VHT Hybrid Manual

MOH - Omni Med
Village Health Team (VHT)

Hybrid Training Manual
The Republic of Uganda
1st Edition (February 2011)
Hybrid manual adapted from the original VHT

Manual and the new 2010 Ministry of Health
Manual
By Dr. Jennifer Thompson & Zachary Tabb
Original Manual 2010 Manual
1
Table of Contents
PART ONE: OVERVIEW 4
I. How to Use this training manual 5
ii. Design and Preparation of training plan 6
a. preparation of the training plan 6
b. preparing for each training activity 7
c. carry out each training activity 11
PART TWO: VILLAGE HEALTH TEAMS 13

I. Concept of the Village Health Teams 14
a. The Village Health Teams 14
b. key actors in community health 16
c. what are the key tasks of the VHT members 17
PART THREE: VHT RESPONSIBILITIES 19

I. Community mobilization and empowerment 20
II. monitoring 24
a. introduction to monitoring 24
b. how to draw a village map 26
c. how to use a village map 27
III. Record Keeping 29
a. creating a VHT record book 30
b. creating a quarterly summary report 32
c. analyzing village records 34
IV. home visiting 35
a. the steps of home visiting 36
b. VHT role play 38
c. referral and follow-up 40
V. VHT Tasks Following Training 42
a. meeting with the village leader 42
b. selecting leadership for your village health team 43
c. linking with the local health center 44
d. holding monthly team meetings 46
e. share information with village groups during health talks 46
2
PART V: HELP SAVE LIVES 47
I. Child Growth and Development 48
a. germs 48
b. fever 49
c. malaria 51
d. immunization 58
e. control of diarrhea 62
f. food and nutrition 67
g. breastfeeding 71
II. Lung Infections 75
a. pneumonia 75
b. tuberculosis 76
c. drug resistance 80
III. Sexual and Reproductive Health 82
a. family planning 82
b. antenatal care 86
c. postnatal care 91
d. sexually transmitted diseases 95
e. human immunodeficiency virus and acquired immune deficiency
98
syndrome
IV. Environmental Health 102
a. sanitation 102
b. water 104
c. personal hygiene 106
d. domestic hygiene 107
e. food hygiene 108
3
Part One
Overview
This guide has been prepared for the training team who will be responsible for training Village Health
Teams to carry out health promotion and health education activities in their communities. The guide offers a
training methodology that will facilitate your work in preparing VHT members for the work they will do. This
methodology will help them develop the skills required for their very important mission. The training should
be carefully planned, and well organized. Handling adult learners requires knowledge, care and experience to
give the VHT the skills needed to carry out their tasks.
4
I. How To Use This Training Manual?
This simple Village Health Team training Manual has been designed for the training of VHT members to
equip them with appropriate knowledge and skills so that they can be able to empower and mobilize
communities for health action. Each topic contains a brief introduction and list of learning objectives. The
learning objectives are meant solely for the facilitator as a guide regarding the important points for the
Participants to learn by the end of the presentation. Facilitators’ notes corresponding to the learning
objectives are provided at the end of each topic. The facilitators’ notes are numbered for easy reading and
understanding. It is recommended that the facilitator reads through the facilitators’ notes before facilitating a
training session.
At the beginning of a VHT Training a systematic organization should be done to ensure that all the
required training materials are available, participants’ invitations should have been sent and a training
timetable prepared. In addition to the above, time management and co-ordination skills are equally desirable.
A minimum of two facilitators should be present for each training session. One facilitator is responsible for
presenting the session, while the other performs the back-up duties, such as observing participants reactions,
assisting in monitoring small group work, prepare participants for role plays and demonstrations, and
attending to practical matters (e.g., handouts, flip charts and other related issues).
During the training sessions, get as many VHT members involved in sharing leadership roles. In fact,
part of the morning on the first date is best used to select individuals who will be class leaders during the
training week (e.g., president, energizer, time keeper, and secretary). Giving leadership roles to the
participants is a good way to tap different skills and resources of Participants while building their confidence.
The training team should meet at the end of the day to consider the feedback from the VHT members,
to assess their effectiveness and to review plans for the next training. The facilitator should take their own
notes prior to the training to be used during the training.
5
II. Design and Preparation of the Training Plan
You and your colleagues may use this Training Manual to help you design and prepare the training
activities for the VHT members. It is suggested that you organize these activities into a 5-day training plan in
which you specify the topics to be taught each day, the person or persons designed to teaching the topics, and
any resources the teachers will use during the training (e.g., markers, flipcharts, example of the records chart,
etc.). Also, maintaining a consistent break schedule for the VHT Participants providing snacks, drinks, and/or
simply a stretch or an energizer is highly advisable as it offers for Participants a chance to rejuvenate and
maintain focus. The training days are long, usually starting from 8am and finishing between 4pm and 5pm.
Since many of the Participants have not been in school for several years (sometimes several decades), these
breaks help the Participants remain attentive throughout the training, and therefore, more likely to pay
attention and retain knowledge following the completion of the training.
A. Preparation of the Training Plan

1. Content
Once the VHT trainers have received their training on VHT implementation, they should proceed with the
development of a training plan establishing the events, the times, the persons that will be in charge, and the
resources that will be used to train the VHTs.
2. Learning Objectives
Learning Objectives have been provided in each topic area to help guide the facilitator in their
presentation. The Learning Objectives represent the “take home” message for each topic. When recruiting
facilitators for each topic, explain that the Learning Objectives serve as a guide for relating the topic
information.
3. Plan Development
In preparing the training plan, you should try to answer the following questions:
 Which villages will be trained
 How many VHTs will be trained?
 How will they be chosen?
 Who will go to speak to the LC1s about the selected VHTs? When?
 Who will get the envelopes for the invitations and schedules?
 Who will deliver the invitations and schedules? When?
 Who will identify and reserve the training site? When?
 Who will purchase the supplies needed for the training? When?
 Who will print and laminate the materials needed for the training (e.g., pre/post test, Guide to
Healthy Homes)? When?
 Other (e.g., do any of the selected trainees have vision impairment and require glasses? In this case
this should be discussed with the LC1 during the mobilization process)
6
B. Preparing for Each Training Activity
It is suggested that Facilitators carry out one or more of the following activities in preparation for
undertaking a training event. You may wish to use the following steps to design and prepare for each training
activity:
1. Meet and Organize

Meet with colleagues, fellow health workers, other partners (NGOs, CBOs, etc.). Talk with them in
general terms about the training that you have decided to carry out. Find out who is available to help carry out
the training and their degree of enthusiasm, and try to define the following with them should they agree to
facilitate a lesson:
a) Date(s) of their topic. This will depend on their availability as well as the availability of the other
Facilitators. For example, if Facilitator A can only teach on Mondays and Wednesdays and Facilitator B
can only teach on Wednesdays, then Facilitator A’s presentation date would have to be Monday while
Facilitator B’s presentation would have to be Wednesday. Situations like this are very common and
inquiring from the potential Facilitators all available days and times (some can only teach in mornings,
others only in afternoons) allows you to develop the most accommodating schedule for everyone while
still incorporating all the necessary topics to teach.
b) Time required for presentation. Each topic is typically around 1 hour or up to an hour and a half.
Facilitators should make a sincere effort to avoid taking longer than this time due to the volume of
information that needs to be presented to VHT Participants during the training week. However,
incorporating VHT Participant questions typically will add on to the Facilitator’s designated time, and
this fact should be disclosed to the Facilitator prior to their talk, preferably during the initial discussion
in which you receive their commitment to present.
c) Necessary materials.
The following teaching materials will be necessary to carry out the training:
 Flipcharts (at least 3 rolls of 50 sheets, white, not brown as markers show better on white)
 Markers (blue and black mostly, but also red and green)
 Masking tape (at least 4 rolls)
 Pens (1 per participant)
 Exercise books (1 per participant)
 Name tags (1 per participant) *Note: VHT Participants really appreciate these name tags and often will
keep them for wearing during their home visits. Therefore, a sincere effort should be made to provide
these.
 Record Books (large, black, 200 page, hard-cover books. 1 per participant)
The following supplemental VHT materials should be supplied to VHT Participants:

 VHT Guide to Healthy Homes
 VHT Participant Handbooks
 Pre/Post Knowledge Assessment
 Certificates
 T-shirts
7
The following cooking materials will be needed at the training:
 Plates (at least 1 per person. In addition to Participants, this may include Facilitators, organization’s
staff, and any other people)
 Forks
 Spoons
 Knives
 Cooking pots
 Spreading knives
 Fire wood
 Jerrycans (large cans for collecting water, smaller cans to be used as hand-washing stations)
 Cups
 Soap
The following food items will be needed at the training (prior to carrying out the training, deciding which
days VHT Participants will get which snacks, meals, and drinks, and in which combinations, will help Training
Organizers to know the budget requirements for the trainings. Below are suggested inclusions. But it’s
important to keep in mind that each Training Day should have 3 breaks: morning, lunch, and afternoon):
Breakfast:
 Bread (2 slices per person per day as serve for breakfast)
 Blue band (spread between bread slices)
 Eggs (hard boiled, 1 per person for days agreed upon)
 Tea, Soya, and/or Coffee (for each morning as served for breakfast)
Lunch:
 Matooke  Tomatoes
 Rice  Onions
 Cabbage  Green peppers
 G-nut sauce  Carrots
 Beef  Salt
 Peas  Other foods as desired
Breaks:
 Water (small bottles, 500mL. 1 per person per day)
 Juice (small, e.g., Safi, 200mL. 1 per person per day)
 Soda (300mL, 1 per person per day, or for days agreed upon)
 Mandazi (1 per person per day, or for days agreed upon)
 Cake (1 per person per day, or for days agreed upon)
d) Place:
The following are potential training sites. Prior to conducting the training, the manager or coordinator of
the site should have given permission.
 Churches or Mosques
 Schools
 Community Centers
 Health Centers
8
The following are needed to be present at the training site, or provided by the time of the training.
 Benches, chairs, or other seating arrangements
 Lockable storage space for leaving the training materials overnight
 Area to cook during the five days, preferable with protection from rain
e) Funds:
The funds for training will depend on the amount, type, and variation of the training materials listed
above. The above list is more adjustable in some areas (e.g., which meals to cook each day and the beverages
to offer) than other areas (e.g., the teaching materials listed above is a minimum list and should not be
reduced). Furthermore, prices differ depending on where goods are purchased (e.g., rural or urban areas,
different regions of Uganda).
2. Select Participants
Before developing a list of participants, you should obtain the population household counts for villages.
These numbers, from the most recent census, are available at the Sub-County and District headquarters.
Because the VHT Program assigns VHT Members with the responsibility of 25-30 homes each, having these
numbers helps you determine an approximate figure for how many VHT Members in each village.
Knowing this figure, it is next necessary to determine how many VHT Members you are able to train.
This depends on the budget, and the section above should give you a good sense of how many you are able to
train. Once knowing the number, you can refer back to your village VHT-count list and determine which
villages you will train.
Some Sub-Counties or Districts have already developed a list of participants. If this is the case, you
should obtain this list prior to training. With this list you can then use your village VHT-count list, decide which
villages to train, and then visit the villages to speak with the LC1 chairperson about your interest in carrying
out a VHT training.
If your area does not have a list of participants, it is necessary to compile a list. First, check to see
whether your Sub-County is in the progress of developing such a list. If not, work alongside Sub-County
officials to develop a list that you can use to hold a VHT training. One way to compile a list is to hold village-
level meetings with the LC1 chairperson. During this meeting you want to discuss what the Uganda Ministry of
Health (MOH) Village Health Team (VHT) Program is and the criteria the Uganda MOH looks for in a potential
VHT. Since the ownership of the community is vital to the program, it is critical that the community decide
who would be good candidates. If they choose the VHT Member from the start, they will more likely listen
once the VHT Member is visiting their home in the near future. The following selection criteria are laid out by
the MOH:
 Maturity (above 18 years of age)*

 A resident of the village
 Able to read and write
 Able to speak at least the local language
 A good community mobilizer and communicator
 A dependable and trustworthy person
 Interested in health and development
 Willingness to volunteer for the community good
 Available to volunteer
9
Note: An additional criterion not explicitly set forth by the MOH but advisable would be the exclusion of
youth not currently in school, or the avoidance of youth in the process of applying to school**
*The MOH states that someone 18 years or older is eligible for training as a VHT. However, because of cultural
issues with 18 year olds still viewed as children, these individuals usually do not perform well following the
training. This is due to the fact that not only are they still viewed as children in the community, but they
usually still view themselves as children. Therefore, when they are required to visit their neighbor’s homes and
counsel people much older, they are not received well at the house and their message is disregarded, because
they are seen as young. Moreover, as they see themselves as youth, they usually become uncomfortable in
the work and eventually become inactive in the program. Therefore, it is advised that if you need to develop a
new list of VHT candidates, you request someone who is mature but at least in their mid-twenties so that they
will garnish more respect in the community.
**It is not uncommon to encounter a youth who is above 18 years, but still in school. These individuals do not
make effective VHT Members because during the day they are in classes and then in the evening they have
housework and school work occupying their time. Therefore, you should request LC1s to not include in-school
youth because it is both unfair to the VHT Program and the community, but also unfair to the youth who
would be overburdened by the volunteer and distracted from their school work, despite perhaps meeting the
other requirements set forth by the MOH (e.g., willingness to volunteer). Similarly, alternative candidates
should be found for youth applying to go back to school because following the training they might soon leave
the community thereby depriving the community of one VHT Member and increasing the workload for the
remaining VHT Members.
Now that you have a list, speak with the LC1 chairperson (if you have not done so already) about your
interest in conducting a VHT training for the names listed. If the training site you wish to use is also located in
their village, you can discuss with them about how to contact the manager or coordinator of this facility to
obtain permission for its use. Speaking with the LC1 chairperson is important and serves as one of the first
steps for community ownership (especially since VHT Members are answerable to the LC1) and shows respect
to the local authorities.
3. Set Objectives
Review the learning objectives. Remember that the objectives should be measurable, observable, and
realistic. The objectives have to be adjusted according to the following: time available for training,
assignments and tasks to be assigned to the VHT members, and the degree of enthusiasm of participants.
4. Plan Details
Discuss with other facilitators how you will carry out the training activities. Points to discuss include on
which days and in which order Facilitators plan to teach, what materials are available and what activities will
take place during the Facilitators’ presentations. It is also important to know which topics can and cannot be
rescheduled not only to different days but different times (e.g., morning, afternoon). It is not uncommon that
Facilitators are late to their assigned day, or that they have to cancel at the last minute. For the Training
Organizers, it is important to be prepared to teach the Facilitator’s topic(s) should they need to cancel, and to
be prepared with “floating” topics that can be shifted from later in the day or week in case the Facilitator will
be late to their assigned time.
On the other hand, rather than representing a challenge, any unexpected time gaps that emerge can serve
as opportunities to review previously taught topics, address any questions VHT Participants have, perform VHT
10
Role Plays, and discuss supplemental topics (e.g., drug resistance) related to the larger health topics discussed
in detail in this manual. Examples of these topics will be mentioned later in this manual.
C. Carrying Out Each Training Activity

Keep in mind the following guidelines as you lead each exercise in the training.
1. Follow the Training Guide

This training guide has been carefully designed to provide the necessary sequence of activities to help
VHT members build the knowledge and skills they need to do their work. Follow the training guide just as it is
written for the first two or three times you deliver the training. Consider this training guide as a map of how
the training should be carried out. The first few times you follow the map, you need to proceed exactly as
instructed; however, after using it for a few times, you may be able to take a few small detours or a few small
shortcuts.
Keep in mind that you do not need to organize the training in the order that topics are presented here.
Of course, some topics need to come first in the training week, such as VHT Concept and Record Keeping.
However, you do not need to wait until all the community mobilization topics are completed before
presenting health topics. In fact, it is advised to present health topics each day, for the reason that this system
varies the day’s presentation and helps the participants stay engaged. However, by the second day, all
community mobilization oriented topics should have been completed, leaving the rest of the week for health
topics.
2. Adhere to the Training Schedule

The training week is 5 days long from the morning around 8am until the early evening, between 4pm
and 5pm. For lunch, 1pm is a good time to hold a mid-day break and allow the Participants to socialize with
each other. However, before that time, and after, there are many opportunities to fall behind schedule or get
off track. It is important to remember this during the training. One common source of this is the Facilitators
themselves. It is not uncommon that a Facilitator takes more time than he or she is allocated. Sometimes, it
requires requesting the Facilitator to stop at that point, explaining that later the topic will be finished (e.g.,
when there is a time gap that emerges from a delayed Facilitator). Knowing when to stop a Facilitator who is
taking much longer than their designated time is important and depends on having a general conception of
the day’s schedule of topics (one or two topics, or several) and of the week’s schedule (can later topics be
pushed to another day? How will this affect those days’ topics?).
However, more important than knowing when to stop a Facilitator—perhaps for the sake of
subsequent Facilitators who may have already arrived and be waiting—is knowing how to pace a Facilitator
once they have started to teach. Communicating beforehand is important, but also communicating to the
Facilitator during the discussion is necessary. This can be done through hand signals to move on to the next
point of discussion or requesting that only one or two more questions be asked before the Facilitator moves
on. Performing these small steps allows the Training Organizers to present the complete training manual to
the Participants without excluding important information.
3. Trainee Interaction
Having portions of each teaching session involve participant interaction (e.g., VHT role play, small group
work, trainee-involved demonstrations) addresses different learning styles, offers variety to the trainee
sessions and helps to improve information retention. Furthermore, offering interaction creates more dynamic
training sessions and therefore enjoyable sessions for the Participants making them eager to come each day.
11
4. Probe for Answers from the Participants
For all the topics listed in this manual, the topic points all have answers listed. However, your job is to help
Participants reach their own answers. Do not read the answers to them, at first. Begin by presenting the topic
point (e.g., methods to prevent malaria) and ask the Participants which answers they know. This will let them
recognize how much they already know, reaffirm their knowledge in a given area, and make them feel more
engaged in the training. All this will help them stay participative and retain more information. For example,
you may ask, “Can you think of anyone else?” “Where else can you look?” “How else can it be done?” Asking
open-ended questions—rather than closed-ended questions (“yes” or “no” answers)—help make the training
more of a discussion allowing Participants to feel they have something to contribute.
5. Give Participants Time to Answer

Participants may be shy about answering, or they may need some time to decide what to say. Each time
you ask a question, give them at least 7 seconds before you begin to probe. However, it is also important to
keep in mind the overall length of time each Facilitator has to present a topic. Therefore, allow Participants
time to provide answers, while at the same time being attentive to when they no longer have answers to
provide (e.g., either because they do not know anymore answers, or because they are tired). At this point, it is
the Facilitator’s job to progress the topic onto the next issue.
6. Listen and Repeat

When each participant gives an answer, repeat the answer. This will show that you are listening and it will
ensure that everyone has heard the answer. This is especially important when participants speak softly and
when the group is large. Also, never discourage an incorrect answer. Sometimes, an answer is not related to
the question you have asked, at which point the question should be repeated. Other times, the answer is
incorrect or might even be a common myth or misconception (e.g., mosquitoes transmit HIV). If this occurs, do
not ever laugh at or ignore the Participant’s answer. Instead, first thank the Participant for contributing,
offering a neutral response, such as, “Well, that’s not the answer I was looking for right now.” If the answer is
a common myth or misconception, use the opportunity to clarify it. This also contributes to the overall
teaching of the topic.
7. Move Around During Group Work

Including group work into presentations is a good way a Facilitator can address different learning styles
and add variety to long discussions. During small group work, move around the room to observe how people
are working and to answer any questions they may have. This also allows you to take note of common issues
that arise during the group work and address these when each of the small groups have gathered together
again.
12
Part Two
CONCEPT OF THE VILLAGE HEALTH TEAMS
13
I. The Village Health Team (VHT)
A. The Village Health Team
Facilitators: Begin by reading the Introduction of the Village Health Team Program.
A Village Health Team (VHT) is a non-political health implementing structure and the equivalent of
Health Center 1 (HC 1). VHTs are responsible for monitoring the health of community members at the
household level. A VHT is selected on popular vote after sensitization and consensus building of all village
members from all households, such as following a community meeting lead by the LC1 discussing the VHT
Program to all residents present at this meeting who can later decide who they feel would be good
candidates. Each VHT member is responsible for visiting and monitoring the health status of their neighboring
households.
The VHT Program structure encompasses the processes of community mobilization and empowerment
to foster the delivery, management, and improvement of health services at the household level. The VHT’s
overall goal is to achieve an improved quality of life by strengthening healthcare service delivery at household
levels and to establish a household health information system that will help to inform health planners who
can, in turn, introduce targeted healthcare interventions. The VHT acts as a link between the government,
other existing local structures, and community organizations interested in health issues to bring health
services nearer to the people. A VHT also bridges information gaps between the health service providers and
the households and communities.
Facilitators: DO NOT take the time to write the Learning Objectives as a group. Writing all the Learning
Objectives at once is not an efficient use of time. These are listed so that Facilitators know what needs to be
covered during the presentation.
Learning objectives:
By the end of this topic, participants should be able to:
1. Define the Village Health Team.
2. List the qualities of an effective VHT Member
3. Explain the overall goals of the VHTs
4. Explain the 6 key actions of VHTs.
5. Discuss key actors in community health.
6. Describe the tasks of a VHT Member
FACILITATOR’S NOTES:
(You should write each of the following questions on flipchart paper, not writing subsequent questions until
the current question has been addressed fully. Once the correct answers have been mentioned, write them
underneath the questions.)
Facilitators: Tell the Participants that before you will discuss Village Health Teams (VHTs), you want to
discuss the community and its health.
14
ASK Participants the following question:
“Who is responsible for improving and maintaining the health of our communities?”
PROBE Participants so that the following individuals and groups are mentioned as answers:
 Families
 Local Leaders
 Health Staff
 Local Providers, such as TBAs, Traditional Healers, etc.
[NOTE: If they mention more than these – great!]
STATE to Participants that they are correct. Each of these people or groups has to work separately or together
to improve the health of the village.
STATE It is EVERYBODY’S responsibility to improve and maintain the health of the members of
our communities!
STATE the acronym of T.E.A.M.:

Together
Everyone
Achieves
More
Facilitators: Now discuss the concept of VHTs
1. The Definition of a Village Health Team (VHT):

A Village Health Team (VHT) is a non-political health implementing structure and the equivalent of
Health Center 1 (HC 1). VHTs are responsible for the health of community members at the household level.
The Members of VHTs are residents of their communities. Following training to become a VHT, VHT Members
are charged with the responsibility of monitoring the health status of their village, collecting important health
information for health service providers at higher level health centers (e.g., HCII, HCIII, HCIV), and educating
and counseling their neighbors regarding the common health issues causing the greatest burden to their
homes and community.
2. Qualities of the VHT Members:
*Facilitators, be sure to present this in the form of a question because it will allow Participants to develop a
list of what they think are the most important qualities, thereby helping themselves to internalize the list
and later practice these qualities as VHT Members.
ASK the Participants to raise their hands to answer this question:
“What are the characteristics or qualities that people want in a VHT member?” (pg. 11)
15
PROBE the Participants to ensure that the following characteristics are mentioned:
 Willing to volunteer for the good of the village

 Respected and trustworthy
 Interested in health
 Has previous experience volunteering or working in health
 Gets along well with neighbors
 Willing to listen to others
 Has respect for self and others
 Does not judge others
 Can keep information private
Note: the person should also be available to work. For example, current students should not be selected
because they would be unavailable. Furthermore, current or recently enrolled students are not likely to be
respected in the community as they will likely still be young.
3. What is the Overall Goal of the VHTs?

a. To achieve an improved quality of life by strengthening service delivery at household levels
b. To establish a household health information system that will help health planners introduce
targeted healthcare interventions.
c. Foster positive health care-seeking behavior.
B. Key Actors in Community Health

ASK Participants:
“Who are key actors in Community Health you mentioned earlier?”
PROBE the Participants so that they again mention the following:
 Families
 Local Leaders
 Health Staff
 Local Providers, such as TBAs, Traditional Healers, etc.
DISCUSS with Participants each of the important Key Actors in detail below
1. Families
In each home, parents and guardians are very important because it is the family that puts into practice the
daily care needed to be healthy and stay healthy. Examples of these actions include:
(List these on the flip chart paper for Participants to see)
 Washing hands with soap before eating and after using the latrine
 Preparing food in a clean and safe environment
 Timely vaccination of children
 Timely vaccination of pregnant women
 Maintaining cleanliness and good hygiene
 Getting treatment as soon as a family member falls sick
16
Facilitators: Discuss each of the key actors mentioned below only briefly because later sections will discuss
in further detail about how VHTs can work with each of them.
2. Health staff
The Health Unit staff members are responsible for supporting you and advising you when necessary.
Coordinating with families, health staff, and local authorities will help keep the village members healthy
through the exchange of important information about your community. It is very important to keep regular
contact with health center staff because they will welcome your help to volunteer at the health center (e.g.,
immunization days, patient registration) and need help to coordinate health center outreaches. In addition,
they need to receive the household records you are trained to keep so that they can know the accurate health
status of your community and design and deliver the appropriate health interventions. This information can
also be used to more accurately supply medicines in high demand by the community. The health workers at
the health units nearest to your village will be your main contact persons for your VHT work.
Facilitators: you should not write down each of the Local Authorities mentioned. Only discuss them with the
Participants. This section is discussed later in the section on working with village leaders.
3. Local authorities and civic, opinion, and religious leaders

These are the sub-county and parish chiefs; LCI, LCII, and LCIII Chairpersons and their executives and
councilors; local government officials, priests, teachers, cultural leaders and clan leaders; and other village
volunteers, prominent businesspersons and farmers, and other decision-makers in the village. Some of the
important decisions are those involving improvement of the drinking water supply, Garbage management,
road conditions, home improvements, etc. These individuals will be important to network and partner with
when you plan to hold community meetings or programs.
C. What are the Key Tasks of the VHT Members?

