ) A child with cough or difficulty in breathing should have breathing rates counted for 30
seconds only
24. ( ) ( ) Decision should only be made by men in all aspects
25. ( ) ( ) Communities should be involved in the prioritizing and planning activities
26. ( ) ( ) The best way to prevent ourselves from getting malaria is by taking Coartem tablets daily
27. ( ) ( ) A person can get malaria through drinking unclean water
28. ( ) ( ) Sleeping under an insecticide treated mosquito nets does not prevent you from getting
malaria because a mosquito can pass through the small holes.
247
29. ( ) ( ) Mentally ill patients should be chased from the community as they may be Dangerous
30. ( ) ( ) STDs are dangerous for unborn babies
31. ( ) ( ) Having sexual intercourse with an infected partner once is enough to give you the HIV virus
32. ( ) ( ) There is a vaccine which can prevent AIDS
33. ( ) ( ) HIV can be transmitted from mother to unborn child
34. ( ) ( ) Pregnant women need more food that usual
35. Please describe two ways in which disease can be spread.
______________________________________________________________________________________
______________________________________________________________________________________
36. Please draw a line from nutrients to what it does. Water is an example.
Carbohydrate foods protect from diseases
Fats used by the whole body for good health
Water body-building growth promotion
Protein foods energy- giving
Vitamins and minerals energy-giving
a. What are two signs of malnutrition?
______________________________________________________________________________________
______________________________________________________________________________________
b. Why is it necessary to take children to the under-five clinic for weighing?
c. Please plot Janet’s weight on the following chart. Janet was born on December 14th, 1994
248
Age
Birth weight 2.5 kg June 5.0 kg After weighing and plotting

January 3.5 kg August 5.5 kg these weights, what would
February 4.5 kg September 5.0 kg you say to Janet’s mother?
March 4.5 kg October 5.0 kg
May 4.5 kg
37.What are three ways of HIV virus transmission from one person to another? ______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
38. List three family planning methods

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
39. It family planning necessary ____________________________________________

Why, or why not_________________________________________________________
_______________________________________________________________________
249
40. In a few words explain what you think is the role of the CBV?
_______________________________________________________________________
_______________________________________________________________________
41. How often should small children be fed? ___________________________________
42. By what age should a child complete all the immunizations? ___________________
43. What are the 4 general danger signs which tell you to refer a child immediately?
A.
B.
C.
D.
44. Please list signs of dehydration in a child

A.
B.
C.
45. Clara is 4-year-old, and she weighs 16 kg. She has a fever and has been sweating a lot. What do you
do and what do tell the mother? Please explain in detail 1,2,3 and so on.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
46. Sara Phiri has twins aged 12 months. Please explain to Ms Phiri why she should bring her babies to
be weighed regularly.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
47. When should a pregnant woman go to the Health centre or Hospital for antenatal care?
______________________________________________________________________________________
______________________________________________________________________________________
250
48. Name three type of family planning devises (contraceptives). List advantages and disadvantages of
each type.
Method Advantages Disadvantage
49. Where can the community find family planning devices. ____________________________________
Tick the correct answer on the question below.
50. The risk of problems in pregnancy can be greatly reduced if –
1. ( ) Pregnancies were spaced at least two year apart
2. ( ) Women younger than 18 and older than 35 would avoid getting pregnant
3. ( ) All of the above
251
Appendix 6 Answers to Pre/Post – test
1. T 23. T
2. F 24. F
3. F 25. T
4. F 26. F
5. F 27. F
6. F 28. F
7. F 29. F
8. F 30. T
9. F 31. T
10. T 32. F
11. F 33. T
12. T 34. T
13. T 35. Through air e.g., TB & measles
Through sexual intercourse
14. F Through insects e.g., mosquitoes
252
15. F 36. Carbohydrates - Energy giving
Fats - Energy giving
16. F Water - Used by body for good health
Protein food - Body building-growth development
17. F Vitamins and mineral - Protection from diseases
18. T (a) Weight loss
19. F Oedema of both feet
20. T (b) To monitor their growth
21. T (c) Answer on the graph not provided
22. F
37. Through unprotected sexual intercourse

