Introduction

Every child that is seen at a health facility with mild diarrhoea, and every dehydrated child that has been successfully treated at the facility, will be sent home to follow Plan A of the WHO/CDD Diarrhoea Management Chart, Case Management in the Home (give increased fluids, continue feeding, and seek medical care when needed). Unlike many other treatments, which are provided by you as the health worker, case management in the home is entirely the responsibility of the mother or other child caretaker. If correctly carried out, it can have a significant impact on the health of the child. How well the mother carries it out depends partly on how well you advise her.

Advising a mother on home case management is often the last activity carried out during a consultation, and often the least well done. The advice and the manner in which it is given are often not sufficient to enable the mother to understand and have confidence in her ability to care for her child's diarrhoea. There are many reasons for this: the health facility may be crowded, a health worker may have little time, and it is not always clear just how to advise the mother. When you assess and treat a child with diarrhoea at a health facility, there is a systematic approach which allows you to follow the same process each time: "Look, Ask, Feel, Decide, Treat." Advising a mother on how to care for the child at home may seem like a less structured activity; it is definitely one which calls for good judgement and understanding on your part.

The purpose of this guide is to help you to improve this activity, by teaching a process which will allow you correctly and effectively to advise mothers on home case management. The process should also make it easier for mothers to remember the advice you give. The guide is to be used during a case management training course, or by health workers already trained in case management.

This guide includes two sample elements. The first is a suggested process to follow when advising mothers; the second is a visual aid (a pictorial Mother's Card) that you can use. These have both been adapted by your national CDD programme for use in your country.

Suggested process for advising mothers

This process will help you do several things. First, it will help you to limit what you tell the mother. In the short time you usually have with a mother, it may not be possible or realistic to give a great deal of information, nor can you expect her to reach a deep understanding. However, it should be possible in a limited time to convey the essential messages, and to make sure that the mother understands them and can carry them out.

Second, it will help you to structure the conversation. For each main point, the structure follows a series of steps:

Ask the question(s);

Praise and Encourage the mother's helpful practices;

Advise the mother what to do (and why);

Check her understanding.

There may also be cases where you will need to:

Refer her to a group session.

Third, the process will help you to focus on what the mother already does and knows. It gives you a way to praise and encourage what she does correctly, and to help correct what she does wrong.

An outline of the conversation between you and the mother would look something like this:

ASK - PRAISE - ADVISE - CHECK

(A P A C)

Ask about drinking
Praise and encourage the mother
Advise

Ask about eating
Praise and encourage the mother
Advise

Check the mother understands about eating and drinking

Ask about medication/treatments
Praise and encourage the mother
Advise

Advise the mother on signs to watch for

Check and review all advice using the Mother's Card

(Refer the mother to a small group session if necessary)

Review of the steps

Step 1: Ask the question(s).

Ask each question in two parts: the first part will orient you to how the child has been treated (e.g. "Has your child been drinking?"); the second part will help you get more information ("What has he been drinking? More, less, or the same amount as usual?" - or - "Why not?").

Step 2: Praise and Encourage the mother's helpful practices.

It is likely that the mother is doing some very good things for the child's diarrhoea (e.g., giving the child plenty of liquids to drink). If this is the case, praise the mother, and encourage her to keep doing these things.

Step 3: Advise the mother what else to do.

Even if the mother does some things correctly in treating her child's diarrhoea, she probably does not do everything right. She may also want (or need) to be told why some things are necessary. Use simple language and words that the mother will understand.

Step 4: Check her understanding.

This step will allow you to see exactly what the mother has understood from your advice, so you can complete the information or correct any misunderstandings. Use open questions, and let the mother explain in her own words; use the Mother's Card to review information.

(Optional): Refer her to a small group session in which she can learn how to prepare ORS, or arrange for her to have a review of the rules of case management in the home, if you feel this is necessary.

Skills you will need

In order to advise mothers well, you will need to be able to:

Remember the rules of case management in the home.

Use simple language.

Ask questions.

Find and encourage helpful behaviours (and advise against those that are harmful).

Give realistic advice.

Use the Mother's Card effectively.

Decide if the mother needs to be referred to a group session.

Depending on the organization of the facility where you work, and the time you have available, you may also need to be able to:

Conduct a small group session.

Important:
If the child needs treatment, make sure the treatment is given first,
then advise the mother.

It may be difficult to give careful and correct advice when there are many clients waiting, and when you feel as if you are simply saying the same thing to mothers over and over, every day. Remember, though, that the mother may never have heard this advice before. Even if she has, she has come to the health facility probably because she needs help in remembering the advice.

There are three points you must always observe:

Treat the mother(s) with respect.

Give advice that is realistic.

Be patient.