Task 1: Record and examine
Task 2: Visit village members
Task 3: Save lives
Task 4: Link the village and the health unit
Task 5: Mobilize the village
Task 6: Hold monthly team meetings
Each of these tasks has activities that VHT members carry out. This training manual gives you
information about how to carry out the six tasks and their activities. During training, you will learn about
these tasks and activities.
17
What are the 6 Key Actions of VHTs?
EXPLAIN to Participants that a VHT is a group of village members who*:

 Record and keep village health data quarterly
 Check for danger signs in village members who are sick
 Refer village members who are sick or are supposed to go for healthcare (e.g., immunization and
antenatal care) to health workers
 Report village sickness to health workers
 Mobilize the village members for health activities

 Promote health to prevent disease
*Facilitators, be sure to write these 6 key action words on the board so that the Participants will do the
same in their exercise books. These 6 key actions will later help the VHT Members to better understand their
responsibilities.
As a VHT member…
You should know your village well, share information and advice with village members to educate and
counsel them regarding the disease burden in your community, refer village members to health services for
care, link between your village and the health unit, and mobilize the village for health activities. Your
knowledge, skills, and willingness to serve will help ensure the health and well-being of the village.
ASK Participants if anyone has any questions about VHTs.
18
Part Three
VILLAGE HEALTH TEAM RESPONSIBILITIES
19
I. Community Mobilization And Empowerment
The main objective of this module is to enable VHT members to acquire community mobilization and
empowerment skills and information so as to motivate household members to organize the community
resources (human and financial). VHT empowerment will facilitate imparting knowledge and skills to
household members to enable them to take appropriate social, political and technical actions.
Mobilizing the village means calling and bringing together the members of the village for a purpose—
such as a health talk, immunization, mobile HIV counseling and testing services, or even a survey. It can also be
important to mobilize village members for health activities such as cleaning the area around a common water
supply. A village often can accomplish more than a small group of people or even several small groups.
1. Define community mobilization
2. Define community empowerment
3. Explain the purpose of community mobilization
4. Explain the importance of community mobilization
5. List examples of opportunities for community mobilization
6. List community members who can help in community mobilization
7. Describe some health activities for which the community can be mobilized
ASK Participants:
“What does community mobilization mean?”
PROBE Participants to ensure the following answer is mentioned:
Community mobilization is the planned process of creating awareness and generating community
support and participation so that the community owns and sustains the program.
ASK Participants:
“What does community empowerment mean?”
PROBE Participants to ensure the following answer mentioned:
20
Community empowerment, on the other hand, is the process of imparting knowledge and skills to
communities or individuals to enable them to take appropriate actions using locally available resources.
ASK Participants:
“Why do communities need to be mobilized?”
PROBE Participants to ensure that the following points are made:
 To get village members involved in making decisions that affect them

 To help village members get more information
 To help village members make better decisions
 To share and learn from each other better ways
 To improve their health and well-being
Lecture points:
1. The importance of community mobilization for VHTs.
 Facilitates the contribution of materials and human resources from all community members
 Encourages participation of all community-based organizations.
 Creates ownership and involvement through shared decision making and communal actions.
 Encourages sustainability efforts.
*Offering examples for the above point helps to illustrate their importance and relevance to the VHT
Member
2. Opportunities for social mobilization and community empowerment.

Community mobilization differs from one community to the other; however, the following are some of the
selected opportunities VHTs should exploit:
 Market days.
 Religious services.
 Social gatherings
 Health service delivery (e.g., antenatal clinics, routine immunization clinics, etc.)
 Political gatherings, (e.g., political rallies, commissioning ceremonies, etc.)
 Use of existing institutions such as schools, Community–Based Organizations (CBOs), literacy groups,
micro financing groups, etc.
 Local council meetings, stakeholders’ workshops, etc.
NOTE: These are only examples, and Participants might have more suggestions or ideas
ASK Participants
“Who can help you mobilize village members for health activities?”
21
PROBE Participants to ensure some of the following people are mentioned
 Traditional leaders  Village-based organization leaders

 Traditional healers  Retired civil servants
 Religious leaders  LC members
 Headmasters/mistresses and teachers  Traditional Birth Attendants (TBAs)
 Farmers groups  Youth leaders
 Women leaders
EXPLAIN That when participants return to their villages, many people may ask them what they have learned.
For example, the village leaders may want to hear not only what they have learned, but also what they will DO
now that they have been trained. One thing all VHT members may have to explain is how they will mobilize
their village members for health activities.
ASK Particpants:
“Can you name some health activities for which you may mobilize village members?”
PROBE to ensure that at least the following activities are mentioned:
 Immunization activities
 Outbreaks of disease
 Latrine construction
 Rubbish removal
 Community health talks
 OTHERS?
*Emphasize that this is a good example of why VHT Members should be in regular contact with their local
Health Centers: to know about health activities that will be conducted in their local areas that they can help
to implement. The topic of linking with local health centers is discussed later in the training.
Small Group Work:

Facilitators: Now explain to Participants that they will conduct a short small-group activity to apply the
community mobilization and empowerment knowledge they have received today. Provide each group with
a marker and a sheet of flip chart paper.
TELL Participants that they will break into two groups (if there are a large number of Participants, have the
training group break into 4 groups, 2 Group-As and 2 Group-Bs). Each group identifies a leader, and is assigned
the following responsibilities:
 Group-A members are part of a community mobilization team visiting Nyakibale Village to talk to them
about generation of funds to support the forthcoming Child Day which will be celebrated at the LC’s
house.
 Group-B members are residents of Nyakibale Village who are predominantly farmers. They promise to
provide the required support and write down both the financial and human support they will
contribute.
22
Facilitators: Give the Participants a reasonable amount of time (e.g., 20 minutes) to develop their lists. Once
the allotted time has expired bring the groups back together and have the group leaders present their group’s
list. Once both groups have presented, thank them for their work, offering support and suggestions where
necessary. Lastly, review with the Participants the important points they should remember about the day’s
lecture, including the following points:
 Community mobilization and empowerment definitions

 Importance of community mobilization and empowerment
 People who they can work with to mobilize the community
 Health activities they can mobilize the community for
Although the benefits for community mobilization are numerous, VHT programs may be challenged by the
following:
Table 2: Challenges to social mobilization and community empowerment and how to overcome them.
Social mobilization challenges How to overcome them?
Inadequate commitment to volunteerism Encourage both VHT members and community members to
which may result in exhaustion, fatigue and commit themselves to supporting social mobilization
burn-out. activities.
Identify those activities and work with the implementers of
Competing priorities with promises of
those activities to promote social mobilization activities for
immediate rewards.
the VHT programs.
Coordinate with the service health center for the provision
Inconsistent delivery of health services.
of adequate services.
Plan your social mobilization activities outside the bad
Weather variations.
whether periods.
Encourage all community members to fully participate since
Socioeconomic differences.
health issues do not have class boundaries.
Involve traditional leaders in planning all community
Traditional beliefs
mobilization activities.
23
II. MONITORING
Monitoring refers to routine collection, analysis, and interpretation of information so as to compare
progress on any activity or intervention, to ascertain the attainment of an immediate/long term objective
based on the original plan. Monitoring must be included in any part of the VHT activities as an ongoing part of
planning and implementation process.
1. Define the meaning of monitoring
2. Explain the importance of monitoring
3. Describe the methods of data collection
4. Explain what is a Village Map
5. Explain why a Village Map is important
6. Explain how to make a Village Map
7. Explain how to use a Village Map
NOTE: Facilitators, this is a lengthy yet vital topic that will take most of a day and should not be hurried.
Gauging the audience’s attention and conducting one or more group energizers will be important. Following
the training, VHT Members typically have the most trouble with practicing and adhering properly to the
information conveyed in this topic—more so than any other topic presented during the training. Therefore,
be sure to be attentive to the information presented here.
A. Introduction to Monitoring
ASK Particpants
“What is the meaning of monitoring?”
Monitoring is the routine collection of information (often at regular intervals) related to

activities/events and immediate objectives. It is the process of gauging whether the activities/events are being
carried out according to plan. Monitoring is a vital component of the VHT implementation.
24
Lecture Point:
1. The importance of Monitoring.
 It forms a basis for planning.
 It helps identify the gaps.
 It helps to analyze the situation and also keep track of records/events.
 It ensures proper accountability and utilization of resources.
 It encourages implementers to stick to their plans.
*Offering examples for the above point helps to illustrate their importance and relevance to the VHT
Members
2. Data collection methods:

There are many methods that can be used to collect information however, the most common ones
include:
 Focus group discussion.

 Village mapping.
 Records reviews.
NOTE: You may need to use more than one method to collect village information. The Village Record
Book will however remain the most common tool to be used at the village level. If any other data is required, it
is important to choose the most convenient and appropriate method depending on the information required.
The following table shows some of the most common methods for collecting data:
Note: Facilitator, do not take many questions about details when covering the information in this chart
because each of these methods will be covered in more detail later.
Data collecting methods:

Methods Advantages
• Group Discussions. 1. You can speak to more people at the same time.
This is when a group of six to ten community 2. You get more ideas through brainstorming.
members assemble and discuss certain concerns. 3. This method is good for getting information on
quality of services (e.g., health).
• Village Mapping:
Here community members draw a map of their
village using different pictures to represent 1. It will help people to visualize the community’s
different types of information. problems and achievements.
NOTE: 2. This method is good for collecting basic
1. Maps can be drawn either on the ground or population data.
paper. 3. It involves many people.
2. Village mapping is fun and is a useful way of 4. It helps to divide up responsibility within the
getting many people involved in assessing their village
situations.
25
• Record Review
This involves analyzing the household records you
1. Information can be used for comparison.
keep to identify gaps in services (e.g., Antenatal
2. It does not require a lot of resources.
care, or immunization) or common diseases (e.g.,
TB, malaria).
Facilitators: Now you will explain in more detail the process of Village Mapping. Afterward, you will discuss in
more detail the practice of Recording Keeping and Review.
*This might be a good time for a break, or a group energizer.
B. How Do You Draw Village Map?

EXPLAIN a village map is a drawing in which you include all of the houses of the families that live there, as well
as the roads, water sources, schools, places of worship, etc.
Why is it important to have a village map?

It is important to have a village map because as a VHT you need to know where everything is in your
village. You can use it to help plan village activities, to show people where to go for support, and to show
where risks—such as flood areas, stagnant water, and rubbish dumps—are located. It may also help you
decide where health needs are greatest in the village.
ASK Particpants
“What are some important things to mark on the map?”
 Homes of village leaders (such as LCs, religious leaders, clan leaders, and opinion leaders)
 Members of the VHT
 Homes with children under 5years
 Homes with pregnant women
 Health unit(s)
 Schools
 Water sources and type (e.g., open source, bore hole, etc.)
 Places of religious worship
 Community Centers
EXPLAIN You can draw a village map on the ground using a stick or piece of charcoal. However, you cannot
keep that map for use over time. If possible, draw your village map on a large sheet of paper. When you are
done, make a copy of the map in your Village Register. Each VHT Member should have a copy of the village
map in their Village Record Book.
26
Small Group Work:
Facilitators: Now explain to Participants that they will conduct a short small-group activity to practice the
technique of Village Mapping. Provide each group with a marker and a sheet of flip chart paper. Then,
provide a brief example of how to draw a Village Map using a few examples of water sources, health
centers, households, etc. for the Participants to see. Explain that since space is limited on the paper, they
should not write out the names of household heads, village leaders, water source types, etc. Instead they
should use symbols for households, water source types, health centers, places of religious worship, etc. and
make a key or legend in the corner of their maps. Furthermore, on the maps each household should be
numbered. In their notebooks, the names of the household head should be given a number that
corresponds with the number of their household depicted on the village map. If the name listed in the
notebook corresponds with an individual who holds a position of authority in the village (e.g., LCI, secretary,
religious leader, etc.), this title should be denoted next to the person’s name in their notebooks. Creating a
system like this helps VHT Members to quickly identify the location of resource persons in their village to
help carry out health activities.
EXPLAIN to Participants that each VHT will now practice drawing a map of their village. Although they cannot
take a walk through their village right now, they can draw the map from memory just for practice.
ASK Participants to group together with the other Participants from their village. This is their Village Health
Team. Each Team should find a table or floor space to draw their map.
GIVE each VHT group a flipchart paper and a marker to use for this exercise.
TELL the groups that they have 20 minutes to work and they can start.
MOVE AROUND and provide the Participants assistance or guidance as they draw their maps
Facilitators: When the time has elapsed, call everyone back into the class to present their maps to the larger
group. Have a representative from each group come to the front and discuss what they have included in
their maps and why. As Facilitator, you should observe their map and provide feedback about what they did
correctly and suggestions for additional inclusions (e.g., forgot to include mosque). Lastly, thank the
Participants for their work.
C. How do you use a village map?

1. Divide up responsibilities.
You can divide the village into different parts each for a VHT member. Each member will be
responsible for carrying out his or her tasks and activities in his or her part of the village (This is, in fact,
how the VHT Members were supposed to have been selected in their villages—they were selected by
dividing up the village into different parts).
ASK the Participants
“What does it mean to divide up responsibilities?”
27
PROBE to get the following answer from Participants:
The VHT divides up the village into as many parts as there are members in the VHT. Each member of the
VHT takes responsibility for one part of a village, and carries out their responsibilities in this area. Once you
know your area of the village that you are responsible for, you can then draw a map for this part.
How do you draw a map of part of your village?

Once your VHT has divided up the village, and each VHT member knows what part of the village is his or
hers, you should make a copy of your part of the village. Make sure that your map has all of the same things as
the village map – houses, places of worship, streets, paths, water sources, and other important places and
objects. You draw this map in the same way that you drew the map for the entire village.
2. Identify where vulnerable people live.

Vulnerable people might be children under5, pregnant women, or people with disabilities, for
example.
ASK the Participants
“Why would you want to identify where vulnerable people live in the village?”
PROBE to get the following answer from Participants:
We identify where vulnerable people live so that we can help ensure that their special needs are meant.
Facilitator: The most vulnerable will be discussed often during the Training week and you should tell this to
Participants now. But for the purpose of this exercise, ask the following:
ASK Particpants
“Who are the most vulnerable people in the village?”
PROBE Participants to ensure that the following groups are mentions:
 Children under five years old

 Pregnant woman
 People sick with HIV or AIDS
 Elderly persons
28
III. RECORD KEEPING
One of the key responsibilities of the VHT members is to maintain written data relating to the health of
every household member in the community. It also involves maintaining data relating to recommended good
health practices (behaviors). This process of keeping an account is what is referred to as record keeping.
Note: Facilitators, this topic requires preparation in advance. You should review this section thoroughly,
gathering the necessary materials prior to presenting this topic.
1. Explain the meaning of record keeping
2. Explain the importance of record keeping
3. Create a Village Record Book
4. Explain the importance of Quarterly Reports
5. How to create a Quarterly Summary Report
6. Explain the importance of monitoring good health behaviors
7. Explain the meaning of analyzing records
8. Explain how to analyze Village Record Books
1. The Meaning of Record Keeping.

Record keeping is the process of maintaining written data relating to the health of every household
member in the community. It also involves maintaining data relating to recommended good health practices
(behaviors) in the community.
EXPLAIN As a VHT member, you are responsible for keeping a record of health-related aspects of your village,
its homes, and its family members. You are also responsible for reporting health information to the village’s
leaders (e.g., LC1 Chairman), as well as to the health unit staff. In this section of your manual, you will learn
how to record information and examine that information to help you make decisions about your work. In
another section of this manual, you will learn how to report health information to the health unit staff and to
your village leaders. When you carryout all of these tasks, you help improve the health of your village.
You will use the Village Register to record information about the households in your village – who lives
there, the age and sex of each person, general conditions in and around the house, and other pieces of health
information that are important to the village. In this section of your manual, you will learn:
 What information to collect
 How to record that information in the register
 Where to record it in the register
 When to enter it in the register (pg 24)
2. The Importance of Record Keeping.
29
 Monitor progress in the health status of household members and community.
 Monitor improvements and demand for health services.
 Provides detailed information relating to households within the area of operation.
 Records can be used as an input for planning.
 Useful for future reference.
 Empowers community to realize their situation.
 Helps communities to get more organized when implementing health initiatives.
A. Creating a VHT Record Book

How Do You Create a Village Record Book?
You create a village register by visiting every household in the village, asking questions about people
who live there, and making observations. You write all of the information that you collect in your register.
How Do You Get the Information to Fill in the Village Record Book?
To fill in the village register, you will make house-to-house visits to all the households in your part of
the village. Home visiting will be discussed in more detail later in the training. Fill in the village register using
the information you get from the household members during the home visit. If some information is missing,
leave that part of the register blank. But try to get all the important information and enter it into the register
before you move to the next household. Sometimes the information can be gained later (e.g., the household
member who knows the information might not be home at the time of your visit), and you should discuss with
the household member about returning later to collect the missing information.
Facilitators:
Explain that you will now make a practice Village Record Book on a large piece of flip-chart paper
using the categories mentioned below. This flip-chart should be prepared ahead of time. Have all
participants copy this chart into their small exercise notebooks. Explain that later each Participant will
receive larger notebooks that will serve as their formal Village Record Books. Ask 2 or 3 participants to
provide answers to the categories as an example to all participants of how to fill out the Village Record
Book, filling in the blank lines of the large flip-chart paper you have created. Have all participants also fill in
these answers from the selected Participants into their Village Record Book charts they have created in their
exercise books as practice for the real thing.
The following are the categories to be included in each column of the Village Record Book chart:
1. Household # 12. Tetanus Immunization Complete (Y/N)
2. Head of Household 13. # Mosquito Nets*
3. Head of Household sex 14. Drying Rack (Y/N)*
4. # People in HH (Males, Females, Total) 15. Latrine (Y/N)*
5. # Children under 5 16. Hand-washing place with Soap (Y/N)*
6. # Children with Birth Card* 17. # Persons sick with Malaria
7. # Children with completed Immunization* 18. # Persons sick with TB
8. # Women 15-49 19. # Persons sick with HIV
9. # Pregnant Women 20. # Persons sick with other illnesses
10. # ANC card* 21. Type of water source (P/U)
11. # Antenatal visits*
30
*For #6, the VHT Member should ask to see the Child Birth Card for each child under 5 years.
*For #7, the VHT Member should examine each Child Birth Card available and count the number of children
with completed immunization.
*For #10, the VHT Member should ask to see the ANC for each pregnant woman.
*For #11, the VHT Member should examine each ANC available to determine the number of ANC visits for
each pregnant woman.
*For #13, the VHT Member should ask to see the mosquito nets. This allows the VHT to examine if the net is
hanging properly and how many nets the household actually has.
*For #14, 15, 16, the VHT Member should examine each after the entire interview is discussed. If the answer
given is different than the actual situation (e.g., household member says latrine is present, but there is
no latrine at the home), the answer in the Village Record Book chart should be changed to reflect the
actual situation at the home.
The chart can be created by writing each of the above questions vertically across the top of a sheet of
lined notebook paper from the large notebook given to participants. Each of these questions should be
separated by a vertical line forming columns for each question. For question #4, make the question column
wide enough to divide it further into three columns, one each for #M, #F, and #Total. Using the pre-printed
lines on the sheet of paper, draw rows that are tall enough to fit the name of the head of household so that
anyone can read it. Following each HH # entry, draw additional rows for households that remain to be visited.
Give as homework the task for each participant to visit 4 of their neighbors, 2 to the right and 2 to the
left, to fill out their record books now written in their exercise books. The next morning review their work by
examining each exercise book and checking for mistakes or underreporting. Then give out large notebooks as
instructed below for them to transfer the chart in their exercise books.
The day following the Record Keeping session, hand out the large notebooks that will serve as their
formal Village Record Books. In front of the training class, place the large flip-chart paper that you used the
previous day as an example of making and filling in the Record Book, and have all participants copy the chart
into these notebooks (excluding the example information given the previous day). It is very important to walk
around to monitor the following:
 Are participants creating the table properly? The proper width of columns? The proper number
of columns?
 Are participants including the proper names of the columns?
 Are participants designating which columns require number responses (e.g., children under 5
years: 5) and which columns require symbol responses (e.g., latrine: Y).
Once everyone has their chart completed correctly explain that a new record chart needs to be
compiled every three months, or once each Quarter. Emphasize that at the end of each Quarter, they will
create an individual summary Quarterly Report of the information in their Village Record Book that they have
collected. Explain that an example of how to produce this summary Quarterly Report will be presented later
during the training. Now, collect their Village Record Books and explain that they will receive these notebooks
on Friday during the certificate awarding.
31
B. Quarterly Summary Reports:
As a VHT member, you are supposed to summarize the information that you have recorded in your
Village Register.
ASK Particpants
“Why is it important to submit a summary report to the health unit?”
PROBE Participants to ensure that the answers are mentioned:

 So that the health staff will know about important health information in the village
 So that the health staff can plan for ways to help the village and its members
 So that the health staff know what activities the VHT is carrying out
 So that the health staff can know how they can work with the VHTs to address the community’s health
issues
ASK Particpants
“What do you record in your summary report?”
For the following categories, compile a summary report in the following form:
VHT Name: Date:

Village: Quarter:
Parish: Phone number:
# households heads M, F # women with TT complete

#M # mosquito nets
#F # drying racks
#Total # latrines
# Children under 5years # handwashing location with soap
# with Child Birth Card # sick with malaria
# with immunization complete # sick with TB
# pregnant women # sick with HIV
# ANC cards # with other illnesses
# ANC visits Types of water sources--# protected, #unprotected
# females 15-49
However, instead of listing individual households as in the Village Record Book, for the Quarterly
Summary Report, you take the total numbers (e.g., total number from column “# mosquito nets”) or symbols
(e.g., total all Ps in column “Type of water source”) from all households you have visited. These are the
numbers you include next to each category in the Quarterly Summary Report form described above. In
addition, later this allows you to see the general picture in your village. For example, you would see that
during Quarter 1 out of 100 homes visited by all the VHT Members in your village, 23 families (23/100 = 23 %)
were using a protected water source. You and the other VHT Members hold a meeting and review your
findings. You all agree that this is too low and more families should be using a protected water source because
32
of the risk of illness from drinking unclean water. Therefore, your Village Health Team explains your findings to
the LC1 and requests him to hold a community meeting so you can teach the community the importance of
drinking clean water from the protected source. More about analyzing the Summary Reports is explained
below.
Later, after another three months (another Quarter), you can now compare Quarter Summary Reports
to see the changes you have made in your community. For example, after creating your Summary Report for
Quarter 2, now you see that out of the 100 homes visited by all VHT Members in your village, 45 families
(45/100 = 45%) now use a protected water source after you gave a health talk during a meeting organized by
the LC1. That’s an improvement of 22%! Now, many more people are drinking clean water and staying healthy
thanks to you monitoring the community.
Just like the Village Register this summary form is filled once in three months. That means that you are
not supposed to repeat the information which you summarized in the first three months / Previous Quarter.
You will summarize ONLY that information of ONLY the LAST THREE MONTHS which you have just finished
recording in the Village Register.
Tell Participants that they will make a copy of this individual summary Quarterly Report and deliver it
to the nearest government health center. Their Quarterly Reports will be used by the government health
centers and delivered to the District Health Office to be used for future health programming and resource
distribution. Explain that they if another of the VHT Members in their village has not yet completed their
Quarterly Summary Report they should encourage him or her to finish and offer assistance to help finish it.
Delays in delivery the information from the Summary Reports means the health centers and the District will
not have the information they need to offer appropriate services for the community. But, they should keep
their charts in their large notebooks, so that later they can sit with the other VHT Members in their village and
review the charts and their individual summary Quarterly reports. This serves as a method for monitoring the
health status of their village and allows them to identify areas of health strength (e.g., immunization coverage)
and areas of health vulnerability (e.g., mosquito net usage, latrine coverage).
You will summarize this information and submit to your Team Leader who should summarize for the
whole Village and take it to your VHT Parish Coordinator. The Parish Coordinator then summarizes for the
whole parish and submits to the health centre. The importance and method of selecting Team Leader and
Parish Coordinator for the Village Health Team will be discussed later in the training.
1. Why Should VHT Monitor Good Health Practices?

