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adaptation OF THE WHO/UNICEFCOMMUNITY HEALTH WORKER materials TO INCLUDE HIV and TB

Presented by Sandy Reid

World HealthOrganization

Contents of presentationDescription of the WHO/UNICEF generic training materials for community health workersAdaptation of generic materials to include HIV used in South Africa for a small scale researchAdaptations of generic materials for global use, based on experience and consultations with experts in HIV and TB from various agencies and institutions

WHO/UNICEF Joint statementsprovided the basis for developing the generic materials

DiarrhoeaPneumoniaSevere acute malnutritionIntegrated community case management

Home visits for newborn care

We are probably all familiar with the four UNICEF/WHO joint statements. These give the following main messages:

Diarrhoea: Promote low-osmolarity ORS and zinc supplementationPneumonia: Make management of pneumonia available at the community levelSevere acute malnutrition: Identify using MUAC strip; treat using RUTFHome visits for newborn care: Home visitation during pregnancy and first week of life to promote nutrition, hygiene, cord care, identify sick newborns

These statements form the technical basis for the training materials for CHWs.Caring for the child's healthy growth and developmentCare-giving skills and support for child development Infant and young child feedingPrevention of illnessFamily response to childs illness Caring for the sick child in the community Referral of children with danger signs and severe acute malnutritionTreatment in the communityDiarrhoea Fever (malaria)PneumoniaCaring for the newborn at homePromotion of ANC and skilled care at birth Care in first week of life Recognition and referral of newborns with danger signsSpecial care for low-birth-weight babies

Summary of content of the generic materials

Translating evidence into practiceINITIAL adaptation of MANUALS in SOUTH AFRICA(sa) Research in South Africa to measure the effectiveness of HIV-adapted iCCM materials to be used for training and supervision to increase uptake of MNCH/PMTCT interventions

Ugu Health districtWHO/UNICEF materials adapted in SACaring for the newbornCaring for the newborn at home manualMother and baby cardCounselling cards Facilitators manual

Caring for the sick child in the communityCaring for the sick child in the community manualSick child recording formChart bookletFacilitators manual

(Caring for the well child had not been completed by WHO)

Key lessons learnt from process of adaptation IN SAImportance of a team with different medical skills and experienceOne person responsible for making changes Use of country specific graphicsImportance of aligning messages and changes according to country specific Department of Health guidelines Translate into local lanuage One small change may affect multiple changes in the manualsIt takes time!Training experience IN SA75 Community Health Workers were trained on caring for the newborn and caring for the sick child in the community Training done over two weeksTheory sessions in the morning and practical sessions in the hospital in the afternoon

Successes of training IN SAPractical sessions had great impactAppreciated clearly illustrated and endorsed materialsFelt important when given timers and thermometersProfessional nurses provided the training in ZuluCombination of role plays, DVDs, practical sessions and group sessions made the training interactive and interesting2 Comments from community health workers:I feel professional with all the tools you have given me and the community will trust meYou have given us dignity

9challenges of training IN SAMost of the CHWs knew very little about maternal and newborn careTheir HIV knowledge was outdatedThey had all completed the same education level but they had very different abilities e.g. some could not read Difficulties in addressing cultural issues 2 weeks of training was intense

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STAGES OF Adaptation of manuals for GLOBAL useUNICEF /WHO had existing training modules and tools on caring for newborn, sick child and well child in the communityUNICEF /WHO had discussions on the importance of integrating HIV into the existing materials - May 2012Meeting in July 2012 to discuss the way forwardCollaborating partners met Nov 2012 to identify key interventions to be included in the materialsMeeting in March 2013 to identify how and where key activities could be included in the materialsSeptember 2013 meeting to discuss final draft of manuals and tools

What can we expect from a CHW?Define core and advanced HIV interventions that should be integrated into community health worker training Identify core and advanced competencies of community health workerDefine system requirements and needs for effective implementationIdentify what support was necessary to ensure effective implementation Establish what resources and tools were necessary

As a first step, it is necessary to agree what CHWs can reasonably deliver. This will depend on their skills and what else they are expected to perform at each home visit. The activities for each module are split into integrated (or basic) activities that any or all CHWs could reasonably be expected to undertake, and a second level of focussed (or advanced) activities that would require significantly more training or time.

13Key objectives identifiedIncrease uptake of HIV testing for pregnant women, their partners and their childrenEnsure closer follow-up of the HIV-exposed childImprove case-finding of paediatric HIVImprove the system of referral to health facilities for HIV care and treatmentImprove early initiation of treatment for HIV-positive infantsImprove the retention of HIV-positive women and children in treatment programmes

Assumptions underlying HIV adaptationActivities and interventions inNewborn materials - regular scheduled visitsSick child materials - family approaching CHW with sick child with limited follow up Well-child materials - regular scheduled visits

Activities will be delivered by general CHWs with responsibility for a range of other MNCH interventions

CHWs will not know HIV status of pregnant women or mothersMothers may voluntarily choose to disclose

Activities will be delivered to all pregnant women and mothersInclude 'What if ' scenarios ActivityNewbornSick childWell child1Promote (early) HIV testing +++++++2Promote ARV/ART uptake +++++++3Promote HIV testing in infants/children+++++++4Promote ARV prophylaxis and CTX uptake in infants++++++5Promote ART uptake in infants/children++++6Infant feeding support++++++7Promote testing for syphilis+++8Promote family planning++++++9Promote retention in care++++++10Promote adherence to treatments++++++11Referrals on the basis of HIV exposure+++12Promote TB identification and management++++++13Adolescent emphasis++++TB and HIV Integration of TB and HIV but not always linked Ensure when country specific adaptations are done according to TB and HIV rates, content is not lost

What is not includedKnowledge of HIV statusCommunity-based counselling for testingCommunity-based testingPersonal counselling on ARV uptake/adherenceDosesAdverse effectsPersonal referralFollow-up of individualsDate of next visitsPill countsClinical assessments for ARV related side-effectsINH

Next steps and availability of materialsMaterial available: http://www.who.int/maternal_child-adolescent/en Field tests: Zambia Sept 2014Negotiations with Nigeria and India

World Health OrganizationUNICEFUnited States Agency for International Development (USAID)Clinton Health Access InitiativeSave the ChildrenEGPAFManagement Sciences for Health (MSH)CDC Atlanta and South AfricaThe Children Investment Fund Foundation (CIFF)

Stop TB PartnershipMDG Health AllianceMaternal and Child Health Integrated Program (MCHIP)International AIDS SocietySA Department of Health20 000+ (UKZN)Centre of Rural Health (CRH)Boston Children's Hospital/HarvardZo-life

Thank you!