Issue Contents    Training makes a big difference Training for health workers Learning through experience Training exercise: who will be treated? Towards healthy working Working with community leaders 'AIDS is not a problem for us' Home care training guidelines Courage, compassion and care Training and support Facts about HIV and AIDS Care for common symptoms The health worker's key role Preventing infection Emotional support Confidentiality Nutrition Building on tradition Infection prevention for carers Skin protection Readers' survey News and resources Steps to success in teaching and training Before starting Approaches to education and training Steps to participatory learning 1: Assess what people know already 2: Build on what is known 3: Check people's understanding 4: Problem solving and decision making 5: Evaluating education or training

In this issue:    Increasing skills and confidence for health workers Home care training guidelines Plus Special insert on teaching and training techniques

Jacqueline Wong, a district health visitor, comments: 'Even though I had the theory, I was very shocked when I first saw a patient with AIDS. I just froze. Now it's very different. What helped me most was facing the human reality of the situation, by meeting patients and taking part in the training.'

 
 
Coming to terms with reality 
These factors influenced the design of a modified training programme, developed in 1990. The programme focuses not only on increasing knowledge but also on changing personal attitudes, reducing fears and increasing self-awareness.

Teaching methods reflect the fact that adults learn better when they experience the issues more personally. Exercises such as role play make situations seem more real to the trainees, and involve everyone in the group. 

Small groups of 10 to 15 people attend the training course. The course is one day a week for eight weeks, and is held in an informal and relaxed environment. 

Training content varies according to participants' needs. They fill in questionnaires before they start the course, and also discuss what they want during the workshop sessions. By the end of the training, participants have a better understanding of:
 

	the feelings and needs of people with AIDS;
	human sexuality in relation to themselves and others, and the diversity of sexual behaviour;
	separating illness from sexual practices for the purposes of caring;
	recognising the importance of each individual, regardless of illness or sexuality;
	how to encourage families to accept the patient as a person and to give support to those who are ill, in spite of what the illness is or what caused it;
	educating about preventing HIV and STD infection;
	basic skills for effective communication with the patient and their family;
	issues relating to HIV-positive gay and bisexual men (in view of the discrimination towards them in wider society).

HIV-positive people are invited to join in discussions, along with their family members and experienced nurses. Talking with women with AIDS helps the nurses (mostly women themselves) to understand what they have in common with their patients, and to identity more easily with people with AIDS, both men and women. 

After this training, the nurses are encouraged to continue discussing the issues with their colleagues. Health centre co-ordinators are also able to contact AIDS programme staff with any problems. Support groups for the nurses themselves are being set up, where they can share experiences and advise on problems.

Janey Parris, AIDS Programme Co-ordinator, Eric Williams Medical Sciences Complex, Mt Hope, Trinidad and Tobago.

Training exercise: who will be treated?   This exercise will help health workers to confront prejudices and assumptions about patients' illnesses and lifestyles. Before the training session write down on separate pieces of card short descriptions of an HIV-positive adult or child. For example:   a man with TB. He is married and has male sexual partners. a woman with gonorrhea, who is a sex worker. a woman who was infected with HIV through a contaminated blood transfusion. Her baby has severe respiratory problems. Give one card to each participant, and ask them to imagine that the person is their patient. Write up each description on a chalk board or large piece of paper.  Then say that a cure for AIDS has been discovered, but that it is in very short supply. Tell them that their patient will be first to receive the new drug, but that they each have to decide who they would treat second, then third, and so on. When they have each made a list, begin a group discussion about who they prioritised, and why, and how they made decisions about the order. Encourage them to discuss what thoughts they had, for example about having to treat their particular patient first. They may find this easier to do in pairs. Finish with a group session, during which each person describes how the exercise made them feel, and what they learnt from it.

Courage, compassion and care

Looking after sick people at home is often best, but only if the carers have training and back-up support.

Home care means the things people can do to take care of themselves or the care given to them in their own homes by their family, friends, neighbours, volunteers or health worker. It means caring for people's emotional as well as their physical needs. Some programmes target people who are sick with other chronic illnesses in addition to AIDS, like TB or malaria, or are weakened because of old age or malnourishment. 