Monitoring good health practices can help promote new social norms and build people’s confidence in
their ability to make progress in their health.
2. How to Monitor Priority Diseases in the Community?

Monitoring the occurrence of priority diseases that commonly affect the community is referred to as
disease surveillance. Surveillance means being on the lookout for something and therefore Disease
Surveillance means that a person is on the lookout for one or more particular diseases (e.g., TB, bloody
diarrhea).
Besides being on the lookout for particular diseases, disease surveillance at the community level also
includes:
1. Immediately refer the person to the nearest health facility if you observe the person displaying any
Danger Signs (Referring and Danger Signs are discussed later in the Training Manual).
2. Following up with the sick person you referred to the nearest Health Center to check on her or his
status and to learn whether the health worker gave the sick person any particular instructions (Follow-
up is discussed later in the Training Manual).
33
3. Counseling the family and sick person about ways to prevent the disease from occurring again in the
future.
As a member of the Village Health Team, your job in disease surveillance is finding and reporting
diseases that afflict your community. You may also at times be required to play a significant part in carrying
out the other health actions relating to disease surveillance in your community.
C. Analyzing the Village Records

The information you record in the village register can tell you much about the health and well-being of
your village. In this section, you will learn some basic steps you may take to analyze that information.
1. What Does it Mean to Analyze Information?

When you analyze information, you are looking for ways to tell a story. The story may be about good
things that are happening or about bad things that are causing problems or that may cause problems if they
are not taken care of.
2. How Do You Analyze Information in the Village Register?

You may use the following steps to analyze information in the register:
1. Identify all the bad and good health activities in the register.
2. Identify the area of your concern (e.g. pregnant women, children, clean water, etc.)
3. Add up the total number of people or households in your area of concern
4. From the total number, count how many people are practicing bad or good health activities or
behaviors
5. Ask yourself whether your answer shows a good example or a bad example about your village
6. Decide on the next steps to be done
Decide to inform the LC1 chairperson to call a village meeting and decide on the best measures to be
undertaken, such as holding a health talk (the process of meeting with the LC1 chairperson will be discussed
later in the training). Analyzing your Village Record Book is a great way to better understand the health status
of your community and to take action with the community to teach about preventing illness and encourage
community members to monitor the health of the homes and families. This way everyone becomes
responsible for their own health and practicing healthy behaviors.
34
IV.HOME VISITING
One of the tasks of VHT members is to visit people in their homes, a process called Home Visiting.
During the visits, the VHT members will share ideas and information about health related issues with
household members. This is one of the best ways of understanding people’s problems, observing household
health practices, evaluating diseases that affect them, advising them on where and when to seek medical
attention, making referrals to the nearest health centers and follow-ups on the discharged patients.
1. Define the meaning of home visiting
2. Explain the purpose of home visiting
3. Describe the skills needed to conduct a home visit
4. Describe the steps necessary before, during and after carrying out home visits
5. Explain the meaning of referral
6. Explain the importance of making referrals
7. List the important information to know about their local health center
8. Make a Referral Form
9. Explain the importance of following-up with patients you have referred to the health center
1. Meaning of Home Visiting

Home visiting is an approach used to identify the health and social needs of individuals, families and
the community by meeting the household members in their homes.
2. Why Should One Conduct Home Visits?

1. Home visits should be conducted to provide support to people in their homes.
2. To assess the health conditions of the community.
3. To bridge the gaps (especially information gaps) between the Health Centers and the households.
Facilitators: Discuss with Participants the following points, noting that different VHTs and VHT Members
might have different preferences for home visiting. But the point is to find what will work for each Member
and continue with this method.
35
Your VHT training, as well as other training you may have received, helps you carry out home visits,
during which you will observe the health behavior, household practices, general cleanliness, and health
condition of your neighbors and provide them with advice. You should try to visit every household in your area
of the village once per month.
Before beginning home visiting, you need to meet with the village leaders to plan how you will make
the visits (this will be discussed later during the training). Your planning should include the following:
 Who will do the visits? Will each VHT member visit just the households in his or her part of the
village? Or will two or more VHT members make the visits together, covering both of their parts of
the village?
 When should the visits be made? Will it be a time when all household members are present, on a
specific day of the week, or during a specific week?
 How will the village learn about these visits? Who will make sure that all village members
understand why the visits are going to take place and how the information will be used?
*This last point is especially important. VHT Members will find that they encounter people who resist their
visit or refuse to answer questions because they do not know about the VHT Program. This is why it is so
important to hold a meeting with the LC1 Chairperson to clarify the VHT Program and to organize to hold a
meeting for the community so that VHT Members have the opportunity to explain to all households present
all about the VHT Program and thereby facilitate household participation.
3. Skills Needed to Conduct a Home Visit.

VHT members must have the following skills to be able to conduct successful home visits.
1. Being non-judgmental
2. Knowledge on health issues (ability to pass on, share and explain those known health issues).
3. Excellent judgment (ability to detect and refer complicated cases to hospitals).
4. Good listening skills
5. Good reporting skills (to report severe and emergency cases in the community).
*By the end of this training, VHT Members should have learned these skills.
A. The Steps of Home Visiting?

Before the visit:
1. Identify the purpose of the visit – Are you just visiting or do you want to help solve a problem that you
have identified?
2. Gather your materials – your Record Book, and your Handbook, your “VHT Guide to Healthy Homes,”
and any other materials given to you during training that you find useful.
3. If you have not yet collected data on this household, do so during the first visit, explaining how the
records will be used to inform the Health Centers about the health status of the village. But emphasize
that the household’s information will remain confidential.
4. If you have already collected data on this household, then review this household’s information to
determine about which areas you should counsel the family (e.g., building latrine, completing
immunization, etc.)
36
During the INITIAL, or first, visit:
1. Greet the family member(s) whom you find at home
2. Introduce yourself
3. Explain the reason for your visit. and about the Village Health Team Program
4. Explain to them that their answers are private and will not be shared with others.
5. Ask the questions related to the information you want to fill in your Village Record Book.
6. Record the responses (answers) in your Village Record Book.
7. Make notes about areas that need follow-up (e.g., immunization coverage, ANC visits, etc.).
8. Advising house hold members on where and how to seek medical attention.
9. Making referrals to the nearest health centers (if you see Danger Signs in any household members)
10. When finished, thank the household member for their time and attention. Explain that you would
appreciate coming back soon to further discuss ways to improve the health of their household.
Facilitators: It is important to emphasize that the primary purpose of the first visit is to explain the VHT
Program and to collect baseline information about the household. People might have many questions about
health, and that is good. But the VHT Member on the first visit should not spend most of their time on
counseling the household about health information. The VHT Member needs to ask the questions to get the
information for the VHT Record Book, make observations about the living conditions, and take notes about
areas to follow-up with the household members. It is ok to answer questions the household members might
have. But explain to the household members that you will be making additional visits to discuss their
questions in more detail and ways that might help that household stay healthier. However, if you observe
any Danger Signs in any member of the household, DO NOT wait to refer that person to the Health Center
and to explain why you are referring that person.
During FOLLOW-UP, or additional, visits:

1. Greet the family member(s) whom you find at home
2. Explain the reason for your visit. The reason should involve a follow-up about a previous issue you
found at the household, or a previous question a household member had. Otherwise, the visit will be
to check-in with the household to see whether they have any health questions or concerns.
3. Remind them that their answers are private
4. Make notes about additional areas that need follow-up (e.g., immunization coverage, ANC visits, etc.).
5. Share information with the household members regarding healthy practices they may be interested in
adopting that might help them stay healthy.
6. If there are household members you previously referred, check their condition and progress.
7. Make referrals to the nearest health centers (if you see Danger Signs in any household members)
8. When finished, thank the household member for their time and attention. Explain that you would
appreciate coming back soon to further discuss ways to improve the health of their household.
After the visit:

1. Fill in your chart for the household, if you haven’t done so already.
2. Follow up with the family member(s) regarding previous issues you and they discussed or new
information you wish to share with them.
**The Facilitator can tell a story of home visiting that did not go well or went wrong. This can serve as an
example of what not to do, allowing participants to provide answers about what the VHT did wrong and
then review the steps for before, during, and after home visiting.
37
Explain to Participants that:
 People do not always want to do what they are told.
 Perhaps the changes the VHT was suggesting were too big.
 Perhaps the people in the VHT Member’s village did not understand the importance of making the
changes.
 It is important to show respect in asking opinion
 The household head will know their situation best
 If the household head comes up with the idea for how to change, she is more likely to make the
changes (it is her idea, her change)
Note: This should be a conversation, not a lecture. It is not your job to tell people how to change their
behavior. It is your job to help people see how changing some behaviors can help them and their family
members live healthier.
Keep in mind: If the person has a good experience with the first change she or he tries, she or he may be more
willing to try other changes in the future.
**The Home Visiting section is ideally followed-up with home visiting practice, or VHT Role Play. Then once
the first VHT Role Play has been done, for each subsequent Role Play, the home visiting process—before,
during, and after home visiting—can be reviewed to help prepare the VHT for the community setting. The
more creative the household scenario is (e.g., pregnant woman, no latrine, TB Danger Signs, etc.) the better
the practice for the Participants.
B. VHT Role Play

VHT Role Play is a method for practicing home visiting during the training week without actually leaving
the training site to visit homes. The purpose of VHT Role Play is to give Participants practice home visiting
under the supervision of the Facilitators and the other Participants so that those in the Role Play can receive
feedback about their home visiting strengths and the areas for improvement.
VHT Role Play can be conducted during time gaps between other topics as a way to engage the
Participants and to vary the teaching styles. You should conduct VHT Role Plays with at least four groups
during the training week. They do not take much time and are very important to providing feedback for
Participants while they are all gathered together in a common setting, and they help to reduce Participants’
concerns about visiting their neighbor’s homes and interviewing properly.
Note: This activity should only be conducted after the topics of Home Visiting and Record Keeping have
been presented.
Steps for Running a BASIC VHT Role Play:

1. Explain to Participants that now they have learned about home visiting, throughout the week you will
ask volunteers to practice home visiting called VHT Role Play. Explain that this is their opportunity to
ask questions and receive feedback.
2. Request at least two volunteers from the Participants. Explain that one volunteer will be the VHT
Member and the other will be a member of the household.
3. Explain that the VHT Member will pretend as if they are visiting a home in the area of the village they
are responsible for. This will be the first visit for the VHT Member so they need to practice the steps
they learned for what to do during the first visit.
38
4. Explain that the other Participant is the household and they are free to act as they want. For example,
they can answer all the questions directly, or they can be difficult and try to dodge direct questions.
But they should act natural, as though this were a real guest visiting their home.
5. Explain to the Participants watching in the audience to take notes and try to look for what the VHT
Member does well and the areas for improvement. When the VHT has finished, maybe 15 minutes, the
VHT Role Play will stop. If time permits, at this point a second pair will be asked to do a VHT Role Play.
6. When the VHT Role Play has finished, or if time permitted when both finished, take 15 minutes to
cover what the VHT Member(s) visiting the homes did well and which areas needed improvement.
7. Thank the Participants for volunteering and encourage others to participant when other opportunities
are offered later in the training week.
Steps for Running an ADVANCED VHT Role Play:
Note: An Advanced VHT Role Play should not be the first VHT Role Play conducted during the week, and
should be conducted only after at least two groups have already participated in Role Plays.
1. Explain to Participants that now that they have seen a few VHT Role Plays, you want to encourage
them to create more complicated situations for the visiting VHT Member.
2. Explain that these visits will not be the first visit, so the household will be familiar with the VHT
Member and the VHT Member does not need to ask the questions in the Record Book since it is not
the first visit. The VHT Member is only visiting the household to follow-up on a previous issue or
checking in to see if the household has any health concerns.
3. Ask for a volunteer to play the role of the VHT Member. After this Participant is selected, ask him or
her to go outside while the remaining Participants think of a situation.
4. Ask for suggestions from the remaining Participants for possible situations at the home and number of
household members to be present. For example, maybe the VHT Member will find an angry husband
and pregnant wife fighting because the wife thinks the husband should accompany her to the health
center for antenatal care, but the husband thinks those are women’s issues and has no interest.
Another example might be that one household member has symptoms of TB but does not know that it
is serious. They can present the symptoms to the VHT Member, without telling him or her, and the VHT
Member needs to recognize the Danger Signs. They are free to be as creative as they want.
5. Ask the VHT Member to return from outside and to begin the Role Play.
6. Tell them they will try to determine the issues at home and to make the appropriate recommendations
or referrals. Give them 20 minutes to do so.
7. If time permits conduct a second Advanced VHT Role Play.
8. When the VHT Role Play(s) finishes, have Participants provide feedback as they did for the Basic VHT
Role Play
9. Thank all Participants for their participation
39
C. Referral and Follow-up
Two of the most important duties for you as VHT are referring patients to the nearest health center
who are showing Danger Signs, and later following-up with those patients you previously referred.
1. How Do You Refer Someone Needing Health Care?

Ask Participants
“What is the meaning of referral?”
Probe Participants to ensure that the following ideas are mentioned
Referral is the process a VHT member follows to direct people who need health care to a place where
they can get additional care and treatment from a trained health provider. Referral is an important part of the
work that a VHT member does. A VHT member gives people in his or her village valuable information about
where to get treatment.
When Should You Refer a Person to a Trained Health Worker at the Health Unit?
 Refer any pregnant woman, young children, or newborn if she or he has one or more Danger Signs.
 Refer patients who do not respond to treatment at the community.
Ask Participants
“Why is it important to make referrals?”
Probe to ensure that the following ideas are mentioned

 To save lives
 To make sure that people get appropriate treatment
Explain to Participants that as a VHT member, it is important that you make yourself aware of the health care
services available in your community for effective referral and reporting of major health problems and
emergencies.
Ask Participants
“What information must you know about your nearest health unit?”
Probe to ensure that the following points are mentioned

 Name of the health unit
 Where the health unit is located
 Phone number of the trained health worker
 Services offered at the health unit
 Hours of operation
40
2. How should you refer someone to a trained health worker at the health unit?
To help health workers better understand why the person is coming who you have referred, you
should fill out a basic Referral Form. This will help the health to understand the health issue that patient is
having and also know that a VHT Member has referred this person. Remember to give the patient the referral
form so that they can bring it with them to the health worker.
How Do You Fill Out a Referral Form?
Note: If you do not have a Referral Form, write a note for the person to take to the health unit. Include the
following information in that note:
Name of person being referred

Sex
Date of birth
Sub-County
Parish
LC1
Reason for referral
Name of VHT member making the referral
ASK
“What do you do if you do not know how to write?”
PROBE To ensure that the following points are mentioned.

 If a VHT member does not know how to write, he or she can try to find someone to fill out the Referral
Form for him or her.
 That person can also be a family member of the person who needs to be referred.
 (Participants may have other ideas of who can fill out the Referral Form.)
NOTE: the Referral Form should be filled out right away and left with the patient or the parent of the patient,
so that they can take it with them as they travel to the health unit as quickly as possible.
**Facilitators: Take a few minutes to walk around the room and check that everyone has made a copy of
the Referral Form in their exercise books. Emphasize that Participants should copy the Referral Form into
their VHT Record Books once they receive them.
3. Following-up with Patients You Referred to the Health Center

You should always follow-up with patients you referred to the health center for the following reasons:
 To check whether they have gone to the health center
 To check they have received the appropriate medication or treatment
 To check they are taking the complete dose of medication they have received (you can also take this
opportunity to explain Drug Resistance, discussed later in this Training, and why it is important to take
the full dose not just enough to make the person feel better.
 To answer any health related questions they might have
 To provide health education about their illness, including ways to prevent it in the future
41
V. VHT Tasks Following Training
Following Training, there are several tasks that VHT Members should do as a group, even before they
begin home visiting. These tasks are important for organizing your Village Health Team for its responsibilities
in the community and necessary for informing other important community partners, like village leaders and
local health centers.
1. Explain the purpose of meeting with the village leader
2. Explain the process of selecting leadership
3. Describe the important points to discuss while meeting with local health center staff
4. Describe the purpose of holding monthly team meetings
5. Describe the steps to holding a health talk
Note: Facilitators, the topics of “meeting with the village leader” and “selecting leadership for your Village
Health Team” should be reviewed at the end of the week before releasing the Participants from Training.
Both these sections are important for VHT Members to keep in mind following training. In particular, the
first task VHT Members should perform is to meet with the LC1 to discuss what they have learned and their
new responsibilities.
A. Meeting with the Village Leader

Following the VHT Training, the first task you should complete with the other VHT Members in your
village is to visit the LC1 as a group to discuss your recent VHT Training. Many people will likely have questions
for you. How will you help the community? What services do you offer? What health information have you
learned? But before you meet with your community, as a new VHT Member with recognition as HC 1 you need
to first meet with your village’s LC1. As a VHT Member you are still responsible to the LC1, so following your
training it is important to meet with him or her along with all the other VHT Members in your village to discuss
about the VHT Program, what health information you have learned, and the responsibilities you have been
given by the Ministry of Health, such as home visiting and referral. Then, you should request the LC1 to hold a
village meeting so that you can explain to the community what you have now explained to the LC1 and answer
any questions the community will have about your new role as VHT Member.
Topics to Discuss with the Village Leader:

1. VHT Program
2. Leadership Selection
3. Home visiting
4. Referrals
5. Community meetings/Health talks
42
*Each of these topics is covered during the VHT Training. Therefore, by the end of the training week, you
will have an understanding about each of these points and what to discuss with your LC1 and community.
B. Selecting Leadership for your Village Health Team

After finishing the training it will be important to select leadership who will help address challenges the
other VHT Members in your village are having and who will communicate with the Health Center staff about
volunteering, outreaches, and delivering VHT Summary Reports from your village. The VHT Leaders will be
responsible for mobilizing the other VHTs during community health talks, Health Center outreaches, or other
community projects.
When selecting your VHT Leaders, it is very important to consider the character of the person or
persons, their availability, and their interest in doing the extra work. The VHT Leader will still be responsible
for home visiting, but will have the added responsibilities mentioned above.
Some qualities to consider for the VHT Leaders:

 Good communicator
 Friendly and patient
 Hard working
 Available
 Trustworthy and dependable
 Strong interest in community health and development
*Facilitators, be sure that Participants write down these qualities in their exercise books because they will
need them to help elect VHT Leadership following training.
The VHT Leaders to select are the following:

1. VHT Supervisor—the VHT Supervisor oversees the VHT Program at the Parish level
2. Information Secretary—the Information Secretary oversees the VHT Program at the Village level
The duties of the VHT Leaders include the following:

1. VHT Supervisor
 Hold VHT meetings at the parish and village level to discuss Quarterly Summary Reports, home
visiting, volunteering at the health center and other duties of the VHT Members
 Informing the community about VHT programs
 Work with VHT Members who are facing challenges in performing their duties, such as home
visiting
 Help to explain and/or translate VHT Program materials for other VHT Members having
difficulty understanding language
 Help VHT Members to complete and deliver Quarterly Reports to the health center, including
addressing the issue of long distances to travel for some VHT Members
 Act as a link between the VHT Members and health centers, including communicating
information to and from both groups
 Organize health talks to the community where needed and appoint VHT Members who will
facilitate these health talks
 Analyze VHT Summary Reports to identify the biggest gaps in healthy behaviors in the
community (e.g., such as low immunization coverage) and mobilize other VHT Members to
work toward addressing the issues identified
43
 Coordinate VHT Members to work with other community groups, like CBOs or NGOs, to help in
solving the problems faced by the community
 Involve all the VHTs to participate in health activities taking place at the health centers and
within the communities
 Encourage VHT Members to do voluntary work at the health centers and make health center
visits
2. Information Secretary
 The Information Secretaries have the same duties above, except they focus on the village level
Selecting Your VHT Leadership

The number of VHT Supervisors and Information Secretaries elected in each Parish will vary by the size
of the Parish, the number of villages, and the number of VHT Members within the Parish. Generally, however,
the following are steps that you can use to elect your VHT Leadership:
1. Hold a meeting with all VHTs trained in the Parish
2. Determine whether all villages in the Parish have been trained. If not, only elect VHT Leadership for the
villages that have been trained. When the remaining villages have been trained, organize a meeting
with the new VHT Members to hold their elections and exchange contact information of new VHT
Members and Leaders
3. To elect the VHT Supervisors, divide the Parish into two parts. Elect a VHT Member (with the qualities
listed above) for each part of the Parish, making sure that they fully understand the new duties they
will have
4. To elect the Information Secretaries, determine the number of villages and VHT Members within the
Parish. Generally, one Information Secretary should be selected for every 8-10 VHT Members to work
with them performing the duties listed above. However, if a village is far from the rest of the Parish
and only has a few VHT Members, say 3-4, then the Information Secretary this area elects should only
focus on these 3 or 4 VHT Members and not travel long distances to monitor other VHT Members living
far away.
*VHT Members during training should be reminded that once they have elected their VHT Leadership
(Supervisors and Information Secretaries) the names and contact phone numbers should be given to the
nearest health center and the Sub-County health center. Doing this will allow health center staff to contact
the VHT Leaders to get help from VHT Members for health programs either at the health center or in the
community.
C. Linking with Local Health Centers

