Chapter 1: Training Objectives
Chapter 2: Handling Administrative Arrangements
Note: the introduction and first few chapters of this
guide are available here. For more information on organizing a training
program, contact CHD.
Diarrhoeal diseases are a leading cause of childhood mortality and morbidity
in the developing world. These deaths are caused by dehydration, dysentery, and
persistent diarrhoea. Dehydration from acute diarrhoea of all etiologies and in
all age groups can be treated safely and effectively by the simple method of
oral rehydration therapy (ORT). ORT has made it possible to undertake a global
effort to reduce deaths from dehydration and diarrhoea-associated malnutrition.
Complete case management can also combat deaths from dysentery and persistent
Why Is This Training Needed?
It is essential that every country trains its health staff in proper
diarrhoea case management, including the use of ORT. Diarrhoea Training Units
(DTU's) have been established in a few large hospitals in many countries to
provide this training. However, because DTU's are few in number and can conduct
only a limited number of courses, additional training is needed to meet the
needs of all health workers.
This course is designed to meet the clinical training needs of health staff
who cannot feasibly be trained in DTU's, but are able to be trained in a large
health centre or small hospital. Health staff who should attend include
physicians, nurses, nurses' assistants, and other staff from health centres and
small hospitals where diarrhoea cases of any age are managed, who want to learn
about advances in treatment of diarrhoea, including use of ORT. Health staff
from the facility conducting the training can attend, as well as health staff
from nearby facilities.
The training has two major purposes:
- To Train Physicians And Other Health Workers To Manage Cases Of
Diarrhoea Properly This purpose is accomplished by having participants observe proper case
management and gain first hand experience treating patients. Participants also
obtain relevant technical information from written instructions, short
presentations, discussions with experienced staff and other participants, and
- To Prepare Participants To Improve Case Management In Their Own
This purpose is just as important as the first, but is easy to overlook. Participants may know how to manage cases properly at the facility where they
are trained, but may not be able to use these procedures when they return to
their own facility. Unless there is support for the procedures, participants
will find it difficult to use them. Support is needed in terms of policies,
physical arrangement, supplies, and skilled staff. This training helps participants prepare for this challenge. Using advice
from instructors and other participants, changes are identified that will need
to be made at each participant's facility so that improved diarrhoea case
management can be carried out.
What Activities Will Occur During Training?
This training course will consist of:
- Written instruction and group exercise to develop skills in case
management of diarrhoea, especially oral rehydration therapy
- Active practice sessions in the facility to gain first-hand experience in
the rehydration of paediatric patients
- Presentations to cover technical material on case management, epidemiology, etiology, and prevention of diarrhoea
- Exercises and drills (or repeated practice) of key skills in case
- Individual and group work to plan how to improve case management in
participants' own facilities.
What Type of Facility Can Conduct This Training?
This training can be conducted in a large health centre, district level
facility, or small hospital. The facility should:
- See at least 25 diarrhoea cases under 5 years of age during the week of the
training, with at least 5 of those being dehydrated cases, so that each
participant will be able to practice case management procedures during the
- Have enough space for 2-8 trainees to meet together as a group, either in the
same room as cases are treated or in a room near the ORT area;
- Be located close to several other facilities with health staff who need
training, since the training is suitable for staff from the facility conducting
the training and from other nearby facilities;
- Have staff who are willing and able to serve as course instructors and
- Have one course instructor who is dedicated and committed to improving case
management and who successfully completed a DTU course, where he developed the
necessary clinical skills, saw how the clinical training should be conducted,
and received information on training support available from WHO.
Some facilities that conduct this course may also have 1-2
beds for giving IV therapy to severely dehydrated patients. In contrast to a DTU, the facility conducting this training should be smaller
than a DTU, which is usually located in only a few large hospitals in the
country and can accommodate up to 20 trainees for a full week course. Each facility that conducts diarrhoea management training will be arranged
and will operate somewhat differently from others, but certain characteristics
- The facility may have more than one room, but diarrhoea treatment is
usually provided in a one-room multipurpose assessment and treatment area, where
mothers and children are seen for all sorts of illness and injury. (See the
sample floor plan on page 5.)
- Typically, when a sick child comes to the facility, the child is first
assessed and a diagnosis is made. If the child has diarrhoea and is dehydrated,
he remains at the facility for ORT. Children with most other problems (e.g.,
acute respiratory infections, minor injuries, malaria) are either treated and
sent home, or referred to another facility.
- Proper therapy for diarrhoea is practiced on a routine basis, so
participants can see the therapy and be a part of it. a) Mothers of diarrhoea cases without signs of dehydration are educated on
management of diarrhoea at home. They may practice mixing and administering ORS
solution. They learn to recognize the signs that indicate the child should be
brought back to the health worker. b) Mothers of dehydrated children are asked to stay with their children to
give ORT and continue breast-feeding with the supervision and encouragement of
staff. They are taught how to give ORS solution, continue ORT at home, feed
during and after diarrhoea, and recognize the signs indicating that a child
should be brought back to a health worker. c) ORT is used appropriately; IV therapy is not used when ORT would be
effective. If staff are trained and supplies available, IV therapy is given when
needed. As soon as the child is able to drink, ORS solution is given in addition
to IV therapy.
d) Simple benches are available for people waiting to be seen. Comfortable
benches (or other seats like chairs or mats) with side tables are provided for
mothers giving ORS solution. There is space for movement of health staff,
patients, and mothers.
e) Treatment is provided to diarrhoea cases with other problems, such as
dysentery, which do not require admission. Antibiotics are used only as needed;
antidiarrhoeal drugs are never used.
f) Before diarrhoea cases leave the facility, staff make sure that they have
attended to any other health problems or concerns.
- Proper administrative procedures are followed to
allow the facility to operate smoothly. a) ORS solution is mixed from packets (or in larger volumes if the number
of patients needing ORS solution is sufficient). b) There is adequate ventilation (e.g., fans) and access to toilet and
washing facilities. c) Appropriate supplies are available in adequate quantities. The supplies
are taken out of the storage area and arranged each morning so that they will be
convenient to use.
Why Was This Guide Developed?
WHO realizes that health centres face many problems in trying to provide
training. Hands-on training, which requires each participant to treat several
patients with guidance and support from the staff, can be very effective.
However, hands-on training places considerable demands on the staff and, if not
organized well, can be disruptive to the normal operation of a facility.
It is also difficult to select the most important technical knowledge to
teach in the limited time available for training. There are many decisions to be
made about the skills to be taught, the information to be covered, the
activities of the participants, schedules, operational arrangements and
supplies. These decisions need to be made in the midst of other important and
This guide was written to simplify the process of delivering this course. It
recommends procedures and techniques for both planning and conducting the
training. It contains all materials needed for the course, with the exception of
any additional references you may wish to provide (see Annex A for list of
references). Hopefully, it will reduce the time needed for course planning, and
will result in a more effective training experience for all participants.