The sick person and their carers work as a team, ideally with the support of a health worker or trained community volunteer. She or he must make sure that the patient is cared for as well as possible and that carers feel confident about their role. Carers must also know where and when to seek specialised medical care.

Home care is often preferable to hospital care because:
 

	good basic care can be given successfully at home;
	people who are very sick or perhaps dying would often rather stay at home, especially when they know that they cannot be cured in hospital;
	they are comforted by being in their own homes with family and friends around them, and will often recover from specific illnesses faster at home than in hospital;
	it can help the patient and their family come to terms with AIDS, playing a role in overcoming people's fears, anxieties and prejudices;
	hospitals will be less crowded, so that people who really need to be in hospital can be cared for;
	it can be difficult for family members to fulfill other responsibilities, if they have to stay at a hospital or visit the person often;
	sometimes hospital care is simply not available.

Training and support 
Training is an essential part of a successful home care project. Health care workers and other trainers need to know how best to teach people the basic principles of caring for the sick. The carers (and patients themselves) need to know what to do, and how to give and seek emotional and practical support. 

Support (for the carers) means setting up regular meetings, and ensuring that everyone has at least one other person with whom they can discuss problems, or who can take over for a while. Regular visits by trained volunteers can also help to relieve the pressure on family members. 

Training should include discussion sessions, and demonstrations of the skills needed. Allowing time to practise these activities during the training is also important. Training for carers should include the following topics.

Facts about HIV and AIDS 
Trainees need to know what HIV is, how it is transmitted, and how HIV infection causes AIDS. This section could include other illnesses too, if the project is targeting sick people in addition to those with AIDS.

Care for common symptoms 
HIV infection damages the body's immune system. This means that resistance to organisms which cause other infections is lower. Many symptoms may be related to HIV/AIDS, including chronic and acute diarrhoea, and respiratory, skin and genital infections. All these symptoms may also be caused by other illnesses, or conditions like malnourishment.

Training includes:
 

	how to recognise symptoms, their possible causes, and when carers should seek medical advice;
	ways to manage pain and relieve symptoms using simple techniques and inexpensive remedies, such as gentian violet solution for mouth and skin infections; oral rehydration solution for replacing fluids lost through diarrhoea; and antipyretics such as aspirin or paracetamol for relieving fever. Local herbal remedies may also be valuable;
	how to prevent symptoms developing. For example, keeping the skin clean and dry helps to prevent skin infections.

A patient with AIDS is about to go home from hospital. Their health worker talks with him and his wife about their anxieties. She finds out that they are most worried about what their neighbours and relatives will think. She listens to what they say carefully and discusses possible solutions. She suggests that they try not to hide the problems, but that they ask people for help, although they don't have to say what is causing the illness. She also shows them the necessary skills that they need to care for him at home, and watches while they practise. She also tells them what problems to watch out for. She helps them to think of other people who could give support, and asks them to come back after a month for a checkup.

Building on tradition Ajili is 29 years old, and lives in a village in the Rakai district in Uganda. Her husband died two years ago from AIDS, and now she is ill too.  Her neighbour, Gerald, visits her every second day and helps by doing some odd jobs and by bringing food and herbal remedies. More than this, he offers hope and emotional support, and practical suggestions about how to cope with her illness.  Gerald provides all these services free of charge. He is a member of a munno mukabi group. These are informal groups of villagers, mostly women, who traditionally support each other in times of need, by, for example cooking food at funerals or weddings. He is one of 142 representatives of munno mukabi groups, youth groups and football clubs in 17 villages, who have been trained to care for and support people with AIDS.  This training and support programme (organised by CONCERN) aims to build on an existing community spirit, enabling the villagers to care for anyone in the community who is ill or in need of assistance. This means that group members are not labelled as AIDS workers, and villagers are more willing to see them because their visit does not imply that the sick person has AIDS. Organising the work  Participants for the training course are selected by the munno mukabi group members. Well respected individuals are chosen on the basis of their ability to keep information about others to themselves, and to care for people.  The chair of the village committee also attends the course. It is important to have the support of the village leaders, because they can help solve any conflicts. After the training, the trainees organise a meeting to explain their work to other villagers. In consultation with the village leaders, each trained visitor takes responsibility for about 20 households.  The home visitors usually meet together once a month to discuss their work, and to make sure it is fairly distributed. They often share two sets of households, and sometimes visit together. This means that they can give each other support, and if one home visitor falls sick, or fails to build a relationship with the sick person, the other can continue the work and train another visitor if necessary. Regular visits  The most important part of the home visitor's job is to build up a trusting relationship, through regular visits once a week, with the people in the household. Some find it easier to do things for the sick person, rather than sitting and talking with them. In the local language, the words used for talking with the sick person mean comforting, caring for, and in sympathy with. Although the trained visitors are responsible for most of the work, other munno mukabi group members do some visiting, and are often responsible for practical tasks.  Eamonn Brehony and Margaret Ssemukasa, CONCERN, P O Box 1644, Masaka, Uganda.