One of the primary reasons for the creation of the VHT Program was the need for more assistance at
the community level to address the health issues of households. In Uganda, as with much of Africa, health
workers are overburdened by the numbers of local residents visiting health centers with complaints of
symptoms from preventable illnesses. Compounding the difficulty for health workers in dealing with large
patient intake is the challenge of addressing these preventable illnesses with a lack of knowledge about the
situation at the household.
As a result, the VHT Program was created to bring health services to the household level, not only to
help reduce the high work load for health workers, but also to learn information about the health behaviors
(e.g., sleeping under a mosquito net, attending ANC services, etc.) at the household level. This information
could then be passed onto the local health centers, providing health workers with a greater understanding of
the community’s issues and the first step to improving the community’s health status.
44
Thus, linking with your nearest health center is a vitally important way to help improve the health
status of your community as a VHT Member. Following the training, all the VHT Members of your village
should go together to visit the staff of your nearest health center to begin the discussion about how to work
together. Remember, as a VHT Member the Ministry of Health Uganda considers you at the level of HC1.
When meeting with your local health center, there are a few points you should discuss:
1. Quarterly Summary Reports
 Explain to the in-charge of the health center that you have received MOH-approved training on
how to collect data at the household level through home visiting. Every quarter you will be
delivering records to their health center containing information to help the health center
understand more about the community they are serving. Also, explain that these records
should be copied at the local health center for their records and then delivered to higher level
health center, or the District Health Offices, by the health center’s records assistant. The
District has requested these records for the purposes of understanding the health status of
local communities and to determine more accurate health resource and service allocations.
2. Exchange of VHT Member Contact Information
 To help establish the link between VHT Members and local health center(s), you should
exchange contact information with health center staff. Not only give them the names, villages,
and phone numbers (if available) of the VHT Members, but also obtain the health workers’
contact numbers. Providing the health center staff with your contact information allows them
to reach you when they plan to conduct a community outreach or hold a special clinic, such as
for vision or the elderly, at the health center. Moreover, possessing the contact information of
the health center staff allow you to contact them in case of any health emergency in the
community, such as the outbreak of a severe illness, like cholera, or when an individual has
received a serious injury.
 Explain that you have selected leaders among the VHT Members in your area. Ask the health
center staff to make notes of these leaders, so that when staff need to reach out to the VHT
Members, instead of calling all the VHT Members, they can call the leaders who will then
communicate the message to the health center staff, and vice versa.
3. Possible Volunteer Opportunities
 Discuss the possibility of establishing a volunteer schedule with local health center staff to help
carry out their services at the health center on busy days, like immunization days. Explain that
you are not there to take the job of health center staff, but rather to support them when they
are faced with heavy patient numbers. Examples of possible volunteer opportunities include
ordering patients by severity of illness, helping register those during immunization days, helping
to weigh infants, helping to count medications, or any other activity the staff may appreciate
assistance with.
 Furthermore, discuss with health center staff the possibility of visiting to conduct health talks.
As patients wait to see a health worker, this can be your opportunity to discuss the importance
of completing the full dose of medication and the issue of drug resistance. Alternatively, you
could discuss the importance of soon-to-be-mothers receiving at least 4 antenatal care check-
ups for the health of themselves and their babies. These are only two examples, but any of the
health topics you learn about during your VHT Training could be topics for health talks at the
health center.
4. Participating in Community Outreaches
 Discuss the option of participating in community outreaches the health center staff plans to
hold. Often times the outreaches receive large numbers of local residents who otherwise would
not be able to attend the local health center due to the challenges of distance and transport.
45
Discuss with health center staff ways to help as with similar services provided at the health
center itself.
D. Holding Monthly Team Meetings

All Village Health Teams should hold monthly team meetings to share information and to plan for the
coming months. Each team may organize its monthly meeting in the way that seems best to its members.
Team meetings will help you stay organized and help you to focus on the common issues affecting your
community. Team meetings provide an opportunity for you and the other VHT Members of your village to
develop a plan to address the health issues you have found through home visiting and filling in your Record
Books, such as holding a village health talk or presenting your findings to the health workers who can organize
an outreach for your community.
1. Share with Each Other What You Have Done and Learned During the Month
Although each of you in the VHT is responsible for carrying out your tasks and activities in your part of
the village, all of your VHT members should come together and meet at least once a month for the purpose of
sharing what has been done and what has been learned about the village. During these meetings, you can help
each other identify new ways to do things and solve problems. These meetings should be organized by the
VHT Leaders your group selected. When you describe a problem you are having in your part of the village, you
may find that another team member has had that same problem and found a good way to solve it. When he or
she explains how the problem was solved, you may be able to learn from that experience how to solve your
own problem.
Note: It is important that each VHT member has a chance to speak.
2. How Should You Organize a Monthly Team Meeting?

Each VHT can organize the monthly team meeting in the way that seems best for that team. For
example, if the team has chosen a leader, that leader may organize and run the monthly meeting. On the
other hand, the members of your team may choose to take turns in organizing and running the monthly
meeting. What is important is that you agree on how to organize and run the meeting and that every VHT
member should have an opportunity to ask questions and to share information.
E. Share Information with Village Groups during Health Talks

You may have opportunities to share information about health with groups of people, such as during
village meetings, in the waiting room of the health unit, or perhaps during parent-teacher meetings at schools.
You may use some of the same steps to prepare for giving health talks that you used to prepare for home
visits.
What are the steps for carrying out a health talk?
Before the talk:

1. Identify the topic of the talk. Ask yourself questions such as, “Whom should I talk to? What topic would
be interesting for them? What do I want them to do after hearing my talk?”
2. Gather your materials - your Handbook, your “VHT Guide to Healthy Homes,” and any other materials
given to you during training that you find useful.
46
During the talk:
1. Greet the members of the audience.
2. Tell them the topic of your talk and why it is important for them.
3. Use the materials you have brought with you for your health talk
4. Take notes of the important points being discussed
At the end of the talk:

1. Ask for a volunteer to repeat the main points of your talk.
2. Ask what people may want to do differently as a result of this talk.
*Another important use of the health talks is to discuss what you have found using your VHT Record Books
and with the Summary Reports you will create every three months. For example, if you find that many
homes do not have complete immunization for their children under 5 years old, you can request the LC1 to
hold a village meeting so that you can discuss the importance of immunization. You can do this for each
health issue that you find to be a potential problem for your community. Also important, these meetings
can be used to show the community members what they are doing well. For example, if most homes have
latrines and drying racks, you can explain that these homes are helping to reduce illness and risk of death
from sanitation problems, like diarrhea. Because of these homes, the whole community is safer.
47
Part Four
Help Save Lives
Your village has chosen you to be a member of the Village Health Team because they have
confidence in you as a responsible, trustworthy person. There are many ways in which you can help
save lives in your village. One of those ways is to help people recognize when a person has a danger
sign and therefore needs to receive treatment from a trained medical provider right away. In this
section of the manual, you will learn about a number of ways you can help save lives in your village.
48
I. Child Growth and Development
This section of “Child Growth and Development” reviews common diseases and conditions that affect
all people, but have detrimental effects on children. The topics include Fever, Malaria, Immunization,
Breastfeeding, Diarrhea, and Nutrition. You will gain background information about these topics, why they are
important, and how to recognize and manage danger signs for specific disease states. Many of the diseases
that are responsible for child mortality are ones that could potentially be prevented with behavior changes.
And so the goal of these prevention methods and this referral system is to decrease the profound effect of
these conditions.
One way to introduce this section to the participants is to discuss the “Top 5 Causes of Death in Africa”. Ask
the participants to list these common conditions. Some answers may include “poverty” or “ignorance”
which are great answers, because these issues often underlie the major diseases/conditions. However, try to
elicit answers that are related directly to health. Each of the conditions listed will be covered in the clinical
lectures.
Top 5 Causes of Death in Africa

1. HIV/AIDS
2. Malaria
3. Lower Respiratory Infections
4. Diarrheal Diseases
5. Perinatal Conditions ( “ F a c t s about health,” 2002)
A. GERMS
Each condition will be covered in greater depth throughout these clinical lectures. However, there
must be some background information that will supplement a VHT’s understanding of these common
conditions. To begin these clinical lectures, one must have a basic understanding of germs, infections, and
how our body responds.
Learning Objectives:
1. Definition of a Germ
2. How does the body react to Germs?
1. What is a Germ?
Germs are substances that are so small they cannot be seen except with a microscope. These germs can
be divided into groups called bacteria, viruses, fungi, and protozoa. Examples of germs include HIV, Malaria,
and Syphilis. When the germs enter the body, they cause harm in different ways making the person sick. This
state is called an Infection. Understanding how germs affect people and knowing how to prevent illness can
save lives.
49
2. How does the body react to Germs?
The human body has different methods of protecting itself from the effects of germs
1. Skin—acts as a barrier to prevent germs from getting inside
2. Coughing, Sneezing—behaviors allow us to get germs out
3. Inside the Body
We have a defense system made up of special cells that recognize and kill germs. This defense is called the
“Immune System”. The major players in our immune system are the Antibodies which recognize the way a
germ looks, attach to the germs, and then kill them. The immune system can then remember the different
germs they encounter. In this way, infections are less severe the next time, and the person may never get sick
from that germ again. For example, antibodies for Malaria remember the germ so the next infection is less
severe.
Use illustrations to make the concept of Antibodies more clear. The antibodies recognize, attach, and kill
germs that enter the body. The antibodies then remember what germs look like so they are easier to fight
when they enter the body the next time.
Germ Antibody
B. FEVER
Learning Objectives
1. Understand the meaning of fever as a reaction of the body against infection.
2. List the types of infections that cause Fever
3. Understand the difference between fever and malaria
4. Know when to be concerned about fever
5. Know what can be done at home when someone is sick with fever
1. Definition
- A fever is an increase in body temperature. This is the body’s response to infection. Germs are the source
for all infections, and they only survive at specific temperatures. One way the body responds to fight the
infection is to raise the temperature.
- Use the example of boiling water. The purpose of boiling water is to use the high temperature to kill
germs. This topic will be discussed in more detail under “Environmental Health”, but many people will
understand this concept and will be able to relate this to the human body.
50
2. Types of Infections that cause fever
- Keep the participants engaged by asking them to list the types of infections that can cause fever
- Malaria is just one of many infections that cause a fever. Other infections include pneumonia, stomach
infections, kidney/bladder infections, STDs, ear infections, the flu, meningitis, and others.
3. Fever vs. Malaria

- Many people believe that anyone with a fever must have malaria. However, Malaria is the disease caused by
an infection that commonly results in a fever. Fever is the body’s reaction to ANY kind of infection. Malaria
and Fever are NOT the same. Malaria is the disease, and fever is one of its symptoms.
- This is important to understand, because many people are misdiagnosed and are sent home with the wrong
treatment. People often die because they were treated for malaria while the other disease progressed.
- It is important to understand that there are MANY causes of FEVER, but only ONE cause of MALARIA.
Therefore, as you gain more knowledge about different diseases (e.g., malaria, pneumonia, etc) that
commonly affect your community, you must keep in mind that many of them will have fever as one of the
signs. As VHT, when visiting your homes and talking with household members about their health, remember
to ask, “Fever and what?” This tells you whether the fever might be associated with malaria or whether it’s
a sign of another disease, like pneumonia.
- For example, fever with joint pain and severe headache might be malaria. BUT, fever with chest pain and
coughing is likely to be pneumonia. These differences are important to understand and will help you save
the lives of members of your community.
4. When to be Concerned about a Fever

- Most children are very active—always wanting to play and interact with each other. When a child is very sick
and has a fever, their behavior often changes before you can recognize the symptoms. The child does not
seem interested in playing, has no desire to eat/drink, does not seem alert, does not smile, may have pale
skin, or seems very weak.
5. What to Do at Home
A. Do NOT bundle up someone with blankets who has the chills. When a child is shivering, the natural
instinct is to cover the child to keep him/her warm. However, the added heat will only contribute to the
elevated temperature.
B. Remove excess clothing or blankets
C. Use warm water for bathing
D. Do NOT use cold water. Like the concept of adding warmth to the child during the shivering stage
of the fever, it is also important to avoid using cold water. The body’s natural reaction to the cold will be to
raise the body temperature.
E. Encourage plenty of fluids—clean water that has been boiled
F. Panadol at an appropriate dose by age/weight will help lower the temperature, but this is not a
cure to the underlying problem—the infection that is causing the fever itself.
51
C. MALARIA
1. Understand the meaning of Malaria
2. Learn why Africa is so greatly affected by Malaria
3. Statistics about malaria in the world, Africa, and Uganda
4. Understand how malaria is transmitted between people
5. Recognize the myths about Malaria
6. Understand and recognize the Danger Signs of Malaria
7. Know what can be done at home in cases of malaria
8. Understand the methods of preventing Malaria
9. Know the treatment schedule of Coartem
10. Understand the side-effects related to malaria including the harm to one’s health and livelihood.
11. Understand the Role of the VHT
12. Common Questions from VHT participants
1. Definition of Malaria
Malaria is a disease caused by a parasite (a type of germ) that is carried by mosquitoes which results in
an infection in the blood. Malaria is transmitted by a mosquito if it bites an infected person and carries the
parasite to a healthy person. This parasite only survives in mosquitoes and human bodies. The spread of
malaria takes place if the environment is conducive and when our bodies are exposed to mosquito bites.
Malaria is responsible for the deaths of many people every day in Uganda and the majority of these deaths
occur among children under 5 years of age.
2. Why is Africa greatly affected by Malaria?

Many people are curious as to why Africa is so greatly affected by malaria while other, more developed
countries are not. Despite the political intricacies that may be involved with malaria prevalence, there are
several scientifically-based reasons.
The mosquito species, Anopheles gambiae, is responsible for high transmission. The predominant
parasite, Plasmodium falciparum, commonly causes severe malaria. The weather conditions of Africa allows
for transmission year round. Together, the mosquitoes with these dangerous parasites can be very
devastating to a population. In addition, resource scarcity and socio-economic instability hinders efficient
malaria control activities (“Impact of malaria,” 2010).
3. Statistics:
It is important to have a basic idea of how malaria is a global player
- 3.3 billion people (half of the world’s population) live in areas at risk of malaria transmission
- The World Health Organization estimates that in 2008 alone
- 190-311 million clinical episodes
- 708,000-1,003,000 deaths
52
- 89% of malaria deaths worldwide occur in Africa
- Malaria is the 2nd leading cause of death from infectious disease in Africa, after HIV/AIDS. (“Malaria
facts,” 2010)
4. Transmission:
- The female Anopheles mosquito is responsible for transmitting the Malaria parasite. The female bites
a human to acquire the necessary blood for egg production. When the mosquito receives the blood of
someone infected with malaria, the mosquito holds the germs until it bites a healthy person. The mosquito
releases the germs into the healthy person who then develops the infection.
- The time of day for active mosquitoes is from 7pm to 7 am. This is the time when mosquitoes feed—
biting to obtain the required blood meal.
*It is important to stress certain points about the mosquitoes, because they will relate to the different ways
malaria can be prevented. These points include:
- The time of day when mosquitoes are active: 7pm to 7am
- The female mosquitoes lay their eggs in water
- Mosquitoes live in areas with bushes/weeds
- Mosquitoes transfer malaria germs from an infected to a healthy person
5. Myths about Malaria

Keep the VHT members engaged by involving them in this conversation about malaria myths.
Explain that since now they know the basic information about malaria, what are some other beliefs that are
shared within their community. They could add some other common myths that can be helpful to discuss
during future trainings. At the end of the list, inform the VHTs that these are false beliefs related to malaria.
- eating mangoes and maize during their seasonal harvest
- drinking dirty water
- jumping over some fetish
- sitting under the sun for a long time
- walking in the rain
- an expression that the child does not belong to a specific clan
- caused by the flu
- from the bushes
- stagnant water
- waist beads on babies can prevent malaria
- bed nets cause cancer
53
6. Signs and Symptoms of Malaria
Malaria symptoms can be divided into 2 categories: Uncomplicated and Severe/Complicated
Keep the participants engaged by asking them to list the symptoms of malaria. Because malaria is so
common, almost everyone can describe what it feels like.
Uncomplicated Malaria
- These symptoms include fever, chills, sweats, headaches, nausea, vomiting, body aches,
tired/weakness, pale skin
- These symptoms should be recognized and the patient should be immediately referred to the health
center for the appropriate tests and treatment. While these symptoms seem very minor, treatment within 24
hours is necessary.
The Fever:
Malaria has a wide spectrum of symptoms, but the most common is fever. The fever is very characteristic in
how it recurs every 48-72 hours when the parasites cause the red blood cells to burst, releasing the parasites
and their toxins.
There are 3 stages of the fever each time it occurs:
1. Cold Stage—sensation of cold, shivering
2. Hot Stage—fever, headache, vomiting
3. Sweating Stage—sweats, return to normal temperature, tiredness
Severe/Complicated Malaria
- These symptoms are related to organ damage secondary to the infection. These symptoms should be
recognized and the patient requires immediate referral to the health center. The infection can quickly
progress to death if proper treatment is delayed.
- Severe/Complicated Malaria is most common in children under 5 and pregnant women
- These symptoms include the following:
- Neurological: abnormal behavior, loss of consciousness, seizures
- Gastrointestinal: persistent nausea/vomiting
- Respiratory: Difficulty breathing—breathing quickly, cannot catch a breath
- Cardiovascular: Low blood pressure and cardiovascular problems that can manifest as
dizziness, inability to stand or walk due to weakness
- Vascular: Severe anemia that is seen as very pale skin and white palms. Also, abnormal blood
coagulation can occur with parasite activity within red blood cells.
7. What to Do at Home
The treatment of malaria requires medicine that kills the parasites. These types of medicines are called
“antibiotics”. Examples include Fansidar and Coartum. There are some interventions that can be done at
54
home before or after the visit. It is important to remember that these methods will not cure the disease but
will help with some of the symptoms of malaria.
1. Encourage the child to take plenty of fluids
2. If the child is breastfeeding, continue breastfeeding
3. Use a warm piece of cloth to reduce the body temperature
4. Reduce heavy body covering or cold water during the fever, because this will increase body
temperature
8. Malaria Prevention
- The methods of prevention are related to reducing the number of mosquitoes and mosquito bites. It is
important to make a relation to the points made about mosquitoes and the different prevention methods.
Sleep under an Insecticide-Treated mosquito Net (ITN), especially the most vulnerable groups—
children, pregnant women, elderly. Treated bed nets serve as two purposes. The net itself will prevent the
mosquitoes from biting when they are most active at night (7pm to 7am), and the insecticide will kill the
mosquitoes.
 Treat mosquito nets at least twice a year
 Clear wild bushes around the house. This will decrease the numbers of mosquitoes living near the
house.
 Stagnant water is where the eggs are laid. Removing this water will decrease the number of
mosquitoes around the house.
- Throw away all empty tins and bottles that may collect water.
- Fill all pits holding stagnant water around the house
- Clear all water drainages to reduce mosquito breeding grounds
 Pregnant women are advised to take at least 2 doses of Fansidar during pregnancy to protect them
and their unborn babies against malaria
 Close windows before dark to avoid mosquitoes entering the house
9. Treatment
 Treatment should be prompt—within 24 hours of symptom onset.
 Remember to always take the full treatment—specific number of tablets for the required number
of days at the recommended times.
 If symptoms persist despite treatment, refer the patient to the nearest health center
55
10. Malaria Treatment Schedule
This schedule is provided to allow the VHT to monitor/inform the patients who are sent home with a malaria
diagnosis. This is not training for making VHTs drug distributors. During follow-up visits, the VHTs should be
able to advise their patients on the specifics about their treatment plan.
Age Day 1 Day 2 Day 3

Morning Evening Morning Evening Morning Evening
3 months – 3 years
1 1 1 1 1 1
(5 – 15 kg)
3 years – 7 years
2 2 2 2 2 2
(15 – 25 kg)
7 years – 12 years
3 3 3 3 3 3
(25 – 35 kg)
> 12 years
4 4 4 4 4 4
(> 35 kg)
11. Coartem
The following information regarding Coartem is helpful to the facilitator. It is important to have some
background information on this drug as it is used so commonly in Uganda. This information will also be
helpful in answering some questions that may arise during the lecture.
 Coartem is a combination of two anti-malarial drugs: Artemether 20mg and Lumefantrine 120mg. The
treatment course for uncomplicated malaria consists of twice daily dosing for three days.
 The Artemether component acts by interfering with parasite growth in RBCs. The Lumefantrine
component is also an anti-malarial but little is understood about its specific action
 This medicine should be taken with food for optimal absorption. Continue to take the medicine if the
patient cannot tolerate food, but encourage food when improving.
 This drug may reduce the effectiveness of hormonal contraceptives (e.g. birth control pills). One
should be advised to use additional family planning methods to better ensure pregnancy prevention.
 Some people can have serious allergic reactions to this medicine which are called “hypersensitivity
reactions”. The patient should immediately stop the medication and seek assistance at the health
center at the first sign of skin rash, difficulty breathing, severe sore throat and difficulty swallowing,
and swelling of the face.
 Coartem should be used during pregnancy for uncomplicated malaria if the potential benefit outweighs
the risk. No human studies have proven risk of adverse pregnancy outcomes, but animal studies have
shown increased fetal loss.
 There is no information regarding effects of overdose (“Coartem,” 2010)
56
12. Effects of Malaria
 Anemia
- The red blood cells (RBCs) are responsible for carrying oxygen to all parts of the body. Malaria
parasite lives inside RBCs and causes them to burst or function poorly. When the RBCs burst, they release
toxins, and these broken cells are unable to carry the oxygen the body needs. Then, the body is unable to
function normally, children cannot grown and develop, pregnant women cannot provide enough oxygen and
nutrients to the baby resulting in pregnancy complications and death to the mom and/or baby.
 Socio-Economic
- Malaria is such a prevalent disease state in Africa that medications are often affordable.
However, the lack of effort towards prevention only results in higher incidence rates causing more drug stock-
outs and therefore more seriously ill people. When people are sick, there is low productivity, poorly educated
children, and a community that is struggling to survive.
- Through prevention methods, people are sick less often, adults are able to work and provide
for their families, children are able to attend school and study, and the whole community can function more
smoothly.
13. Role of the VHT

- Inform the community—ways to prevent malaria, why prevention is
important, why early and complete treatment is ideal
- Proper/effective Net use
- Recognize signs and symptoms
- Refer to health center within 24 hours of symptoms
- Proper medication regimen
- Distribute bed nets when available and inform proper use
- Maintain records about bed nets and those sick with malaria
- Volunteer at the health center—health talks, assistance
- Become a model for the community—clearing bushes, filling stagnant water, keeping windows closed
at night.
Common Questions from VHTs:

 Can people develop immunity after having malaria?
- People do not become completely immune to malaria. However, people who live in areas of high
transmission, tend to have less severe symptoms because they have improved their defense system over time.
 Why are the female mosquitoes responsible?