Through re-use of needles drug users
Through mother to child
38. Oral contraceptives

Intra uterine devices
Injectables
Barrier method
Permanent sterilization
39. Yes, it allows having children only when you want them.
40. To support communities with promotive, preventive, and curative services
253
41. Young infants to breastfed as much as they want, to be breast fed at least 8 times in 24 hours day
& night. Children above 6 months in addition to breastfeeding, should be given other foods 3
times in a day.
42. By the age 1 year
43. - If a child is not able to drink or breast feed
- If a child is vomiting everything
- If a child has had convulsions related to the current illness
- If a child is unconscious or lethargic
44. - Lethargic, unconsciousness
- Restless, irritable
- Sunken eyes, skin pink slow or slow
45. Clara could be having malaria.

Do RDT and if positive treat with antimalaria (Coartem)
Tell the mother to bring back immediately or take the child to health facility if fever persist or she
stops eating, or becomes sicker, or start convulsing. If these signs are not there to bring Clara in 2
days for review.
46. Sara Phiri should bring twins regularly to be weighed because twins share fee ding, therefore
they need to be monitored regularly to check if they are growing well or not so that appropriate
feeding advice is given.
47. As soon as they discover they are pregnant
254
48.
Method Advantages Disadvantages

Oral contraceptives Easy to take Cause Can forget to take
no pain
Cause nausea
Taking every day
Injectables Long lasting Painful
Permanent method Done once You cannot reverse it They need an

operation
49. Nearest health facility or community-based distributor
50. All of the above.
255
256
257

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REPUBLIC OF ZAMBIA

AIDS Acquired Immune- Deficiency Syndrome

The Government of the Republic of Zambia through the

Community Health Workers (CHWs) have been acknowledged

Prof. Lackson Kasonka

The 5th edition of the Community Based Volunteer facilitators

Special thanks go to UNICEF who provided Technical Assistance

Our gratitude also goes to MoH leadership and Community

To all of you, we remain grateful for your unwavering support.

Dr. Patricia Mupeta Bobo

Acting Director Public Health and Research

This manual is dedicated to all front-line Community Based Volunteers in Zambia.

Role of the facilitator

As a facilitator, you do four basic things:

Answer the participant’s questions as they occur.

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

Provide additional explanations or practice to improve skills and understanding.

Explain what to do in each session.

Compliment the participant on his correct answers, improvements, or progress.

You encourage participation:

What NOT to do….

Do not talk too much. Encourage the participants to talk.

Read the handbook,

Plan ways to help with difficult sections and answer questions,

Participant Learning Objectives

(Write on the flip chart the learning objectives)

By the end of this training course, participants will be able to describe:

Organization and Management

· The concept of primary health care in community health services.

· Organisation of women groups such as SMAGS.

· The kinds of communication, and counselling skills.

· Community partnerships and empowerment.

Promotive services will include among others;

· Promotion of family planning including provision and distribution of Short-Acting Contraception

· Refer patients with perceived danger signs in pregnancy

· Maternal check-up for danger signs at home,

· New-born check-up for danger signs at home.

· Promotion of early initiation of breastfeeding.

· Promotion of exclusive breastfeeding and promotion of proper and supplementary complementary

· Promote security and safety.

· Nutrition, growth monitoring and promotion.

· Promotion, and parenting education on nurturing care for ECD.

● Lost to follow tracing

● WASH - access to safe water supply

● Hygiene promotion and education

● Counselling and support on Kangaroo Mother Care.

● Prevention and management of emergencies and other illnesses.

● Mental health promotion and substance abuse prevention

· The concept of integrated management of childhood illnesses (IMCI)

· Management of Mild to Moderate Acute Malnutrition during home visits.

· Diagnosis and treatment of malaria at all ages.

· Home care of chronic illnesses

• Community Based Volunteer Handbook

• Job aids (Community Health Counselling cards and flip chart)

• Permanent resident in the Community.

• Mature person (Male or Female).

• Able to read and write in local languages and English.

• Must accept to be a volunteer.

• Willing to learn and change.