Skin protection

The risks of HIV transmission in the health care setting are very low, especially if carers minimise skin contact with blood and body fluids. 
 

Health workers and carers need training in the principles of good hygiene and in 'universal precautions'. The universal precautions protect against hepatitis B and other infections in addition to HIV, and the guidelines should be followed with every patient, whether or not they are known to be HIV-positive. They include how to:    avoid skin and eye contact with patients' blood and other body fluids; dispose of waste safely; follow appropriate cleaning, disinfection and sterilisation procedures; and  prevent needle stick and other injuries.

Clean, intact skin is an excellent barrier to HIV. There is an extremely low risk of infection from HIV or hepatitis B if blood comes into contact with unbroken skin. 

However, it is possible that the virus could enter the bloodstream where the skin is damaged. This is most likely if there are open cuts and abrasions or if the blood remains in contact for a long time. However, few, if any, cases of such transmissions have occurred.

In order to minimise the risks the following precautions are advisable:
 

	Latex gloves should be used if, and only if, contact with blood or body fluids is likely. If gloves are in short supply, keep them for when they are needed most, such as when the worker's skin is damaged and when extensive and prolonged blood contact is expected.
	Health workers should examine the skin of their hands and forearms for cuts, abrasions, insect bites, blisters or other damage before starting work. Any open wounds should be covered with a waterproof dressing. If this is not possible gloves should be worn, or direct contact with blood should be avoided.
	Whether or not gloves are to be used, the hands and forearms should be washed thoroughly with soap and water before and after caring for a patient, avoiding damage to the skin and particularly to any areas that are healing up. Take care when using scrubbing brushes because these may damage the skin if they are used too harshly
	Any blood and body fluids should be carefully washed off with soap and water from the skin (or other areas such as the eyes) as soon as possible. Take care not to damage the area when doing this.
	If gloves are not available, minimise skin contact with body fluids, and wash hands after contact. If clothing or sheets are soiled with body fluids, try to handle them without touching the soiled areas. Or, use a piece of paper, plastic or cloth, or even a big leaf to pick up the item using the paper as a barrier. Small plastic bags can be used instead of gloves, tied around the wrist at the top.
	Wash soiled items separately from other laundry, wearing gloves while doing so or trying not to touch stained parts. Rinse off any blood or diarrhoea with water. Wash in warm soapy water, and dry as normal, in sunlight if possible. Bleach solution or boiling water can be used, but are not necessary. Normal washing and drying kill the virus.
	Needles, syringes and blades should always be considered as possible sources of infection, and handled with great care to avoid accidents. They should either be disposed of safely, or cleaned and sterilised before reuse.

Re-using gloves? 
Latex gloves can be safely used again, if they can be thoroughly washed and sterilised or disinfected after use with each patient. Better quality latex gloves (the more expensive they are, in general), will withstand re-use much better than poor quality gloves. If possible, gloves should be worn while cleaning the used ones, to avoid contaminating the hands. 

1. After use the gloves should be inspected. Damaged ones should be disposed of safely. Intact gloves should be washed clean of any blood or body fluids using water (but not soap). Soap can make the latex sticky. 