- The females must have a blood meal for their egg production. Males only require nectar as their food
for survival. The females acquire the blood, so they are therefore responsible for the parasite transmission.
 If I feel like I have malaria, can I just go to the pharmacy to buy the medicine I need?
- The best course is to be evaluated by a health care professional. They will assess your other
symptoms and perform a physical exam. Additional tests can be done to determine if the illness is actually
malaria. Another disease process may be present, and therefore, the malaria medication would not be
57
appropriate. People often misdiagnose themselves with malaria, so it is strongly encouraged to seek medical
advice from a trained health professional. The pharmacies should be used for over the counter medications
(such as Panadol) and to purchase medications when the health center is out of stock.
 What do I advise someone when they say they do not have enough money to buy bed nets for their
family?
- Bed nets have been proven to reduce the malaria frequency, especially when used for those must
susceptible (pregnant women, children, and elderly). Explain that it is more cost effective to save money and
purchase a bed net than to pay for the health center visits and medications to treat the malaria when it
occurs. Bed nets allow for people to lead more productive lives, because they are sick less often, they are
spending less money on medications. So in the overall picture, bed nets are more cost-effective and worth
saving for if the government or other organizations are not providing.
 Can I take Coartem to prevent malaria?
- No. Coartem acts by interfering with the growth of parasites in the RBCs. Therefore, the malaria
parasites must be present in order for this drug to work. Taking this as prophylaxis would be costly and
unnecessary.
Malaria Pathology/Physiology Review

This section is dedicated to the facilitator to gain a better understanding of the pathology and physiology of
Malaria.
(“Malaria: biology,” 2010)
58
D. IMMUNIZATION
Immunization is the protection of a person against specific diseases with vaccines to build up the
body’s defense system. Immunization targets mostly children less than five years. The vaccines can be given
orally or through an injection. Opportunities to complete the immunizations are at health facilities which
carry out routine immunizations and government-funded mass immunizations called National Immunization
Days (NIDs).
It is estimated that about 44% of children are fully immunized (“Getting it right, 2008). By spreading
information about the importance of immunization, VHTs can greatly influence the change towards full
immunization across Uganda.
1. Explain the meanings of Immunization, Immunity, and Vaccination
2. Identify the target groups for immunization
3. Identify the eight immunizable diseases
4. Explain the importance of immunization
5. Describe routine immunization and National Immunization Days
6. Outline the immunization schedule
1. Definitions
- Immunization is a means of protecting a person against specific diseases by building up the body’s ability to
fight diseases (defense system).
- Immunity means that the body is able to fight germs that cause that particular disease.
- Vaccination is when medicine called a “vaccine” is given by injection or by mouth.
2. Who Are The Targets For Immunization

1. Children under one year (including the newly born)
2. Children under 5 years who may have missed earlier opportunities
3. Women of child-bearing ages (15-49) *Tetanus
4. Pregnant Women *Tetanus
3. What Diseases Can Be Immunized?

1. Poliomyelitis (polio)
Polio is a viral infection that attacks the nervous system. The initial symptoms include fever, headache,
vomiting, and generalized pain. This infection can result in total paralysis. Children under five are at the
highest risk of infection. Thos infected at a young age may develop symptoms later in life. There is no
treatment or cure. This vaccine has succeeded in drastically reducing the incidence of this very debilitating
disease.
59
2. Tetanus
Tetanus is a bacterial infection that attacks the nervous system. These bacteria live in the soil/dust and enter
the body through deep cuts or wounds. This infection can result in spastic paralysis. Tetanus can occur at any
age, and boosters are required to maintain adequate immunity.
3. Whooping Cough (Purtussis)
Whooping Cough is a bacterial infection that causes a very severe cough. The scientific name for the bacteria
is Bordtella purtussis or commonly known as Purtussis. This disease is very contagious especially among
school children. Symptoms are most severe in babies which can result in difficulty breathing and death. This
disease is known as “Whooping Cough” because of the sound a child makes when taking a deep breath after a
fit of violent coughing—like a high-pitched whistle.
4. Diphtheria
Diphtheria is a very serious bacterial infection that causes fever and a severe sore throat. This infection mostly
occurs in children. Diphtheria is very uncommon due to immunizations.
5. Tuberculosis (TB)
Tuberculosis is a bacterial infection of the lungs that can potentially spread to all parts of the body. These
germs are transmitted to other people through the air. The vaccine is called “BCG” (initials that stand for the
physicians who discovered the vaccine). It provides immunity especially through childhood, but does not
completely prevent TB into adulthood.
6. Hepatitis B
Hepatitis B is a viral infection of the liver, causing severe damage to this important organ. The virus is
transmitted through blood, unprotected sexual intercourse, and from mother to child.
7. Haemophilus Influenza
Haemophilus influenza is a bacterial infection that affects various places of the body resulting in pneumonia,
meningitis, otitis media, epiglottitis, cellulitis, and bacteremia. This infection is most severe in young children.
8. Measles
Measles is a viral infection that causes four common/recognizable symptoms: skin rash, mouth sores,
cough/pneumonia, sore/painful eyes. This disease has potential for activation later in life which is more
serious and can affect brain function.
60
4. Immunization Schedule
Table 5: Showing an immunization and Vitamin A schedule for children
How and where the
Age of the child Vaccines given Diseases prevented
vaccine is given.
Drops in the mouth and
At birth or soon Polio 0 and BCG
Polio and Tuberculosis injection on the right
after. vaccine
arm.
At 6 weeks old (that Polio, Diphtheria, Whooping Drops in the mouth
Polio 1
is one month and two cough, Tetanus, Hepatitis B and Injection on the left
DPT-HepB+ Hib 1
weeks). Haemophilus influenzae. thigh.
At 10 weeks (that is Polio, Diphtheria, Whooping Drops in the mouth
Polio 2
two months and two cough, Tetanus, Hepatitis B and Injection on the left
DPT-HepB+ Hib 2
weeks) Haemophilus Influenzae thigh
At 14 weeks (that is 3 Polio, Diphtheria, Whooping Drops in the mouth
Polio 3
months and two cough, Tetanus, Hepatitis B and Injection on the left
DPT-HepB+ Hib 3
weeks) Haemophilus influenzae thigh.
Injection on the left
At 9 months old. Measles Measles
arm.
VITAMIN A SUPPLEMENTATION
Prevents blindness
At 6 months old and
Vitamin A and strengthens
every 6 months until Drops in the mouth.
supplement resistance against
5 years of age.
other diseases.
5. When Should Immunization Be Done?

A. Start immunization at birth with BCG (to protect the child against tuberculosis) and the OPVO – Oral
Polio Vaccine (to protect the child against polio)
B. Complete all of your child’s immunization before the first birthday (under one year)
C. Take all children who were not given the first doses at birth to a health facility to be immunized at
the earliest opportunity
D. Allow all eligible children (0-5 years) to be immunized during the special immunization days
(commonly known as National Immunization Days – NIDs)
E. All women of child bearing age (15-49) and pregnant women should be immunized against Tetanus.
It is important that pregnant mothers get immunized against tetanus before 6 months of pregnancy. This
protects them and their unborn babies from tetanus.
6. What are the benefits of immunization?

A. Immunization increases the children’s ability to fight disease. Immunization protects a child against
several killer diseases. A child who is not immunized is more likely to suffer from illness, may become
permanently disabled or undernourished and may eventually die.
61
B. Consistent immunization on a national/global level can potentially eradicate these very dangerous
diseases over time.
C. Protects mothers, newborn babies, and mothers-to-be from tetanus
D. It contributes to the child’s proper growth and development
E. It saves time and money which would have been spent on treatment
F. Protects the family and community from eight immunizable diseases
7. What are Side Effects of Immunization?

How do you manage them?
A. Fever: A child may develop a mild fever. If such a case arises, cool the body with a damp warm
cloth. Alternatively, dress the child in light clothing. You may also give Panadol tablets. If the condition does
not improve, go to the nearest health center.
B. Swelling: The injection site may swell. If that happens, leave it to heal by itself.
C. Scar: In case of BCG Vaccine, a red scar or sore may appear. Do not apply any medication. It will
heal by itself.
8. False Beliefs About Immunizations

**As VHT you are likely to encounter many misconceptions or false beliefs about immunizations. It is
important to educate people about the importance of immunization and how receiving these
immunizations can save their lives and the lives of their children by preventing the infection of fatal
diseases.
Some false beliefs you are likely to incur include:

1. Immunizations don’t really work and are unsafe
2. Immunizations actually give you the disease and are a deception to get you sick
9. Role of VHTs
A. Encourage
Encourage parents, family members and caregivers to take their children for immunizations according to the
immunization schedule above
B. Inform
Tell caregivers and families with young children when and where the next health unit immunization outreach
will take place
C. Organize
Help health workers organize people in your village for special immunization activities such as National
Immunization Days (NIDs) or Sub-National Immunization Days (SNIDs) or during child health days and during
outreaches
62
D. Volunteer
Volunteer at the health center to assist the staff during their immunization days. VHTs can be very helpful
during these days when the health center is providing for a high volume of patients.
10. What Are The Key Immunization Messages To Give Caregivers And Families With Young Children?
- Take a child for immunization 5 times before he or she is one year old
- Immunization is safe and protects children against eight childhood killer diseases
- Each time, remember to ask the health worker when to take the child back for the next immunization
- Keep the immunization card safely and take it with the child every time you visit the health center for
treatment
- Inform your neighbors about the importance of immunizing their children.
E. CONTROL OF DIARRHEA
Diarrhea is a disease which makes a person pass watery stools three or more times a day. It makes the
body loose water fast and may lead to death if not treated promptly. They are two different types of diarrhea.
These are:
1. Diarrhea with blood (Dysentery).
2. Diarrhea without blood.
Diarrhea is one of the major cause of death among children below five years.
In this topic discussion will focus on: explaining the meaning of diarrhea, the major causes of diarrhea;
prevention of diarrhea, the process of preparing home-made and packaged ORS.
By the end of the topic participants will be able to:
1. Explain the meaning of diarrhea.
2. Describe the causes of diarrhea.
3. Describe the signs and symptoms of diarrhea.
3. Describe how diarrhea can be prevented.
4. Explain how diarrhea can be managed at home
1. The meaning of diarrhea?
Diarrhea is an illnesses which make a person pass frequent watery stools (three times or more in a day). The
victim’s body looses water and may lead to death if not treated promptly. Diarrhea is among the major cause
of death among children under five years.
2. Types of Diarrheal Diseases:

They are two different types of diarrhea. These are:
1. Diarrhea with blood (Dysentery).
2. Diarrhea without blood.
**For the purposes of this talk, the focus will be primarily on diarrhea without blood. This is because if the
Diarrhea has blood this is a significant DANGER SIGN and the child or adult should seek immediate
treatment from a health center.
63
Diarrhea without blood is further divided into three types based on the duration:
1. Less than 2 weeks
2. 2-4 weeks
3. More than 4 weeks (1 month)
The most common type of diarrhea is diarrhea without blood that lasts less than two weeks. For this
type you do not require medicines to treat it; it will pass on its own. However, you still need to stay healthy
and during this talk, you will learn how.
The other two types of diarrhea without blood, the type that last 2-4 weeks and the type that lasts
more than 4 weeks, are signs of other problems and you should refer someone with either of these types to
the health center for check-up. The type that last for more than 4 weeks might be a sign of AIDS, so you should
refer this person to the health center for check-up and HIV testing.
3. Causes of Diarrhea
The major cause of diarrhea is dirty living condition. This allows dangerous germs to get into contact
with the food to be eaten or water the community members drink, the germs then get into the person’s
stomach and/or intestines. Below are the various ways in which germs get into a person’s body:
1. A person eats foods and drinks water contaminated by these germs or kept in dirty pots, buckets,
plates, pans, cups or any other dirty containers.
2. Eating food without washing hands with soap and water.
3. Eating food, which is not properly cooked.
5. Touching stool (faeces) or vomit of a sick person with bare hands and eating later without washing
hands.
6. Eating spoiled foods.
7. Malaria
8. AIDS
9. Malnutrition
**The relationship between malnutrition and diarrhea is cyclical. When you have diarrhea you lose two
very important things: water and nutrients. The lost of water is the reason why diarrhea is the number one
killer of children under 5 years because it results in dehydration, which we will discuss today. However, the
loss of nutrients is also dangerous and can lead to a state of malnutrition. Importantly, the loss of nutrients
from diarrhea weakens your body and makes it harder for your immune system to fight off disease and
infection which then in turn cause more diarrhea. For this reason, malnutrition leads to diarrhea and
diarrhea leads to malnutrition.
Malnutrition Diarrhea
64
**As mentioned before, your body loses both water and nutrients in diarrhea. However, the most
important thing your body needs is water and that’s why the loss of water is what leads to the unnecessary
loss of life in Uganda and all over the world.
4. Dehydration
The loss of water leads to a condition called Dehydration, and if a person is dehydrated, or without
water, for too long they can die. The symptoms of dehydration include:
1. Little, dark, or no urine at all.

2. Dropping-in of the “soft spot” on the top of the child’s head.
3. Sunken eyes.
4. Feeling thirst.
5. Pinched skin does not snap back into place
6. Weakness and fatigue
5. The Following Signs Require Immediate Referral To The Health Center

1. Confusion.
2. Unconsciousness.
6. How can we prevent diarrhea?

Diarrhea diseases can be prevented through observing the following hygienic practices:
The Four Fs Prevention

Fingers Wash hands with SOAP
Food Cover food, cook food properly, eat food hot
Flies Cover latrine
Feces Properly dispose of feces in the latrine
Diarrhea
**Explain that each of these Fs serve as an opportunity for germs to cause infection which then can lead to
diarrhea. So the way to prevent infection would be to eliminate or prevent germs from spreading at each of
these points. Some examples are given. Participants might have other suggestions.
65
A similar chain involves water, called the Safe Water Chain
Source Use protected source
Container Use clean containers, wash them with SOAP
Storage Use clean storage, cover storage
Use BOIL or treat water before drinking
Diarrhea
**Explain that at each of these points, germs have an opportunity to cause infection, in a similar way as for
the 4 Fs. So the way to prevent infection would be to eliminate or prevent germs from spreading at each of
these points. Some examples are given. Participants might have other suggestions.
Hand-Washing Using Soap

Many families in Uganda wash their hands. However, few of these families use soap regularly and
during the most important times. Without soap, water is not effective enough to clean germs from hands and
to prevent illness. YOU NEED SOAP to reduce the spread of germs and to prevent illness.
Here is how soap works. Soap works by trapping germs within a “soap prison.” Just as soap is hard to
grip when it’s wet, germs can’t grip to your hands or body when you mix soap with water. As you scrub your
hands and body with soap and water the germs become trapped in the “soap prison” and can no longer grip to
your skin and are washed away as you rinse with clean water. But without soap, germs are still able to grip to
your skin and remain there even after you rinse with water. So when you then begin to eat your food you
allow germs to enter your body and cause infection. This is why hand-washing using soap reduces infection
and saves lives. As VHT you can teach the importance of always using soap.
*Using pictures to explain this point will help relate the material
The following times are when you should always use soap:
1. Wash hands with soap before preparing food for children.
2. Wash hands with soap before feeding children.
3. Wash hands with soap after visiting the toilet/latrine or touching/cleaning babies after their toilet.
4. Before eating
5. After handling a sick child or adult
6. Wash your hands with soap and water if you touch the stools (faeces), urine, dirt, and rubbish. They
may contain germs that can spread diarrhea.
7. How can diarrhea be managed at home?

A. Bloody diarrhea:
1. Refer immediately to a healthy facility (with a child taking ORS on the way).
2. Reassure the caretaker/mother.
66
B. Non bloody diarrhea:
*Because the patient is losing water and nutrients, these are the things that they need to replace
into their body
1. Encourage more breastfeeding (for children).
2. Encourage more intake of oral fluids (if a child is able to drink).
3. Encourage more food intake to replace lost nutrients
4. Replace the lost body fluids by giving ORS.
5. For those unable to drink or eat anything refer immediately to the health facility.
8. How to prepare packaged ORS?

ORS must be given to every child who has been infected with diarrhea or shows signs of dehydration in
order to replace the lost fluids. It’s important to recognize that dehydration can also result from excessive
vomiting, and ORS is appropriate to give under these circumstances. However, if the child or adult continues
to vomit and cannot keep fluid within their body, this person needs to go to the health center IMMEDIATELY.
Packaged ORS, also known as Recommended Home Fluids (RHF), is available at health centers for free
or can be purchased from drug stores. As VHT, you should visit your nearest health center and pick up a supply
of packaged ORS for emergencies in your community. If you don’t have packaged ORS available, you can use
the following steps to prepare it at home using common ingredients:
1. Get a clean container with a fitting lid.

2. Measure 1 liter or 2 clean beer bottles (500mL each) or two clean rwenzori (500mL each) or two
large plastic cups (500mL each) of clean drinking water and pour it in the container.
3. Put one sachet of ORS into the water.
4. Stir until it dissolves.
If you don’t have a package of ORS, then mix the following:

½ (one half) teaspoon (small spoon) salt
8 teaspoon sugar
1 Liter of boiled or treated water, which has been left to cool
Stir until dissolves
5. Give in small portions to the child using a cup or a spoon.
Give ORS as often as possible anytime the child makes a stool. If the child continues to vomit, give a 10
minute rest and then give more ORS. If the child cannot keep fluids within their body, then refer
IMMEDIATELY to the health center. Encourage more fluid (fresh juices, water, soup) intakes. Do not mix the
ORS with liquids such as milk, soup, fruit juice or soft drinks – only mix with clean water.
67
**There are some very important things to remember about ORS:
1. ORS is NOT a cure and NOT a method of prevention. ORS is only MAINTAINENCE, meaning that it
won’t stop your diarrhea but will allow your body to have enough water not to die from
dehydration. In fact giving, ORS to a healthy person is risky because of the excess salt present in
the ORS solution. Too much salt is unhealthy.
2. If a mother is still EXCLUSSIVELY breastfeeding her child, DO NOT give ORS. Breast milk is the best
thing for the child and the mother should breastfeed more often than she would if the child did
not have diarrhea.
3. Do not keep the prepared ORS beyond 24 hours.
4. Each person is different so give as much ORS to the person is thirst for. The person might not need
the entire 1 Liter in a day, or the person might need 2 or 3 Liters.
F. FOOD and NUTRITION

Although Uganda produces a wide range of foodstuffs, access to and utilization of such foods remains a
problem often resulting in malnutrition.
Malnutrition can be either over or under-nutrition; the latter being more prevalent in children under 5 years in
Uganda.
The state of being malnourished means that the body is denied the right qualities and quantities of
food. A malnourished body is susceptible to disease
In order for an individual to be well nourished, one needs the right proportions of food substances, called
nutrients, in the diet which are found in the three food groups: energy giving, body building, and protective
foods.
1. Explain the meaning of nutrition
2. Describe the different food groups needed by the body
3. Assess nutrition status of children under 2 years
4. Explain common types of malnutrition
5. Discuss causes of malnutrition
6. Discuss management of malnutrition
7. Explain dangers of malnutrition
8. Explain the role of the VHT
9. Describe how to use the MUAC strip properly
1. Definition of Nutrition
- Nutrition is the process by which food is eaten, digested and utilized for the normal body function. Nutrition
may be good or bad—the latter commonly known as “Malnutrition”
- Nutrition is also the process of giving the body the right types of food in the right combinations. Good
nutrition is a basic requirement for proper child growth and development. The body requires the following
food groups:
1. Body building foods
2. Energy-giving foods
3. Protective foods
68
2. Food Groups
A. Body-building Food
- These types of foods help human bodies grow
- “Proteins”
- Examples: fish, beans, milk, groundnuts, meat, chicken, soya
B. Energy-giving Food
- These types of foods provide us with energy to do our work
- “Carbohydrates”
- Examples: rice, sorghum, cassava, maize flour, yams, potatoes
C. Protective Food
- These types of foods protect us from getting diseases by boosting our immune system. They
make our body health and strong
- “Vitamins” and “Minerals”
- Examples: Fruits (pineapple, watermelon, oranges, mangoes) and Vegetables (greens, dodo,
cabbage, egg plant)
Together, the three food groups provide the foundation for normal development and growth. While
energy-giving foods are most common, it is important to understand that when carbohydrates are the only
food source, this can lead to problems. Young children on a diet of carbohydrates alone will not have proper
brain development.
You can use the analogy of the materials for a house when describing the three food groups. If our
bodies are the house, the bricks can be related to proteins which build our body structure. Carbohydrates
are the materials that hold the house together, because these give us the energy to function. And vitamins
and minerals can be the roof which offer protection and keep the body safe.
3. Assessing Nutritional Status

One of the ways through which the health worker will know whether the child is
malnourished/underweight is through regular growth monitoring of all children under 2 years. The
caretakers/mothers should therefore ensure that their children are examined and weighed regularly to
monitor the child’s growth. Growth monitoring is found on the child health cards. This can be done easily
and free of charge at your nearest health center. It is important to keep your Child Birth Card in a safe place
and take it every time you take your child for services at the health center (e.g., immunization, weighing,
deworming, etc.)
Growth monitoring is a process of regularly measuring the weight of the child to find out how the child is
growing, to detect problems early and help caretakers give the best food and care to help the child grow well
and healthy. Measuring a child’s growth is therefore a way to keep track of the child’s health.
4. Malnutrition
A. Malnutrition occurs when the body is denied adequate quantities and qualities of food needed by
the body. Malnutrition-related diseases contribute to a large number of deaths in Uganda among children.
There are 3 types of malnutrition: Underweight, Marasmus, and Kwashiorkor
69
B. Causes of Malnutrition: Several factors may individually or in association with others cause
malnutrition. Such factors include poverty, diseases, and lack of knowledge on food value. Poverty may lead
to failure in accessing the food in terms of quality and quantity. Disease may limit one’s utilization of food to
the body. Failure to know which foods to eat for good health may also result in malnutrition.
C. Occurs commonly during the transition from breastfeeding to taking solid foods. These children are
either not fed enough food or they are given proportionately too much of one type of food.
- Food may be unavailable
- Families may feed the head of the household and older children first, leaving very little for the
younger children
- Since carbohydrates are the most common food source in a
Ugandan diet, children suffer from malnutrition because they are only given these types of foods.
5. Types of Malnutrition
A. Underweight
1. characterized by excessive weight loss
2. evaluated at the health center for regular weight assessment—review records if the child is
gaining weight and keeping with the average growth of children of similar age
3. Signs—smaller/thinner for age compared to the average size
4. Treatment
a. give the child the proper food types at the right time ~3-4 times daily
b. advise the caretaker/mother to take the child to the health center
c. promote breast feeding up to 2 years
B. Marasmus
1. Marasmus is a condition that affects young children, mostly under 5 years. It is a sign that a
child is not getting enough food needed by the body. This child is severely underweight, caused by excessive
starvation. This could be related to an underlying disease. This disease may occur at any age, but often
manifested in children under 1 year.
2. Signs and Symptoms
- The child’s weight is below the average for his/her age
- The child has an appetite for food
- Shrunken/wasted appearance with loose skin and wrinkles
- Child’s whole body is very thin; little muscle mass, no fat
- Constant irritability, cannot be consoled/comforted
- Generalized apathy, may look scared of surroundings
3. Treatment
- Refer this child to a health facility.
- The only treatment is the provision of enough food
70
- Advise the caretaker to give a diet consisting of all three food groups. Care must be
taken to begin feeding the sick child with soft foods and in small, frequent feedings until the body gains some
strength.
C. Kwashiorkor
1. Kwashiorkor is a condition that is caused by poor-feeding practices. It occurs in children
between 6 months and 3 years. This condition usually occurs when the child has stopped breastfeeding and is
given carbohydrates alone instead of a balanced diet. Kwashiorkor is defined as a lack of protein intake
2. Signs and Symptoms
- Swollen hands and face
- Thin/reddish hair
- Muscles are weak/wasted—upper arms, thighs, and neck
- No interest in surroundings
- Skin loses color and becomes light
- Skin starts to peel, developing sores and infections
3. Treatment for Kwashiorkor
- Provide a diet rich in protein and increase caloric intake: milk, groundnuts, meat. Give
food frequently but in small amounts since the child is not used to eating adequate foods. Remember that
because Kwashiorkor is a lack of protein, the treatment requires diet rich in these foods.
- Refer to the health center to ensure adequate food intake
- De-worming—any underlying condition that may contribute to malnutrition should be
addressed and treated appropriately. The child’s condition will continue to worsen if an underlying disease
such as worms is left alone.
- Vitamin A supplementation: Extra doses of Vitamin A rich foods that are administered
to children between 6 months and 5 years. Vitamin A protects the child’s eye sight and reduces their
susceptibility to childhood diseases by boosting their bodies’ immunity. In Uganda, Vitamin A supplements
are administered to children every 6 months at health facilities or during mass immunization campaigns. As
VHT it is important to encourage families to take their children to receive free vitamin A tablets at the health
center.
6. Dangers of Malnutrition
Malnutrition is not only detrimental to the health of a child but also has social and economic implications to
the family and to the community.
A. Death
B. Blindness
C. Impaired brain development—failure in social, economic and academic progress
D. Unnecessary expenses on frequent trips to health centers, because these children are at higher risk
of contracting diseases.
E. Poor production—Family members are forced to provide greater assistance to these sick children,
leaving other productive/paying jobs behind.
71
7. MUAC Strips
- MUAC stands for “Mid-Upper Arm Circumference”. It is a special strip that is used to measure the size of the
upper arm of a child. You may use the MUAC strip to check any child who is at least 6 months old. The strip is
not accurate for age/weight if the child is less than 6 months. To check for this danger sign, take the following
steps:
1. Set the child on the mother’s lap while you measure the child’s arm.
2. Hold the MUAC strip in your right hand with the blank side facing you and the fatter end of the strip
to the right
3. Wrap the MUAC strip around the upper left arm of the child. Position the MUAC strip halfway
between the child’s elbow and shoulder
4. Thread the thinner end of the MUAC strip through the small slit in the broader part of the strip,
coming up from below the strip
5. Pull the strip gently to tighten it around the child’s arm. Do not pull it tight, and do not leave it
loose.
6. Identify the color of the strip that shows through the small open square in the broader part of the
MUAC strip
a. Green—the child does not have this danger sign
b. Yellow—the child is close to having this danger sign. If the nutritional status does not
improve soon, the child will be malnourished.
 Advise the mother or caregiver to have the child
examined by a trained health worker
c. Red—the child has this danger sign.
Refer to health center immediately.
8. Role of the VHT
A. Recognize danger signs of malnutrition and refer to health center.
B. Inform households about proper nutrition, especially for those children who are transitioning from
breast milk to regular food. Always encourage a balanced diet including all of the food groups.
C. Assess malnutrition using the MUAC strip
G. BREASTFEEDING
Breast feeding is the process of feeding a baby on the mother’s milk for child survival and
development. Children less than 6 months of age should be exclusively fed on breast milk, because it has the
necessary food nutrients: proteins, carbohydrates and vitamins for healthy growth in those first 6 months of
life.
1. Explain the meaning of exclusive breast feeding
2. Discuss the importance of exclusive breast feeding
3. Explain when a mother should breast feed
4. Explain the process of managing engorged breasts
5. Discuss the issues of breastfeeding for mothers who are HIV+
72
**Possible activity at the end of the lecture: Role Play—VHT providing information and advising a new mother
about the benefits of breast feeding her newborn
1. Definition: Exclusive Breastfeeding
- This is the process of feeding a baby only breast milk (without giving any other food or drink) for the first six
months of the baby’s life
2. Why should a mother breastfeed?

A. Breast milk provides the best food for a baby, and the only food a baby needs for the first 6 months
of life.
B. Breast milk contains all the nutrients needed by the baby
C. These nutrients are easily absorbed from breast milk. It is very gentle and does not irritate a baby’s
sensitive stomach. Other foods like porridge, rice, tea, animal milks, and even formula can hurt a baby’s
digestive system by exposing it to germs and diseases
D. Breast milk provides all the water a baby needs, even in a hot/dry climate
E. It protects the baby against infections and provides extra immunity against childhood killer diseases
F. Breast feeding can help protect the mother from getting pregnant at a rate of 18%
G. Colostrums (the first milk) can help clean the baby’s stomach and have the first stool
H. Breast milk costs nothing, it is always warm and clean
I. Breast milk is important for bonding between a mother and child
J. Breastfeeding immediately after delivery helps keep the newborn warm
K. Hormones released in the mother’s body when breastfeeding can help the uterus return to its
normal size
3. When should a mother breastfeed?
A. Start breastfeeding within 30 minutes to 1 hour after delivery
B. Do not give your baby water. He/she is getting enough fluid from the milk
C. Feeding on demand after birth helps the breast milk to flow easily and can help prevent blocked
breasts, engorgement, and abscesses.
D. Feed the child day and night—at least 10 times within 24 hours
E. The best way to feed a child 0-6 months is to exclusively breast feed. This means that the child will
take only breast milk and no additional food, water, sugar, or herbs. The exceptions are medicines and
vitamins that may be provided by the health center when necessary
F. Breastfeed the child on each breast. Do not wait until one is empty to use the other
73
4. How does a mother know that a baby is getting enough breast milk?
A. If the baby urinates at least 6 times per day
B. The urine should be light in color and not strong smelling
5. How to manage engorged breasts?

- Dip a piece of cloth in warm water. Apply the cloth around the engorged breast. This may help stimulate the
milk to flow normally
6. Information for HIV+ Mothers

Breastfeeding Questions regarding HIV+ Mothers
- This is a difficult situation because one must weigh the risks and benefits of HIV+ mother
breastfeeding their infants. While breast milk can transmit HIV, breastfeeding is important for the overall
growth, providing adequate/cost-effective nutrition. In addition, breast feeding gives the baby an opportunity
to build his/her defense system and form an immediate bond with the mother. There is a significant risk of
HIV transmission, but alternatively, there is a high risk of infant mortality due to malnutrition.
- The World Health Organization released new guidelines in 2010 regarding HIV+, breastfeeding
mothers. It is now recommended that HIV+ women should start ARVs after 14 weeks to prevent transmission
during pregnancy. The ARVs should be continued to decrease the risk of HIV transmission through breast milk.
While on the medications, breastfeeding can then continue for the first year of life—protecting the child from
HIV while providing adequate nutrition.
- The acronym AFASS stands for Affordable, Feasible, Acceptable, Sustainable, and Safe—all of the
requirements stated by the WHO for infants to receive formula feeding as an alternative to breastfeeding.
These requirements are hardly, if ever, met resulting in combination feeding of both breast milk and
formula/other food. This mixing practice is harmful to the infant’s health, decreasing the chance of survival
with an added risk of HIV transmission. Infants who receive mixed feeds are more likely to acquire HIV
infection than those infants exclusively breastfed.
- The other foods are known to disrupt the newborn’s GI tract. This situation along with mixing HIV+
breast milk only increases the risk of HIV transmission. Therefore, it is encouraged to exclusively breastfeed
when formula is not an option.
- When ARVs are not available, mothers who are known to be HIV+ should be counseled to exclusively
breastfeed in the first six months of life and continue breastfeeding thereafter unless circumstances are safe
for replacement feeding. After six months, complementary foods can be introduced and continue
breastfeeding for the first 12 months of life. Breast feeding should stop once a nutritionally adequate and safe
diet without breast milk can be provided
- Mothers known to be HIV+ who decide to stop breastfeeding at any time should stop gradually within
one month. Mothers or infants receiving ARV prophylaxis should continue prophylaxis for one week after
breastfeeding is fully stopped.
- Alternatives to Breastfeeding:
- Less than 6 Months:
1. Commercial Infant Formula
2. Expressed, heat-treated breast milk
**Animal milk is NOT recommended before 6 months
74
- Over 6 Months:
1. Commercial Infant Formula
2. Animal milk (boiled for infants under 12 months)
3. Introduce other foods
- If infants are known to be HIV+, exclusively breastfeed for the first six months and continue
breastfeeding as per the recommendations for the general population—up to 2 years ( C h e t t y , N a i d u , &
Newell, 2010)
Common questions from VHTs about breastfeeding

What about HIV transmission from mother to baby when she has cracked nipples? Can HIV in the blood infect
the baby? Are immunizations needed when a mother is breastfeeding?
- While breast milk provides antibodies to help protect the baby and build the immune system, this
benefit is only present while the child is breastfeeding. This is important in the beginning of life when the
child is most susceptible to disease, and when the child reaches 2 years he/she can start developing his/her
own immune system. Immunizations, on the other hand, can potentially provide life-long immunity for very
dangerous diseases (e.g. polio). Together, breastfeeding and immunizations help protect the child.
Breastfeeding, however, is more of a short-term process and is not specific for the diseases that have a long
history of morbidity and mortality.
75
II. LUNG INFECTIONS
This section of lung infections was modified to include two major topics: Pneumonia and Tuberculosis.
Also added to this section is Drug Resistance. The Drug Resistance topic can also fit with the basic discussion
about germs and fever. However, it also fits with the growing concern of resistance among Tuberculosis
strains. Either way, these three topics can be presented together in a very cohesive format.
A. PNEUMONIA
Pneumonia is an infection of the lung caused by germs including viruses, bacteria, and fungi. This
infection is very serious and is a “Top 5 Cause of Death” in Africa. According to the World Health Organization,
an estimated 1.6 million children die from pneumonia every year—more than AIDS, malaria, and tuberculosis
combined (“Pneumonia”, 2010).
1. Define Pneumonia
2. Why is it important to study Pneumonia?
3. What are the signs and symptoms of Pneumonia?
4. How is Pneumonia transmitted?
5. What is the treatment?
6. What is the role of the VHT?
1. Definition
Pneumonia is any infection of the lungs. This infection is caused by many different types of germs
including bacteria, viruses, and fungi.
2. Importance of Pneumonia
Pneumonia remains a common cause of death, especially to children under 5 years. This is often the case,
because children who are sick are treated for malaria without proper testing or assessment of the other
symptoms. The child has a fever, and people too often assume the diagnosis is malaria. Malaria medications
do not kill the germs that cause pneumonia, so the infection can become worse and result in death.
3. Signs and Symptoms:

The signs and symptoms of pneumonia include the following:
 Cough
 Chest Pain
 Difficulty Breathing
 Fever
 Weight loss
76
It is important to recognize the combination of symptoms related to pneumonia. Fever alone rarely
occurs, so it is crucial to understand the other symptoms involved to help distinguish the infection.
Difficulty breathing may be difficult to assess. Young children, particularly babies, normally breathe more
quickly than adults. However, when a child or adult cannot seem to catch his/her breath like they have just
finished a race or when a person is struggling with each breath, forcing air in and out, there may be difficulty
breathing. Also, if an adult is struggling to speak because they are concentrating on breathing, this is also a
very helpful clue. Chest-Indrawing is a sign that can be seen with young children with difficulty breathing. The
top part of the stomach seems to sink in under the rips with each exhalation to help force air out.
4. How is Pneumonia spread?

- The germs that cause pneumonia are spread through the air. When a healthy person breathes in the germs,
they can then cause an infection in the lungs.
5. Treatment:
Medicines must be used to kill the germs causing the infection. The medicine used to kill germs is called
Antibiotics. When someone is sick with pneumonia, tests can be done at the health center to know which
germs are responsible. Then, the appropriate treatment can be given.
6. Role of the VHT:

A. Recognize symptoms and refer to the health center accordingly
B. Inform households about the importance of understanding that not all sickness is malaria and it
should be treated appropriately
C. Encourage the full course of antibiotics
D. Follow-up with patients who are seen at the Health Center
E. Check for signs/symptoms of other household members at high risk
7. Why take the full dose of medications?

- Some people feel better after just a few days of taking antibiotics
- Some people want to save medicine for the next time they are sick
- Without a full dose of antibiotics:
 The person can become sick again
 The infection can be worse
 Medicines may not work as well the next time
B. TUBERCULOSIS
Tuberculosis (TB) is a disease caused by a germ. TB causes very serious side effects including a chronic
cough and weight loss. In Uganda, TB is one of the common killer diseases among adults. Although for a
number of years TB treatment had reduced TB cases considerably, today the HIV/AIDS epidemic has had a
direct relationship with an increase in TB cases. TB affects both children and adults and is highly contagious
unless new behaviors are practiced in a household with a TB patient.
77
Learning Objectives
1. Describe Tuberculosis
2. Discuss the signs of TB
3. Describe how TB can be transmitted from one person to another
4. List the effects of TB
5. Explain how TB can be prevented and controlled
6. Explain the importance of early diagnosis of TB
7. Explain the process of managing a TB patient
*Activity Idea: Role Play—Household member talking about symptoms related to TB to a VHT member who is
responsible for providing advice about referral, treatment, and why the regimen is important to complete.
FACILITATOR’S NOTES
1. Definition: Tuberculosis
Tuberculosis (TB) is a disease caused by a germ. This germ is a type of bacteria whose scientific name is
Mycobacterium tuberculosis. This germ causes a wide spectrum of symptoms including chronic cough and
weight loss. TB is also one of the principal causes of early death for people living with HIV and AIDS.
2. Who is at risk of TB infection?

- Anyone can be infected with Tuberculosis, however certain groups are more susceptible.
- People with poor immune systems:
- Children
- HIV+
- Elderly
- People in close contacts with those infected with TB, especially family members living in the same house
3. How does TB Spread?

- The bacteria can only spread from person to person through the air.
- When a person has active infection in the lungs and coughs  the bacteria can travel through the air  a
person in close contact can breathe in the germ which could then potentially cause an infection.
- A person cannot become infected with TB by sharing a cup, shaking hands, or sharing food. However, this
germ is very contagious and those people who are in close contact are more likely to breathe in the germs
from an infected person. The people most at risk are family members living in the same house.
4. Latent vs. Active Disease
A. Latent:
A normal, healthy adult may not get very sick if they breathe in the TB germs. When the germ is inside
the lungs of a health person, he/she has a strong defense system to build a wall around the bacteria and
prevent it from harming the rest of the body. The germs are then contained in that small space inside the
lungs without any source of escape as long as the immune system is strong. This state is considered “Latent”
because while the germs are present, they are not doing any kind of harm. People live normal lives without
even knowing the germ is present as long as they remain healthy.
78
B. Active:
When someone becomes very sick or has a weak immune system (children, HIV+, elderly), the body cannot
keep up the walls around the bacteria. The germs are then free to cause infection—in the lungs and
elsewhere throughout the body. When the germs are free, this is called “Active” Tuberculosis. This can occur
when someone breathes in TB germs with a poor immune system. This can also occur in someone who was
previously healthy and unaffected by TB but some circumstance has made him/her have a poor immune
system—then the bacteria can become free and cause harm.
5. Signs and Symptoms of TB

The symptoms are related to the location of the infection. Because TB starts in the lungs, the symptoms
are most often seen here.
- Persistent cough: over one month, with blood in the sputum
- Fever
- Excessive sweating at night
- Chest Pain
- Difficulty breathing
- Weight loss
- Poor appetite
If left untreated, TB can spread to other parts of the body resulting in a wide variety of symptoms
- Pain in the back, arms, legs
- Diarrhea
- Severe Constipation
- Abdominal Pain
6. Treatment
- It is important to know that TB is a curable disease when recognized and treated early
- There is a specific combination of antibiotics that are taken every day for about 6-8 months
It is important to stress the importance of taking the full course.

- Incomplete treatment can result in the germ spreading to other parts of the body or developing drug
resistance
DOTS: Directly Observed Treatment System

- People who are infected with TB and undergoing treatment must report to health professionals for their
refills.
- This system was created to ensure patients improvement/care and prevent drug resistance that may occur
with incomplete treatment
- The health center will determine when follow-up visits are necessary. At first a patient may return to the
health center once a week to once every 2 weeks until they prove compliance. Then, they may return for
refills every month. If a patient fails to return to the health center, a nurse will contact him/her and visit
him/her at home.
7. Effects of Tuberculosis
- Has potential to spread throughout the body
- Long course of sickness—out of school/work/community activities
- Spreads easily especially among family members—very contagious and difficult to control
79
8. Prevention
- BCG vaccine at birth—This is not a perfect solution for TB. However, the BCG vaccine does help protect
young children from developing the illness. People are still at risk of Tuberculosis later in life.
- Early recognition and treatment
- Complete treatment
- Evaluate family members (Elderly, young children, people who have chronic illnesses)
- Cover mouth when coughing (help prevent spread of germs through the air)
9. Role of the VHT

A. Frequent visits to households with TB
B. Record members of household with TB infection
C. Encourage full course of medicine and explain why it is important
D. Review immunization cards and encourage BCG vaccination at birth
E. Encourage good nutrition—including all food groups
F. Inform the community
- TB is a curable disease when it is recognized and treated early
- Stop the discrimination
10. Discrimination
- Someone who has TB is also assumed to have HIV
- However, this is not always the case. Those people with HIV are just more likely to also contract TB because
their immunity is very poor
- People with TB are often shunned from their communities and treated differently
- People who are on the appropriately treatment should not be isolated because they are no longer infectious
- A VHT has the power to inform the community in order to stop the discrimination
11. TB of the GI System

- Mycobacterium bovis—another type of germ that is related to the Mycobacterium tuberculosis
- This germ is commonly found in un-boiled/unpasteurized cow’s milk
- Causes a severe stomach infection resulting in diarrhea, fever, stomach pain, and even death if not
recognized and treated early
- The signs/symptoms are often confused with other stomach infections, so people often suffer a great deal
before treatment is given
- The most important way of preventing this infection is to always boil cow’s milk prior to drinking
80
C. DRUG RESISTANCE
**Illustrations can help describe this process. Using a picture that shows how all of the germs are killed
after taking the full dose of antibiotics. Then use a second picture to show that some germs remain if a
person only takes a partial dose. Explain and illustrate how these germs that remain can change and
become stronger against medicines. There is no need to explain the details, but an overall understanding is
important.
- When someone takes the full dose, all of the germs are killed and the person is healthy again
- When some takes part of a dose, some germs remain and those few can change and become stronger
person gets sick again
 infection is worse
 Medicine may not work as well = Drug Resistance
- Drug resistance does not just develop in pneumonia, but it can occur in any infection treated with antibiotics
- This is very dangerous, because new drugs need to be developed in order to fight these stronger germs. It is
a long process to develop new drugs, leaving these people sick for a longer time, increased number of deaths,
and disease spread
Analogy of Drug Resistance:

You wash your clothes with Omo, and one of your white shirts is very dirty from the dust. Instead of
letting the shirt soak and then scrub to make sure it is perfectly clean, you carelessly wash and let it dry. You
wear the white shirt (that is now a light brown) and it gets very dirty again. Because it was not cleaned
properly the first time, no amount of Omo can get the stains out now. It’s like the dirt is resistant to Omo.
Recognizing Danger Signs

The lists of danger signs are a good summary following each section of health topics. This section
describes the importance of referral, the meaning of a danger sign, and specific signs that should be
recognized followed by referral to the health center.
What activities will you carry out to help save lives?

1. Help people recognize danger signs
2. Refer individuals with danger signs to health services
3. Help ensure that all children are immunized
4. Encourage pregnant woman to go for ANC visits and have timely post-partum checks
5. Encourage families to ensure that a newborn gets essential newborn care
6. Give/Advise people on simple first aid for minor injuries and illness
Activity 1: Help People Recognize Danger Signs

What is a Danger Sign?
- A danger sign shows that a person, usually a child or a pregnant woman, is too ill for you and the
family to treat in the village. To help the person survive, you must URGENTLY refer him or her to the health
facility
81
What are the danger signs of a child?
Danger Sign of the Child Danger sign description
1. Cough A child who has had cough for 14 days or more
2. Diarrhea A child who has diarrhea for 7 days or more
3. Blood in stool Diarrhea with blood in the stool, with or without mucus, is
dysentery
4. Fever A child who has fever for 7 days or more. The fever does not
have to show every day, all the time.
5. Convulsions A child who has had a convulsion during his or her current
illness
6. Unable to Eat or Drink A child is not interested/refuses to eat or drink because feeling
sick
7. Vomiting A child who vomits everything he/she eats or drinks
8. Chest Indrawing Chest indrawing is the sucking in of the stomach when
breathing
9. Very sleepy, or A child who is very sleepy is not alert and falls back to sleep
Unconscious after moving. An unconscious child cannot awaken.
10. Too Thin Red on If you use a MUAC strip to measure a child’s upper arm
MUAC Strip (midway between the shoulder and the elbow), and the MUAC
strip reveals the red color, the child has a danger sign.
82
III. Sexual and Reproductive
This section contains three important topics: Family Planning, Antenatal Care, and Postnatal Care.
Together, these three lectures provide important information on how to promote manageable families and
proper care at health facilities during pregnancy and delivery. While these lectures mainly focus on the
woman and child’s health, the VHTs must understand that while visiting households they may often speak to
the husbands/fathers. This information must be shared, because the whole family is involved in making
decisions about Family Planning, encouraging visits to the Antenatal Clinic, and preparing for a safe delivery at
the health center.
A. Family Planning
Family Planning is the practice of spacing child birth using both natural and modern birth control
methods. Birth spacing promotes the health of the mother, children, and the family as a whole. This topic is
particularly important in Uganda, because this country h as the third highest birth rate in the world. By
understanding the different methods of birth control, the availability at health centers, and the benefits of
birth spacing, VHTs can promote changes within their communities that could potentially lead to manageable
households and a more secure population.
1. Define family planning
2. Explain the benefits
3. Explain the different methods
4. List the common myths and misconceptions
5. Role of the VHT
1. Family Planning
Family Planning is the practice of spacing children that are born using both natural and modern birth control
methods. Birth spacing promotes the health of the mother, children, and the whole family.
2. Benefits of Family Planning

A. Mother
1. Frequent/consecutive pregnancies can have serious side effects to a woman’s body/health
2. It is difficult to breastfeed more than one baby under 2 years of age, which can lead to
severe malnutrition
3. Having many children can be very difficult to manage, especially for the mother who is at
home trying to care for them while completing daily tasks. This could lead to unnecessary responsibilities for
the older children and neglect of those children who may need additional care.
83
B. The Children
1. The children do not receive adequate attention from their parents
2. Basic necessities may be lacking—food, shelter, school fees
3. Children are often responsible for caring for one another. For example, the oldest child may
have to stop school to start earning money for the other children’s school fees because the parents are unable
to provide alone.
C. The Family
1. The stress of having many children can put a strain on the relationship between the mother
and father, which brings even more hardships to the family.
2. The parents have to work even more to ensure their children’s basic needs are provided—
clothes, food, shelter, school fees. This is very difficult in a world where well-paying jobs are scarce and in
rural communities that rely on farming and fluctuating market prices.
C. Government
1. Resources are limited in Uganda, but the rapidly increasing population continues to put a
strain on availability—quality schools, jobs, assistance programs, quality health care
3. Modern (Artificial) Family Planning Methods

A. Short-term
1. Pills: Combined or Progesterone-only
2. Injectable contraceptives
3. Condoms
4. Norplant
5. Intrauterine Device (IUD)
B. Long-term
1. Female sterilization: Tubal Ligation
2. Male sterilization: Vasectomy
C. Emergency
- This method uses the synthetic hormone, Levonorgestrel, to prevent pregnancy in an
emergency. Times where this form of contraception is warranted include: recent unprotected intercourse,
inadequate condom use during sex, missed contraceptive pills/injections. This form may only used within 2-3
days of the occurrence to prevent pregnancy. This is not a form of birth control that should be used
consistently.
4. Natural Family Planning Methods

- Abstinence
- Calendar Methods—Body Temperature, Cervical Mucus
- Withdrawal
- Breast Feeding—when exclusively breastfeeding, not yet having periods, baby is less than 6 months
84
- Success depends on:
- a woman having regular menstrual periods
- the couple needs training on how to use these methods properly
- cooperation between the couple
- not appropriate for couples who consume alcohol
5. Artificial Family Planning Methods