2. Then sterilise or disinfect the gloves by: 

	immersing them in boiling water for 20 minutes; OR
	soaking them overnight in 1 per cent sodium hypochlorite, OR
	autoclaving them.

Choice of method will vary with the make of glove used. Each method should be tried out on a different batch of used gloves, to find out which is most convenient, and causes no deterioration (stickiness or tiny breaks). Good quality latex gloves should withstand boiling or bleach immersion many times, but autoclaving weakens them after a few times'.

3. After sterilisation the gloves must be re-examined for damage by either gently blowing them full of air, twisting the cuff closed and holding them under clean water or by filling them with clean water, twisting the cuff closed and squeezing them to see if they leak. Any damaged gloves must be discarded.

4. The gloves should be dried, out of direct sunlight, and their insides dusted with talcum powder (if available) before re-use.

Mike Bailey, Technical Adviser on AIDS, UNDP.

Note: WHO is currently researching into the pros and cons of latex re-use (gloves and condoms.)

Steps to success in teaching and training

In this special insert, AIDS Action provides some practical tips for running AIDS education and training sessions. 
 

AIDS education and training activities share an important goal. Both aim to increase knowledge and confidence, and to encourage change in attitudes and behaviour, whether in people's personal or working lives. Many teaching and training activities focus on simply giving information to people through posters or lectures (see diagram). While it is true that people need to know the facts about HIV/AIDS, information alone does not usually change people's attitudes or behaviours.

 

	Too often education and training activities consist of 'talking at' people, telling them what to do and what not to do, or what they already know.
	Traditional teaching techniques often do not take into account people's own experiences and their understanding of disease, which influence their attitudes to life, death and risk taking.
	These techniques do not give people the opportunity to find ways to solve problems at work, in their communities or personal lives, or to assess change in attitudes or behaviour.
	Educators and trainers often say that they find it easier to do most of the talking because they feel they do not have the skills and confidence to try other methods.

Education and training sessions should start with what people already know and think about AIDS, and should address the issues they are concerned about. This is best achieved using methods that encourage people to communicate with each other. Communication is a two way process and means sharing information, ideas, feelings and knowledge. It means that people themselves do the talking, as well as listening to others. The methods described in this insert help to promote effective communication and are part of what is called the 'participatory learning' approach.

Before starting 
If you are new to AIDS education or training, or even if you have been teaching for a long time, it is a good idea to take time to think about your:
 

	own feelings about HIV infection and AIDS;
	fears and ideas about illness and death;
	attitudes to sex;
	past experiences - the way that you were taught, how you teach now, and whether you need to make any changes in the way that you teach.

In your role as a trainer or facilitator, avoid being judgemental and forcing your opinions on others - listen, and only give advice when asked. Choose your words carefully. Think about:
 

	being direct and clear, while not offending people;
	using words that are locally acceptable to describe sexual practices and male and female genitals;
	your ability to talk freely about sex;
	using words which do not offend people who have HIV/AIDS, or their families;
	using expressions that do not stigmatise or blame people; for example, say person with HIV or AIDS, not victim; and sex worker, not prostitute.

Approaches to education and training    Information giving approach             Information sharing approach     'Top-down', talking at people Encourages dialogue Telling Selling Professional knows best Partnership Teacher directed Learner directed Depends on lectures Uses many methods Teacher makes decisions Promotes decision making

Steps to participatory learning

The five steps described in this insert are all part of successful communication. They can be used to help with planning, organising and evaluating training and education sessions. The exercises provide examples of what you can do for each step, and they can also be used for the other steps too.

1: Assess what people know already

It is easy to waste time telling people what they know already and talking about things in a way that is not relevant to them. It is very important to find out:

	about people's concerns, fear and anxieties;
	what they know about HIV and AIDS and what misunderstandings exist;
	what they think can and cannot be changed through education;
	the factors that influence people's behaviour.

One way to find out what people think and know about AIDS is to carry out a 'listening survey', 

What is a listening survey? 

To carry out a listening survey, the trainer or educator needs to spend time in public places, such as buses or market places, listening to what people are saying. Sometimes the topic of AIDS is not raised at all, because people are thinking about other issues such a drought or the rise in the cost of living. Then it may be necessary to prompt discussion by saying something about AIDS which causes people to react and start talking.

 
'... be there, be aware, but try to remain in the background'
A listening survey is different to a formal kind of survey where certain questions are asked and the responses are immediately recorded by a researcher. In a listening survey, the listener must listen, remember what is said, and write it down afterwards.

Another way to find out what people think or know about AIDS is by doing the beliefs activity described below. 
 
Exercise: Beliefs activity
 

	Take a large piece of paper, or prepare a clean surface on a chalkboard.
	Ask people to name ways in which they think the virus is and is not transmitted. Write down the suggestions.
	Then ask people to place a tick or a cross in columns next to the suggestions marked 'true' or 'false' depending on what they believe.
	Use this information as the basis for a discussion on AIDS or to clear up misunderstandings, and to provide information to fill the gaps in people's understanding.

You could use this exercise in other ways, such as asking people to name signs and symptoms of HIV infection and AIDS. This could help to resolve misunderstandings about the differences between HIV infection and AIDS.

2: Build on what is known 

When you have found out what people know or do not know about AIDS, and what misinformation exists, you can begin to fill the gaps and teach the facts.

Tips for teaching the facts 
Although people need to know the facts, this does not mean that the trainer or educator should do all the talking! It is better to create an atmosphere which enables people to take part as much as possible. Here are some important hints.

Plan the session carefully: 
 

	get your information together and be sure of your facts;
	make sure that the group is not too large and encourage people to form a circle with you as part of it;
	try to break up the session with exercises;
	leave time for a summary and questions.

And, during the session:
 

	use the KISS rule: Keep It Short and Simple, avoiding complicated language;
	talk honestly about behaviour change options - if people are reluctant to talk about sex, start off with other forms of behaviour change they may feel more comfortable with, such as drinking or smoking less;
	avoid making people more fearful, and emphasise the benefits of change;
	repeat the information without boring people by asking them to summarise what you have said;
	use visual aids, and make sure they can be seen;
	break the group into smaller groups to discuss issues, and ask members to summarise their discussions in the main group.

3: Check people's understanding

It is important to check that what you have said has been understood. But tests are not necessary! Different participatory activities can be used to check people's understanding.

For example, try the beliefs activity described in Step 1. Another is called 'check the rumours'. 

Exercise: Check the rumours 
There are many rumours about AIDS. This exercise allows people to talk about these issues, and explore their own fears and prejudices. It also helps the trainer to find out if misunderstandings still exist after a 'teach the facts' session.
 

Before the exercise, write down statements on cards that reflect what you know to be misunderstandings or local rumours about AIDS. Examples include: AIDS is a problem caused by foreigners; HIV infection means a person has AIDS; AIDS is a punishment from God and only people who are guilty need to worry about getting it.

Each person in the group will need at least one card.
 

	Pass the cards around to each group member, and ask everyone to discuss the statements in pairs.
	Ask each person to read out the statement, and comment on whether it is true or false.
	Invite other people's opinions and discuss the conclusions reached.

You can also ask people to make their own statements and use these as a basis for discussion.

Exercises like group discussions also help to reveal misunderstandings.

Exercise: Small group discussion 
In this exercise, six to ten people discuss issues around a specific subject. Allow half an hour to an hour: any longer and people will get tired! Your role is outlined below.
 

	Stress that everyone's opinion is valuable, and make clear that the only rules are that one person speaks at a time, that people stick to the topic, and that no one is obliged to talk;
	Start the discussion with a few questions like the ones below. The questions will depend on what people already know, and the purpose of the workshop. Does AIDS exist? Is it a problem in your community? How does a person become infected? How can we prevent AIDS? Are people changing their behaviour? What stops people changing their behaviour? What can be done about the problem?
	Listen to, and note down what people say. Don't become involved in the discussion, except to guide it by reminding people of the questions, for example. Ensure that everyone has a chance to speak. Encourage people who are quiet, but avoid putting pressure on them.