 Contraceptive Pills
A. Contain hormones that prevent ovulation—the egg is not released from the ovary, so fertilization is
not possible
B. May also help women with problems including heavy menstrual bleeding and painful periods
C. Pills are started on the first day of the woman’s period. They must be taken everyday at the same
time of day for them to be effective. If a pill is forgotten, it must be taken immediately.
D. A woman is able to get pregnant soon after stopping the pills
E. Safe for most women—should not be used in women over 35 years, smokers, or have other health
problems—hypertension, diabetes
F. Side Effects: nausea, spotting, mild headaches, weight gain. These side effects usually improve in
the first few months.
G. Inconsistency with taking the pills along with unprotected sex can results in pregnancy. If a woman
has difficulty taking the pills regularly and continues to miss, it may be necessary to advise a different family
planning method.
 Condoms
A. Prevent sperm from entering a woman’s uterus by trapping the fluids inside
B. Prevents pregnancy and protects against STDs including HIV/AIDS
C. For highest efficacy, they must be used correctly and consistently
D. A new condom must be used for each time having sex
E. Safe, no side effects
 Injections
A. Two methods of injectable family planning in Uganda: Depoprovera and Injectaplan
B. Given every 3 months—convenient and effective
C. Side Effects: missed periods, irregular bleeding, nausea, headache, dizziness
- Symptoms usually resolve after a few months
- Women should be seen by a health care professional if symptoms persist
 Implants
A. Capsules that release continuous hormones, placed under the skin of the upper arm
B. Can last up to five years but can be removed earlier if the woman desires fertility
C. Insertion and Removal by health care worker
D. Fertility returns after removal
85
 IUD (coil)
A. A small device that releases continuous hormones is inserted into a woman’s uterus
B. Can prevent pregnancy for up to 10 years
C. Can be inserted at anytime except during pregnancy
D. The device can be removed at any time when fertility is desired
E. Insertion and Removal by a health care worker
6. Long Term Methods

 Tubal Ligation
- Used when a woman has decided not to have any more children
- Performed by a trained health worker
- Small operation that involves cutting the fallopian tubes to disconnect the ovary and uterus
- The woman continues to have periods and sex normally
- Does not cause changes in body weight nor does it reduce the urge for sex
 Vasectomy
- Used by a man who has decided not to have any more children
- Performed by a trained health worker
- Simple operation to cut the tube carrying sperm from the testicles
- Pain medicine is given via injection
- The man can return home after the operation
- The testicles are unaffected, the man can continue normal sexual behavior
7. Emergency Contraception Pills

- If a woman has unprotected sex and does not want to become pregnant, she should use emergency
contraceptives as soon as possible (within 3 days for best results).The pills do not harm or stop an established
pregnancy. This should not be used as a regular method of family planning
- No protection against sexually transmitted diseases or HIV/AIDS
- Does not offer long term protection against pregnancy
8. Myths about Family Planning

1. Infertility after using the Family Planning methods
2. Delivering deformed babies
3. Excessive fattening or slimming once on the F/P methods
4. Weakened sexually for men who have had vasectomy
5. Reduced vaginal fluids for women
6. Pale skin
7. Extra bleeding during menstrual period
86
9. Role of the VHT
1. Provide households information regarding Family Planning—the methods/services provided at the
health center, the benefits of birth spacing, and correct the possible myths
2. Volunteer at the health center to teach about Family Planning benefits and methods
B. ANTENATAL CARE
Antenatal care is health care given to a mother, father, and the unborn baby during pregnancy.
Antenatal healthcare will promote and maintain physical, mental, and social health for the whole family. This
also prepares the mother for successful delivery and breastfeeding. Antenatal care goes beyond visiting the
clinic. It is a family, community, and social concern.
Many people consider pregnancy as an issue that must be handled by the woman alone. However,
pregnancy involves the entire family. Men often think it is a woman’s responsibility to know everything about
pregnancy. However, as fathers and now VHTs, it is also your responsibility to learn these important points to
better take care of your communities.
- The maternal mortality ratio is about 435 deaths per 100,000 live births (“Getting it right”, 2008). By
encouraging regular antenatal visits and safe deliveries in health centers, the goal is to significantly reduce this
statistic.
Activity: Divide the training group into small groups. Keep group sizes less than ten VHTs. Make one group
completely men. Provide paper and markers to answer the following questions:
1. Why is antenatal care important?
2. What services are provided at the clinic?
3. What is the minimum number of clinic visits?
4. Danger Signs in pregnancy?
5. What materials should be included in the “Mama kit”?
Give about 20 minutes to answer these questions. During the lecture, allow each group to contribute their
answers.
1. Describe the importance of antenatal care
2. Discuss the danger signs during pregnancy
3. Outline the services given at the antenatal clinic
4. Identify the number of times a pregnant mother should visit an antenatal clinic
5. Describe the roles played by male partners during the antenatal care period
1. Definition of Antenatal Care
- The service given to a mother and her partner during pregnancy. It is important that a woman starts
her antenatal visits after she has missed two menstrual periods
87
- Every pregnancy is different, and so antenatal care is necessary for each pregnancy no matter how
many children the woman has. Whether this is the first or tenth pregnancy, antenatal care is important for
each one
2. Importance of Antenatal Care

A. Prepare the mother for safe childbirth and successful breastfeeding
B. To help the mother experience a normal pregnancy/delivery
C. To monitor growth of the unborn baby
D. Promote and maintain physical, mental, and social help for the mother and family
E. To detect and treat pre-existing conditions or complications that may arise
3. Services offered at the Clinic

 HIV counseling and testing
- Each pregnant woman will be tested for HIV at her first Antenatal Clinic visit. This process
requires a small blood sample which involves a needle stick. HIV testing is confidential, and the woman will be
able to return with other HIV+ mothers to receive advice, further testing, and HIV treatment that will decrease
the risk of transmission to the baby. This treatment is called PMTCT—“Prevention of Mother to Child
Transmission of HIV”. Treatment during pregnancy can decrease the risk of transmission from 25% to 2%.
- Many women fear going to the Antenatal Clinic, because they do not want to be tested for
HIV. However, it is important to encourage these visits, because steps can be taken to decrease the risk of the
child. As covered during the HIV/AIDS lecture, it is more important to know one’s status to take the necessary
intervention than to live in denial or fear.
 Immunization against tetanus
 Syphilis screening and treatment
 Urine testing for sugar and protein
 Early detection and management or referral of high risk pregnancies
- “High Risk” does not necessarily mean there is a problem with the pregnancy. It is important
to understand that this only means special care must be taken to ensure a safe outcome. Only through
antenatal visits will the woman know to take the special precautions necessary.
 Prevention of malaria
- IPT (Intermittent Preventive Treatment): Each pregnant woman should receive at least 2
rounds of effective anti-malarial drugs at curative doses. Fansidar is often given regularly at antenatal clinic
visits
 Iron and Folate supplements and management of anemia
- Iron and Folate are important for the baby’s development. Anemia—which is often related to
low iron during pregnancy—is very common and can have very serious side effects on the baby. Replacing the
iron can prevent the anemia. Folate is needed for proper brain and spinal cord development.
88
 De-worming
- Pregnant women regularly receive Albendazole at the ANC visits. Women who are infected
with worms during pregnancy may have difficulty getting all of the proper nutrition. Therefore, the baby may
suffer from the malnutrition of the mother. To prevent this from happening, all women receive Albendazole
to treat the worms.
 Information on risk factors, danger signs, and birth preparedness
- The important danger signs to remember will be covered later in this lecture
 Information on Family Planning
4. Where should you advise a woman to give birth?

A. It is best for a woman to give birth in a health facility because there she will be attended by a
trained health provider which is safer in case there is any problem. A trained health provider who attends a
birth gives the mother care after delivery and gives the baby essential newborn care.
B. If the birth takes place in the home, and a trained provider is not in attendance, someone who
attends the birth should carry out the essential steps of newborn care which will be discussed later.
5. Danger Signs during Pregnancy

There are 9 danger signs in pregnancy that should be recognized and referred to the health center
immediately. These include:
1.
Vaginal Bleeding
2.
Fever
3.
Persistent, severe headaches
4.
Baby has stopped moving
5.
Too weak to get out of bed
6.
Severe abdominal pain
7.
Swelling of fingers, face, legs
- Swollen feet and ankles are very common in pregnancy. However, this generalized swelling is
a danger sign and should be referred to the health center.
8. Water has broken before the expected time
9. Convulsions/seizures
89
6. Mama Kit
These are the materials required at the health center for delivery. These items should be gathered in
advance. Waiting to the time of delivery will be more difficult to find the supplies and having enough money
to buy them. It is best to be prepared.
When discussing this section while using the activity as described above, some VHTs may list items such as:
clothes for the baby, wash basin, transport, money, food, etc. These things all have their purpose at the
time of delivery, but they are no specific to the “Mama Kit” which are the minimum materials required by
the Health center and used during the delivery.
1. Two new razor blades
2. Two pairs of gloves
3. Two and a half meters of plastic sheeting
4. Soap
5. Clean cord/thread
6. Clean pads/cotton for the mother
7. Minimum number of visits to the ANC clinic

- The minimum number of visits is 4. The first visit should be after 2 missed periods. To complete four visits,
she should return every 2 months thereafter.
An illustration makes it easier to understand a rough schedule of when the woman should attend the visits.
Explain that the woman will receive a date for her next appointment by the health care worker. These dates
are specific to the days of antenatal care at the health facility and to the regular intervals needed to be kept
by the woman.
?
1 2 3 4 5 6 7 8 9
8. Role of the Father

- The major role of the father during pregnancy is to be supportive. This role includes helping with house
work, providing adequate food, being faithful to prevent infection, and avoiding quarrels.
- Domestic violence is very common during pregnancy because it brings a lot of stress to the couple and the
family as a whole. Any violence in the home is wrong, no matter what the issue may be. However, violence
during pregnancy is even greater putting both the mother and baby at serious risk.
- Show support by attending antenatal visits
- Save and ensure money for the Mama Kit and for possible emergencies during pregnancy and labor
- Keep yourself available to provide assistance in case of emergency and especially at the time of delivery
90
9. Role of the VHT
- Know the danger signs of pregnancy and make referrals to the health center
- Encourage Antenatal Clinic Visits
- Teach the importance of antenatal care
- Discuss these issues with both the mother and father. Reinforce the role of the father as a supportive
figure in the family—helping with daily tasks, being faithful, saving money, being present
- Volunteer at the health center to provide assistance on antenatal clinic days
10. How to Encourage ANC Visits

A. When you hear or notice that a woman is pregnant, ask her family whether you can go talk with
them about some of the ways to ensure that she will have a healthy pregnancy and a successful birth
B. Share with them the information above about the services she will receive
C. If possible, share success stories about other pregnant women in the village who have gone for
timely ANC visits and have had healthy pregnancies and successful births
Common Questions from VHTs

 Why is it that some women who attend the antenatal clinic have abnormal babies and women who do not
attend have normal babies?
Answer questions like these very carefully, because the goal of this lecture is to encourage regular
antenatal visits and deliveries at the health centers. Explain that the purpose of antenatal visits are to
detect any problems during pregnancy. Only when these problems are detected early can appropriate
steps be taken to help ensure a safe delivery. However, some problems cannot be detected, and it is
true that mothers who attend the ANC visits have abnormal babies. However, some of the same
problems would have resulted in miscarriage instead if left unattended.
 Why are some babies born lame?

There is no perfect or simple explanation for this question or any question asked about why babies are
born with an abnormality (lameness is usually most common). It is easy to get lost in the details of fetal
development, but the details are not necessary. It is best to explain how there are millions upon
millions of interactions that take place for fetal development. There are specific signals that
orchestrate this very tedious process. When the interactions and signals are missed or incorrect, this
can result in abnormalities. A baby who is lame could have had problems in the signals for muscle,
bone, or neurological development.
 Why are only syphilis and HIV tested during antenatal clinic visits?
These specific diseases are tested during pregnancy for many reasons. But ultimately, they are
common and severe enough to justify frequent testing. If positive, appropriate steps can be taken to
treat/prevent transmission or adverse results. Also, these tests with their results are readily available
and at low cost. Together, these reasons make testing both cost-effective, efficient, and worthwhile.
91
C. POSTNATAL CARE
This is care given to the mother and the baby after delivery. This is a very important time for the
mother who has just delivered and for her baby.
As mentioned before, Maternal Mortality is estimated at 435 deaths per 100,000 live births. In
addition Infant Mortality is estimated at 137 deaths per 100,000 live births (“Getting it right,” 2008).
1. Discuss the importance of care after delivery
2. Discuss how to care for the newborn baby
3. Discuss how to care for the mother after delivery
4. Discuss the danger signs for mother and baby after delivery
5. List the services given to the mother and the baby during the postnatal clinic
6. Discuss the role of the VHT in postnatal care and follow up
1. Definition: Postnatal Care
- Postnatal care is the service provided to a woman and her newborn baby following delivery.
2. Importance of Postnatal Care

A. Most problems occur within 24-48 hours after delivery—infection, bleeding, death
B. Women and their babies can die because of problems during and after delivery
3. Danger Signs of the Baby

A. Difficulty breathing
- Babies normally breathe more quickly than adults. You can see if the baby is having difficulty
breathing when the muscles around the stomach sink in or when the breathing is very slow
B. Convulsions/seizures
C. Failure to breastfeed
- Babies may have a difficult time latching to the breast immediately after delivery. However,
the baby should eventually start feeding. It is also a danger sign if a baby who was breastfeeding normally
suddenly refuses or does not seem awake or interested enough to feed normally.
D. Bleeding or pus from the cord
E. Fever
F. Baby is vomiting everything
G. Baby does not cry or the cry is very weak
H. No activity, lifeless, cannot wake up
92
4. Danger Signs of the Mother
A. Heavy bleeding
- This is considered more than 2-3 pads in 15 minutes.
- Remember that vaginal bleeding after delivery is normal. The uterus is contracting down and
getting rid of the all the contents inside. After delivery, the bleeding should gradually become less and less. If
bleeding is excessive or does not seem to be slowing down, the woman should be referred to the health
center immediately.
B. Fits/Convulsions
C. Fever
D. Difficulty breathing
E. Severe abdominal pain
F. Excessive weakness
G. Severe Headache/Dizziness
H. Swollen feet, hands, face
5. Newborn Care
What advice can you give about the care of a newborn after birth?
- Tell the woman and her family that as soon as the cord has been cut, the person responsible for taking care
of the newborn must do the following steps:
1. Dry the baby
2. Wrap the baby in warm, dry clothes
3. Place the baby to breastfeed. When the baby sucks, it is alike a message to the mother’s body to
begin giving milk. The first milk given by the breasts is especially good for the newborn baby—it provides
nutrients and helps clean the stomach, producing the first black stool. Immediate breastfeeding also helps to
release hormones within the woman to help the uterus contract down to its normal size.
4. Check the baby for danger signs at least once per hour for the first 6 hours—During those first
hours, the baby is very vulnerable. Recognizing danger signs quickly can allow you to get help for the newborn
in a timely fashion.
6. Postnatal Clinic Services

A. Examine the mother and baby
B. Monitor bleeding, ensure that the uterus is contracting back down to normal size
C. Pain medicine
D. Vitamin A supplementation
E. Information: Family Planning, Nutrition, Breastfeeding
F. Prevent/Recognize/Treat Disease
G. Give advice on when to resume sexual intercourse
H. for the Baby:
1. ART drugs for HIV + Mom’s babies
2. Immunizations and Vitamin A
3. Growth monitoring
93
7. Minimum # of Visits = 3
A. Delivery
- at the health center or within 24 hours of delivery at home
- If the woman delivers at the health center, the first postpartum check will be carried out
before she leaves the unit. She should return to the health center for the other two visits
- The baby receives the first immunizations at this first visit
B. Before 6 days have passed
C. 6 weeks after birth
- second set of immunizations for the baby
- without any complications/problems, it is considered safe to resume sexual activity after 6
weeks. However, it is ultimately the woman’s decision when she is ready.
Be sure to stress that it is the woman’s decision when to resume sexual activity. It should be no earlier than
6 weeks after a normal vaginal delivery. However, some women argue that it should be much longer than 6
weeks. To prevent conflicting ideas, reinforce the fact that 6 weeks is only a guideline.
8. Role of the VHT

A. Follow-up visits after delivery
B. Recognize danger signs and refer to health center
C. Encourage the father to continue supporting his wife while recovering
D. Encourage the woman to attend the postnatal clinic for the minimum 3 visits
9. How to Encourage Postpartum Visits

- During every conversation you have with the pregnant woman and her family, you should mention
the need for her to go for timely postpartum checks
- Share success stories about other pregnant women in the village who have gone for timely
postpartum checks and have had positive experiences
10. Important Notes for Postpartum Home Visits:
A. Why should you visit a newborn and his/her mother?
– You should visit a newborn and his/her mother so that you can find out how they are doing,
provide advice about their care, and if they have any danger signs, refer them to the health unit for care.
B. What steps will you carry out when you visit?
1. Find out the condition of the newborn and the mother
2. Advise the mother and family on healthy newborn and maternal practices
3. Refer the newborn and the mother as needed
94
Step 1: Find out the condition of the newborn and mother
- During home visits it will be important to get a sense of the overall condition of the mother and newborn.
Ask the mother how she is feeling and how she thinks the baby is doing. Ask if she has any concerns about
herself and the baby. It will also be important to ask family members if they have any questions or concerns.
Some women may feel ashamed or embarrassed to ask questions or even talk about a problem she might
have. This may be a difficult conversation, but it is important to get a good sense of their health after delivery.
Step 2: Advise the mother and family on healthy newborn and maternal practices
1. Mother should exclusively breastfeed the baby
- give breast milk alone without giving any other food or water
- breastfeed on demand—whenever the baby seems hungry
- breastfeed at least 8 times a day for the first 6 months
2. Mother should keep direct contact with the baby
3. Mother and family should keep the baby warm
- no one should be in a hurry to wash the baby
- when bathing, use warm water and dry completely right after
4. Clean the cord with warm, clean water and leave the cord dry and exposed
**Do not apply anything to the cord
5. Mother should take the baby for immunizations according to the schedule
6. Every person who touches the baby should carry out hygienic practices:
- wash hands with soap and water before touching the baby
- wash hands with soap and water after visiting the latrine
Step 3: Refer the Newborn and Mother as Needed

- Review the danger signs discussed during this lecture. When these danger signs are witnessed or mentioned
during home visits, these should be referred to the health center immediately.
11. When the Baby is HIV Exposed

- If the baby is HIV exposed, advise the mother and family members to go to the nearest health facility
- The baby will be given medicine and the mother advised on how to keep herself and the baby healthy and
well
95
D. Sexually Transmitted Diseases
In the past two decades, communities have realized the dangers of Sexually Transmitted Diseases
(STDs). This has been brought about by the degree of suffering and deaths they have caused in almost every
household through HIV/AIDS. STDs are diseases that can be passed from one person to another during sexual
intercourse. They are mostly found in adults who have multiple sexual partners. Examples of STDs include:
HIV/AIDS, Syphilis, Gonorrhea, Chlamydia, and others. The effects may vary from simple itching, swelling of
the testicles, and sores to impotence, infertility, discharge, chronic abdominal pain, and death.
The seriousness of STDs is exhibited by the fact that in Uganda, STDs rank among the top five diseases
for which adults seek heath care services.
1. Explain the meaning of Sexually Transmitted Diseases (STDs)
2. List common signs and symptoms of STDs
3. Describe how STDs can be spread
4. Explain how STDs can be prevented
5. Explain the treatment for STDs
6. Identify the different types of STDs
7. Explain the relationship between STDs and HIV/AIDS
1. Definition of STDs
Sexually Transmitted Diseases (STDs) are diseases that are contracted through sexual intercourse with an
infected person. They may be passed on by mothers/fathers to unborn babies. They often attack sexual
organs but can potentially spread to other parts of the body. The most common STDs in Uganda are
Gonorrhea and Syphilis. STDs are common in sexually active persons between the ages 15-45. HIV/AIDs is
another common STD which causes suffering and death in both adults and children. STDs are a cause of
serious complications leading to:
- High incidences of infertility in both men and women
- Ectopic Pregnancy
- Cervical Cancer
- Low birth weight
- Chronic Pain
- Developmental abnormalities in the newborn
- Death
2. STD Transmission
A. The most common method of transmission is through unprotected sexual intercourse
B. Blood transmission and blood products
C. Infected mother to baby via placenta, at time of delivery, or breastfeeding
D. Sharing sharp objects such as needles and knives
96
3. Types of STDs
- Chlamydia - Hepatitis B and C
- Gonorrhea - Genital Herpes
- Syphilis - Genital Warts (HPV)
- HIV/AIDS - Pubic Lice
- Trichomoniasis - Candidiasis
4. Common Signs and Symptoms

- Watery or thick discharge from the penis/vagina
- Open sores around or on genitalia
- Pain/itching/burning sensation when urinating
- Lower abdominal pain
- Pain and swelling of the testicles
- Itching around genital area
- Infant eye infection within one month of birth
- Rapid weight and high susceptibility to other illnesses (HIV/AIDS)
5. Treatment
- Evaluation from a health care professional is important for proper testing, diagnosis, and treatment
- Most of these infections require antibiotics to kill the germs
- However, some of these infections are lifelong and without cure
1. Genital Herpes
- a virus that causes open, painful sores in the genital area
- lesions may come and go
- virus remains and spreads to sexual partners
2. Genital Warts (Human Papilloma Virus)
- a virus that cause raised lesions, “warts” in the genital area
- women are at increased risk of cervical cancer
- men often don’t have symptoms but still transmit virus
3. HIV/AIDS
- there is currently no cure for HIV/AIDS
- antibiotics are available to help lead a healthy life
- further discussion on HIV/AIDS in another lecture
6. Prevention:
- ABC campaign used to prevent the spread of HIV/AIDS can also apply to other STDs
- A: Abstinence, B: Be Faithful, C: Use Condoms
- The underlying idea to this campaign is to target people with profiles at highest risk of contracting an
STD. The people most at risk are those who have unprotected sex with multiple partners.
97
- However, it is important to remember that a person can contract an STD at any time while sexually
active. The exception is someone in a committed/faithful relationship where both partners are tested
negative.
- Proper condom use has been proven to decrease STD prevalence. However, condoms are not a
perfect solution—Condoms can potentially break, slip off during sex, or easily forgotten (especially under the
influence of alcohol/drugs).
- Some STDs can spread through skin contact before the condom is used. These infections include
genital herpes and warts.
- Although condoms are taught to prevent the spread of STDs, it is still important to be informed about
the risks involved. It is best to always know your partner’s status—be faithful to one another, get tested for
STDs together.
- If you or someone you know has a history of STDs, prompt and complete treatment is crucial.
Informing sexual partners about these infections is also an important step to preventing the spread.
7. What causes the failure to control STDs?