At the end of the discussion:
 

	ask each person for their final comments;
	summarise what people have said, without giving your own opinion, unless you are asked for it;
	talk about any prejudices or misunderstandings, without saying who said what;
	ask people what their ideas are for developing any suggestions that came out of the discussion.

 

4: Problem solving and decision making

Teaching the facts about AIDS provides only the background for attitude and behaviour change. Training and education should go beyond giving information; they should encourage people to talk about problems and work out solutions. Activities can include role playing, telling an open ended story or using visual aids such as picture codes. Here is an activity that helps people to think about and actively participate in solving a problem.

Exercise: Tell an open-ended story 
The facilitator or a member of the group tells a short story which describes a problem, based on a real life situation. It includes people's emotions, beliefs and attitudes. The story stops at a point of decision, and then people discuss possible solutions to the problem.

Here is an example of an open-ended story about a woman called Mary which could be adapted to your own situation:

We live in town, and my husband runs a small business selling vegetables. He has many friends and I suspect that he likes to spend time with girlfriends too. As the bread winner of the family I suppose that he feels free to do what he likes. I think that he has an STD too, although I cannot be sure and of course I cannot ask. He is sometimes violent if I ask too many questions. There are many things on my mind this year: shortages, the drought, rising prices and the fear of getting an STD, this problem of AIDS...and now I'm pregnant again.

Now ask these questions: 
 

	What is happening at home?
	How does Mary feel?
	What advice can we offer Mary?
	What do you think her husband should do?

Encourage the group to discuss the problem and suggest practical solutions; and to tell stories based on their own experience.

5: Evaluating education or training

Many training and education programmes stop short of evaluating and assessing change. Sometimes evaluation is left until the project is nearly finished, or is avoided because change is felt to be too difficult to measure. But evaluation is a very important part of any project, and should start at the planning stages.

The techniques and exercises described in this insert are a useful way to involve participants in the process of evaluation. They help to: 
 

	find out what problems need to be addressed;
	see what people want;
	plan interventions;
	assess changes in attitudes;
	plan ahead for other activities.

Exercise: Structured discussion
You will need about two hours for this activity.
 

	Divide the main group into small groups of six to eight people. Give each group a large piece of paper on which to record information.
	Before the session, and depending on the objectives of the evaluation, prepare a few questions for each group to answer. If you are evaluating a community education project, questions might include: What misunderstandings about AIDS still exist in the community? What are the main problems that have been experienced during the project? What changes in behaviour have been observed in the community since the project started? How should the project develop?
	Each group selects a recorder to list the responses suggested by the participants.
	The recorder will then ask the group to order the responses so that the most important are first on the list, and the least important are last. Make sure that everyone agrees the order.
	Ask everyone to go back into the main group, and display all the response sheets.
	Discuss the responses again in the large group, reach agreement about the order of importance and make a final list.

 

Evaluation also helps the trainer or educator to find out:    if the message has been understood; how it has been received; and if it has been acted upon. Finally, it is important to find out what people think about your session, and how what they have learnt might help them in future or influence what they think or do.

So always make time at the end for people to give feedback on the session. Here are some ideas for finding out what people thought.
 

	Go round the group asking each person to say one thing they have found useful or one thing that they would like to know more about. They could also say one thing they have changed their mind about, or something they didn't like about the session.
	Spend time discussing people's future plans. If they themselves are trainers or educators, encourage them to spend time in small groups working out strategies for changing their approach.
	Spend time developing any ideas or plans that arose out of earlier group discussions.
	Ask people if they would like a follow-up session, and what they would like to learn about or do.

Written by Sue Laver, Lecturer, Department of Community Medicine, University of Zimbabwe.

Illustrations and design copyright Action Magazine, Harare, Zimbabwe.

All these activities, and more, are described in detail in booklets 1 to 6 in the 'Let's teach about AIDS' series. These can be obtained by writing to Healthlink Worldwide, or to Sue Laver, Department of Community Medicine, Box A 178, Avondale, Harare, Zimbabwe.

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