A. Self-treatment with small doses or with the wrong drugs
B. Late reporting/delay in seeking health services
C. Failure to inform partners
8. Relationship between HIV/AIDS and STDs

A. HIV is a virus (Human Immunodeficiency Virus) that causes the disease that is transmitted via sexual
intercourse, blood transfusion, blood products, and from an infected mother to child.
B. Many of the measures for preventing sexual transmission of HIV and STDs are the same and also
address the same audience
C. Patients with a history of STDs also fit the profile of a people who can potentially contract HIV. The
history of unprotected sex is the link between other STD infections and possible infection of HIV. If a person is
found suffering from STDs such as Gonorrhea or Syphilis, the chances of contracting HIV are high. The person
who has a history of recent STD infection should seek medical attention to have HIV testing.
9. Role of the VHT

A. Inform the community about STDs- transmission, common signs/symptoms
B. Do not discriminate those who may want more information or even those who discuss past/current
infections. Instead, inform them to be tested at the health center and complete the treatment
C. Volunteer at the Health Center to pass along this important information about STDs
D. Promote condom use to prevent the spread of STDs and as a family planning method
E. Human Immunodeficiency Virus and Acquired Immune Deficiency

Syndrome
Acquired Immunodeficiency Syndrome (AIDS) is the disease caused by a germ (virus) called Human
Immunodeficiency Virus (HIV). When the virus enters the body, it weakens or destroys the body’s ability to
fight other diseases. There is a wide spectrum of symptoms that can occur with AIDS from rapid weight loss
and night sweats to serious complications from other infections such as pneumonia, diarrhea, and meningitis.
There is no cure for AIDS, meaning people with the infection will likely die from its effects on the body.
However, there are medications available that, when taken correctly, can help promote a long, productive life.
98
1. Explain the meaning of HIV/AIDS
2. Explain ways through which HIV/AIDS is transmitted
3. Describe the different signs and symptoms of HIV/AIDS
4. Describe how HIV and AIDS can be prevented/controlled
5. Explain the prevention of mother to child transmission (PMTCT)
6. Explain the importance of HIV testing and counseling
7. Describe home-based care of people living with HIV/AIDS
8. Discuss the cultural practices that facilitate the spread of HIV
9. Describe the role of the VHT
FACILITATOR’S NOTES
1. Definitions
A. AIDS (Acquired Immunodeficiency Syndrome) is a spectrum of symptoms from diseases that
develop from the viral infection that destroys the body’s immune system
C. HIV (Human Immunodeficiency Virus) is the virus that enters the body and destroys the immune
system
2. STDs vs HIV vs AIDS

A. STDs (Sexually Transmitted Diseases) = a term used to describe all diseases that can spread from
person-to-person via sexual intercourse
B. HIV = a virus that is an example of an STD because it can be transmitted via sex
C. AIDS = the spectrum of symptoms/diseases that result from the HIV infection
99
3. HIV Transmission
Specific body fluids are able to carry the HIV virus. These include blood, semen, vaginal fluids, and breast milk.
The HIV virus can transfer to another person through these body fluids.
A. A person has a wound or cut at the point where his/her body comes into contact with the blood,
sperm, or vaginal fluids of a person who already has HIV
B. A person has sex with someone who has HIV, and the skin of the vaginal walls or penis is broken,
allowing blood-to-blood or semen/vaginal fluid-to-blood transfer of virus
C. A person shares a sharp object (needles, syringes, razors, knives) without sterilizing it
D. A pregnant woman who has HIV can pass it to her baby
1. Before birth/during pregnancy
2. During delivery
3. Breastfeeding
4. HIV Effects on the Body

When HIV enters the body of the newly infected person, HIV destroys the substance in the blood that helps
the body fight and kill germs. These cells that are affected are called CD4 cells. These cells are responsible for
recognizing germs when they enter the body to activate the body’s defense system. Therefore, when these
cells are destroyed, the body loses its ability to recognize germs, and the body becomes a victim to a wide
range of infections.
5. Myths about HIV/AIDS

This is an important discussion to keep the participants engaged. There is a lot to learn about people’s
perception about HIV. There are many myths that may not be included in this list. However, all myths
should be addressed, because the VHT must know how to answer common questions in their communities.
A. A person cannot get HIV by sharing the same room, toilet, spoon, or plates with someone who has
HIV/AIDS
B. A person cannot get HIV by touching or shaking hands with someone who has it
C. A person cannot get HIV through mosquito bites
D. A person with HIV does not “get rid of” the virus by having sex with a virgin or an unaffected
person. This only causes the spread of the virus from one person to another.
6. How can we avoid/prevent HIV infection?

A. ABC Strategy
1. A = Abstinence
2. B = Be Faithful
3. C = use Condoms
B. If you have any sexually transmitted diseases (gonorrhea, syphilis, etc) go to the health center for
treatment.
C. If you have a history of STDs, be sure to have HIV testing at the health center
D. Do not share needles, syringes or razors
E. All persons in a committed relationship should be first tested for HIV and remain faithful to one
another
100
E. Male circumcision
F. Make sure that all instruments used for tattooing and ear-piercing are sterilized
G. Deliver your child in a hospital where services and information are available to prevent mother to
child transmission (PMTCT)
7. Children of HIV+ Mothers

Children of HIV+ mothers can be born without contracting the virus. The Ministry of Health has introduced
a strategy called “Prevention of Mother to Child Transmission of HIV” (PMTCT). In this strategy, pregnant
mothers are encouraged to go for voluntary testing and counseling. The mothers who are found to be living
with HIV are provided with extra information and medications to protect their unborn children from getting
HIV during the pregnancy and during delivery
8. Role of the VHT

A. Visit and Counsel members of your community with HIV
B. Encourage them to take their medications as prescribed by the health worker
C. Encourage a healthy, well-balanced diet with regular exercise and rest
D. Encourage anyone with HIV to report any illness immediately to the health center. A person with
HIV is more likely to have serious complications with common illnesses such as a cold or malaria. It is very
important for them to seek medical advice to receive the proper treatment early in the disease course.
E. Record community members who are infected with HIV and follow-up regularly
F. Encourage HIV testing for those whose status is unknown. Many people prefer to live in denial
about HIV—whether they are ashamed of past events or fear their future living with HIV. Explain that knowing
the HIV status allows one to start taking the appropriate medications to live a longer/productive life, and it
also serves as a way to protect others and prevent its spread.
G. Inform community members about the common misconceptions about HIV
9. How to Care for Someone Who is Sick

A. Do not touch their blood, open sores or wounds, bloody stool/vomit with bare hands
B. Wear rubber or latex gloves when cleaning body fluids and wash hands each time
C. Handle soiled clothes, bedding, and towels with care
D. Wash soiled clothes, bedding, and towels in hot soapy water or water with some chlorine/bleach
10. Signs and Symptoms of AIDS

A. Drastic weight loss
B. Consistent diarrhea for over a month
C. Prolonged fever
D. Persistent Cough
E. Skin rashes
F. Mouth infections/sores
G. New onset of confusion or forgetfulness
H. Any illness that does not seem to resolve
101
Common VHT Questions
 Can HIV be transmitted from person to person by kissing?
- The only recorded evidence of HIV transmission through kissing was through blood transfer from bleeding
gums or mouth sores. The saliva itself does not carry HIV. Closed mouth kissing cannot transmit HIV.
 If someone with HIV cuts himself with a knife and while I am using the same knife, I accidentally cut
myself, can I get HIV? What if the blood is dry? Can I still get HIV?
- In laboratory research, scientists have shown that high concentrations of HIV virus when left to dry for a few
hours, the amount of infectious virus can decrease by 90-99% (CDC research). Although HIV is transferred
through blood, it is very unlikely to become infected with HIV if the blood was dry.
 Can I get HIV from mosquitoes?
- No. There has been a lot of research on transmission of HIV by mosquitoes in areas where mosquitoes and
HIV are very prevalent. There has been no evidence to support this mode of transmission. ( " H i v
transmission: questions," 2010)
 How does a mother transmit HIV to her baby?
- HIV transmission can occur during pregnancy, during delivery, or while breastfeeding. The risk of a mother
transmitting HIV to her child during pregnancy is about 25%. However, with drugs (anti-retrovirals) given
during pregnancy, at delivery, and to the newborn, this risk can drop to 2%.
 How does circumcision help prevent HIV transmission?
- Several theories relate male circumcision with the decreased risk of HIV transmission
1. Foreskin composition: Compared with the dry external skin surface, the inner mucosa of the
foreskin has less keratinization (fibrous protein), a higher density of target cells for HIV infection (Langerhans
cells), and is more susceptible to HIV infection than other penile tissue in lab studies
2. The foreskin is more susceptible to traumatic epithelial injury during intercourse, providing entry for
pathogens.
3. The microenvironment in the preputial sac (between the unretracted foreskin and the glans penis)
may be conducive to viral survival
4. The higher rates of sexually transmitted genital ulcerative disease in uncircumcised men can
increase susceptibility to HIV infection
- Clinical trials in Uganda have shown a 51% lower incidence of HIV infection among circumcised men
compared with men assigned to the wait-list group to be circumcised.
- There have been no significant findings for decreased Male-to-Female transmission (among HIV+,
circumcised males to their female partners)
(“Male circumcision, 2008)
 How effective are condoms?
- This all depends on using condoms consistently and correctly. When used correctly, the condom can trap the
semen to prevent transmission to the female, and the condom can protect the penis from transmission via the
vaginal fluids from the female.
102
IV.ENVIRONMENTAL HEATLH
Environmental health aims at promoting health through good housing, use of safe water, good care for
personal hygiene, food safety, appropriate waste management, and the control of disease vectors and vermin.
The main objective of this module is to provide knowledge and skills to members of the VHT that will
contribute to the prevention and control of environmental health-related diseases. While these VHTs are
going to the households to monitor these practices through record-keeping, it is also important to give them
the knowledge of why these issues are important. In this way, information can spread through the community
and there is greater potential for behavior change.
A. Sanitation
Sanitation is the promotion of facilities, skills, and practices that enable individuals, families, and
communities to improve their quality of life through observing good health and good hygienic practices:
adequate ventilation, safe collection and storage of water, safe disposal of solid and liquid waste, safe disposal
of human excrement, and the control of insects and rodents that can spread diseases
1. Explain the meaning of sanitation
2. Explain the benefits of sanitation
3. List the different components of sanitation
4. List sanitation-related diseases
5. List ways of preventing sanitation-related diseases
6. List challenges to sanitation
1. What is Sanitation?
Sanitation is personal and environmental cleanliness. It includes the promotion of facilities, skills and
practices that enable individuals, families and communities to improve their quality of life through:
A. Safe disposal of human excrement (feces, urine)
B. Practicing of personal, domestic, and food hygiene
C. Safe disposal of waste (rubbish, garbage, animal waste, dirty water)
D. Collection, treatment, storage of safe water especially for drinking
E. Control of insects and rodents that spread disease (flies, rates, mosquitoes)
The topics related to sanitation that will be covered in this lecture include:
1. Water
2. Personal Hygiene
3. Domestic Hygiene
4. Food Hygiene
103
2. What are the benefits of sanitation?
A. Health: Reduced illness from sanitation-related diseases. Many illnesses that have serious effects
including death are related to poor sanitation. Diarrhea is one of the top causes of mortality especially in
children under 5 years. Diarrhea is just one example of an illness that is strongly linked to poor sanitation
practices.
B. Socio-economic: Reduced expenditure on sanitation related disease both at household and
community levels. If anything is a motivation factor, it is money. The cost of treatment, hospitalizations, and
time away from work all contribute to socio-economic decline. However, when
C. Education: Improved performance by school children whose attendance and performance are not
limited due to sanitation-related diseases
D. Environment: Improved environment due to reduced indiscriminate disposal of human waste
(feces, urine), garbage, dirty water
3. Sanitation-related Diseases:
1. Diarrhea—cholera, dysentery, typhoid
2. Skin and eye infections
3. Tuberculosis
4. Intestinal Worms
4. Ways of preventing sanitation-related diseases

1. Collect at a safe water source and respect the safe water chain
2. Safely dispose solid and liquid waste
3. Avoid sleeping with domestic animals
4. Safe food storage
5. Control all insects and rodents to stop them from spreading diseases
6. Keep pit latrines far from sources of water (at least 30 meters)
7. Wash all kitchen utensils with soap and safe clean water
8. After using the toilet and before eating food, wash hands with soap and water
9. Wash all fruits and vegetables with clean water before eating
104
5. Challenges of Sanitation
1. Inadequate sources of safe water
2. Improper disposal of solid and liquid waste
3. Poor food storage
4. Poverty leading to living in densely populated areas lacking basic sanitation needs
5. Inadequate information and myths related to sanitation
B. Water
Water is one of the most essential requirements for the proper functioning of the body. It is also used
for personal and domestic hygiene, such as washing utensils and clothes and for cooking food. The failure to
observe the safe water chain may result in water-related diseases such as diarrhea, worm infections, skin and
eye infections, and vector-borne diseases. It is important to be familiar with the various transmission patterns
so as to be able to identify which particular hygienic behaviors and measures can help to interrupt disease
transmission
1. Identify common sources of water
2. List sources of water contamination
3. List water-related diseases
4. Describe the various ways of preventing water contamination and benefits of a safe water chain
5. Describe ways of keeping water safe from source to consumption (water chain)
1. Common Water Sources
A. Rain water
B. Surface water: Rivers, ponds, swamps, lakes, streams
C. Underground water: wells, springs
2. Ways in which water can be contaminated

A. Direct bathing, swimming and defecating in the water or near the water source
B. Seepage through the soil from a nearby latrine
C. Run-off water contaminated by human and animal excrement
D. Use of dirty vessels, storage facilities and mugs for collecting water
3. Examples of Water-related Diseases

A. Diarrhea—Cholera, Dysentery, Typhoid
- These germs are transmitted through the fecal-oral route
- Causes:
- Consuming contaminated water
- Person-to-person transmission due to lack of hygiene
105
B. Skin and Eye Infections—Trachoma, Scabies
- These germs are transmitted from person-to-person through
contaminated water and lack of domestic cleanliness
C. Liver/GI Tract Infections—Schistosomiasis
- Germs are transmitted via intermediate hosts that live in water
- Snails are one example of a water-living host
D. Water-related Insects—Malaria, Filariasis
- These diseases are related to water in different ways
- Filariasis is due to skin contact with germs
- Malaria is related to the mosquitoes who lay eggs in the water
4. Ways to Prevent Water Contamination

A. Protect all water sources especially spring wells and boreholes
B. Use clean water containers to collect water
C. Avoid washing and bathing near or around water sources
D. Avoid grazing animals near or around water sources
E. Locate pit latrines 30 meters away from the water source
F. Store drinking water in a clean and covered container
G. Treat patients with water-born diseases and discourage them from collecting water from the
community water sources
5. Benefits of Safe Water

All of the following examples are also listed under “Benefits of Sanitation”. These points are important to
reinforce but avoid redundancy by engaging the participants and asking for their input.
A. Health: Reduced illness from water-related diseases
B. Socio-economic: Reduced expenditure on disease and increased productivity at household,
community and national levels
C. Education: Improved performance by school children who are not hindered by water-related
diseases
D. Environment: Protecting water sources and following the practice guidelines to maintain safe water
sources are important steps to improving the environment.
6. The Safe Water Chain

Safe water chain refers to the process of ensuring collection of water from a safe water source in clean
water containers and keeping it safely protected from any contamination at home or in other public places
such as schools.
Protect water by preventing contamination at each step of preparing water—from collecting to drinking.
Each step in this process should be carefully prepared to ensure cleanliness. The most ideal situation: Gather
water at a “protected” water source, boil water to kill the germs that may be present, store the water in clean
containers that have some form of protection—a lid or cap that prevents contamination.
106
C. Personal Hygiene
Personal hygiene is the process of keeping our bodies, teeth, hair, clothes, towels, and all our
belongings clean. Personal hygiene includes behaviors such as washing hands with soap before eating food,
washing our hands after visiting the latrine, cutting hair/nails, brushing teeth after meals, and regular bathing.
Personal hygiene shows that you care about yourself and others to put in the extra effort. The purpose
of personal hygiene is not for show but rather for setting a standard of cleanliness and of taking care of of
yourself.
Learning Objectives
1. Explain the meaning of personal hygiene
2. List the components of personal hygiene
3. Discuss the benefits of personal hygiene
4. Explain how personal hygiene can be maintained
5. Demonstrate how to effectively wash hands, face, body, and brush teeth
FACILIATOR’S NOTES:
1. Definition of Personal Hygiene
Personal hygiene is the process of keeping of our bodies, teeth, hair, clothes, and all personal belongings
clean. Personal hygiene includes hygienic behaviors such as washing of hands with soap before eating food or
washing our hands after visiting the latrine, cutting hair/nails, brushing teeth, and regular bathing.
2. Components of Personal Hygiene

A. Hair: regular washing and cutting
B. Nails: regular cutting and washing
C. Skin: wash with soap
D. Teeth: brush at least twice daily
E. Face: wash with soap
F. Clothing and Bedding: wash regularly with detergent or soap, hang-dry in the sun
G. Hands: wash with soap before eating food and after visiting the latrine
3. Benefits of Good Personal Hygiene

A. Health
B. Socio-economic
C. Education
4. How to Prevent Personal Hygiene Problems

A. Wash hands and body with water and soap regularly
B. Cover your food and water from dirt and flees
C. Use latrines
D. Wash hands with soap and clean water after using the toilet
E. A mother should wash her hands and body before breastfeeding
107
F. Wash hands after attending to your baby
G. Wash hands before and after preparing food.
5. Effects of Poor Personal Hygiene

A. Loosing teeth from tooth decay
B. Poor eye sight as a result of Trachoma or Conjunctivitis
C. Death as a result of dysentery and cholera
D. Bad skin/constant scratching—rashes, ringworm, bedbugs, scabies
E. Sores on the head as a result of lice bringing discomfort
D. Domestic Hygiene
Domestic hygiene is the practice of keeping oneself and one’s surroundings clean. A clean domestic
environment is also a healthy environment. Domestic hygiene examines all issues within the domestic
confinement: the house, the compound, the drainage, the kitchen, the facilities for drying household utensils,
the waste management facilities, rubbish disposal facilities and the animal housing
1. Explain the meaning of domestic hygiene
2. List components of domestic hygiene
3. Explain the benefits of domestic hygiene
4. List diseases associated with poor domestic hygiene
5. Explain the ways of preventing diseases from spreading in the community
6. Definition: Domestic Hygiene
Domestic hygiene is the maintenance of a healthy environment in one’s home and the areas surrounding
the homestead by observing simple health practices to avoid infections—diarrhea, intestinal worms, skin
diseases
7. Components of Domestic Hygiene

A. Clean/neat house with adequate ventilation
B. Clean/neat compound
C. Cleaning tools such as brooms and rags
D. Well ventilated, clean latrine with covers
E. Hand-washing area with soap
F. Separate housing for domestic animals
G. Kitchen
H. Drying rack for clean dishes
I. Water drainage facilities around the house
J. Clean water storage facility
108
8. How can domestic hygiene be achieved?
A. Always use a latrine
B. Collect rubbish and take it to the rubbish pit where it can be burned
C. Build a ventilated latrine at least 30 meters away from the house
D. Clean the latrine regularly
E. Build adequate drainage for bathing and washing water
F. Clean the area around the house and cut down brush
G. Wash dishes with clean water and soap
H. Use a drying wrack that is off the ground to prevent contamination
I. Do not sleep with animals
J. Do not use leaves after using the latrine. Leaves may contain eggs that can survive within the body
and cause serious infection
E. Food Hygiene
1. Definition:
Food hygiene is the process of preparing food in clean surroundings, serving in clean utensils by clean
persons. And when not eaten immediately, food should be properly covered to avoid contamination by flies
and dust. To maintain proper food hygiene, kitchens where food is prepared and served should always be
clean, there should be proper storage facilities, always use clean utensils, and wash hands with soap before
preparing and eating food.
2. What is needed?
A. Clean kitchen
B. Drying Rack
C. Clean person—wash hands before preparing and before eating food
D. Clean utensils
E. Proper storage facilities—cupboards, covers for food
3. Diseases Associated with Poor Food Hygiene: DIARRHEA

A. Cholera
B. Dysentery
C. Typhoid
109
Bibliography
Chetty, T, Naidu, K, & Newell, ML. (2010). Guidelines on hiv and infant feeding
2010. WHO Breastfeeding with HIV . World Health Organization. Retrieved
from
http://www.who.int/child_adolescent_health/documents/9789241599535/en/
index.htm
Coartem. (2009, July 20). RxList: The Internet Drug Index. Retrieved from
http://www.rxlist.com/coartem.-drug.htm
Facts about health in the african region of WHO. (2002). World Health
Organization, WHO. Retrieved from
http://www.who.int/mediacentre/factsheets/fs314/en/index.html
Getting it right for children . (2008). UNICEF Uganda Annual Report 2008 , 9-33.
Hiv transmission: questions and answers . (2010, March 25). Centers for Disease
Control and Prevention, CDC. Retrieved from
http://www.cdc.gov/hiv/resources/qa/transmission.htm
Impact of malaria. (2010, February 8). Centers for Disease Control and Prevention,
CDC. Retrieved from http://www.cdc.gov/malaria_worldwide/impact.html .
Malaria: biology. (2010, February 8). Centers for Disease Control and Prevention,
CDC. Division of Parasitic Diseases.
http://www.cdc.gov/malaria/about/biology/
Malaria facts. (2010, February 8). Center s for Disease Control and Prevention,
CDC. Retrieved from http://www.cdc.gov/malaria/about/facts.html .
Male circumcision and risk for HIV transmission and other health conditions:
implications for the United States. 2008, February. Centers for Disease
Control and Prevention, CDC.
http://www.cdc.gov/hiv/resources/factsheets/PDF/circumcision.pdf .
Pneumonia. (2010, November). World Health Organization, WHO.
http://www.who.int/mediacentre/factsheets/fs331/en
110

VHT Hybrid Manual

Uploaded by

Copyright:

Available Formats

VHT Hybrid Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

VHT Hybrid Manual

Uploaded by

Copyright:

Available Formats

MOH - Omni Med

Village Health Team (VHT)

The Republic of Uganda

1st Edition (February 2011)

Hybrid manual adapted from the original VHT

By Dr. Jennifer Thompson & Zachary Tabb

Original Manual 2010 Manual

PART TWO: VILLAGE HEALTH TEAMS 13

PART THREE: VHT RESPONSIBILITIES 19

A. Preparation of the Training Plan

1. Meet and Organize

The following supplemental VHT materials should be supplied to VHT Participants:

 Maturity (above 18 years of age)*

C. Carrying Out Each Training Activity

1. Follow the Training Guide

2. Adhere to the Training Schedule

5. Give Participants Time to Answer

6. Listen and Repeat

7. Move Around During Group Work

[NOTE: If they mention more than these – great!]

STATE the acronym of T.E.A.M.:

Facilitators: Now discuss the concept of VHTs

1. The Definition of a Village Health Team (VHT):

2. Qualities of the VHT Members:

ASK the Participants to raise their hands to answer this question:

 Willing to volunteer for the good of the village

3. What is the Overall Goal of the VHTs?

B. Key Actors in Community Health

“Who are key actors in Community Health you mentioned earlier?”

PROBE the Participants so that they again mention the following:

3. Local authorities and civic, opinion, and religious leaders

C. What are the Key Tasks of the VHT Members?

EXPLAIN to Participants that a VHT is a group of village members who*:

 Mobilize the village members for health activities

ASK Participants if anyone has any questions about VHTs.

“What does community mobilization mean?”

PROBE Participants to ensure the following answer is mentioned:

“What does community empowerment mean?”

PROBE Participants to ensure the following answer mentioned:

“Why do communities need to be mobilized?”

PROBE Participants to ensure that the following points are made:

 To get village members involved in making decisions that affect them

2. Opportunities for social mobilization and community empowerment.

 Traditional leaders  Village-based organization leaders

PROBE to ensure that at least the following activities are mentioned:

Small Group Work:

 Community mobilization and empowerment definitions

“What is the meaning of monitoring?”

PROBE Participants to ensure that the following points are made:

Monitoring is the routine collection of information (often at regular intervals) related to

2. Data collection methods:

 Focus group discussion.

Data collecting methods:

*This might be a good time for a break, or a group energizer.

B. How Do You Draw Village Map?

Why is it important to have a village map?

“What are some important things to mark on the map?”

PROBE Participants to ensure that the following points are made:

C. How do you use a village map?

ASK the Participants