[MUSIC] [MUSIC] In our prevoius lecture, we looked at the issues involved in identifying, recruiting, and involving people in training programs. It's important to now to look at what the training needs are of the people we will be involving. So this lecture concerns diagnosing training needs, we're going try to figure out what information is needed in order to design a training program for a specific group of trainees. There are various diagnostic questions that we must ask ourselves, such as what tasks do workers have to do? We need to find out if people actually have a job description. And if they do, have their tasks changed recently? Are the workers actually practicing what is in their job description or what they've been assigned to do? And what do workers already know about the tasks that they're doing? Is their knowledge up-to-date? Do they need newer information or additional information to perform those tasks appropriately? More questions that we need to ask include what skills do workers already possess? As we mentioned before in adult education, people come to a training situation with a wealth of experience. We want to know what people already are able to do, what they have been doing. We want to find out where workers would need extra help in order to perform their tasks better. We want to identify those tasks that workers are unable to perform at present, either because they do not have the information to do it properly, or the skills to do it properly, or the tasks have changed and they need to be updated. We also need to find out what workers' attitudes are to their assigned tasks. Do they see the things that they're expected to do, such as record keeping, as an extra burden or do they see it as an important way of keeping track of work and planning for the future? Additional questions include looking at the standard or the ideal of the work that should be performed. There may be standing orders on how to examine, for example, examine a child that has a fever and the questions that a person should ask. We need to find out these standards and they may be built into job descriptions. We also need to find out what clients expect from the workers, and are health workers able to perform what the clients expect. One of the simple things that we found from training volunteer village health workers is that community members expect the village health worker to be able to treat common illnesses. Are we able to train to meet those expectations? Answers to these questions form a baseline from which not only can we develop appropriate content for our training, but also at the end of the training, use this information to evaluate whether we have achieved any changes in knowledge, skills and attitudes on the part of the trainees. In order to do this properly we need to understand the tasks very clearly that the health workers are expected to perform. We need to meet with them and discuss how they're working, what they're doing, their understanding. They can show us step by step how they go about their work. We really need to think carefully about what the trainees will be doing when they go back. How will they implement the skills? How will they implement the task? And therefore by reviewing existing curricula, their basic training that they had before coming to the job, their current job descriptions and the technical literature, we will get ideas about the tasks and jobs that they're expected to perform. Once we have an idea of these tasks, we need to improve it by comparing it, again, like I said with what the community needs and expects, what is acceptable in the local culture. It's important at this point to seek community input. We said we need to involve trainees. We need to involve the clients too, to get their input to see what their needs are, how the health worker will meet them. Is the health workers' current performance meeting their needs? We also can improve and enhance the list of tasks that health workers are performing and our understanding of those tasks by observing them actually doing the job and talking to them about how their work is going. One of the common tasks in a outpatient setting for children, child welfare clinics or antenatal clinics, outpatient pediatric clinics, is the importance of teaching mothers about how to prepare oral rehydration solution, practice oral rehydration therapy when their children have diahhrea. Mothers can't always bring children quickly to the clinic, but if they perform oral rehydration therapy at home, they can prevent the child from going into dehydration, and then death. Now the health worker herself needs to have the skills to demonstrate this process of preparing whatever the locally appropriate formula is for oral rehydration. A number of local salt-sugar solution formulas have been developed in different countries based on different kind of measurements, bottles, spoon sizes et cetera. So when you're looking at this in terms of what the health worker is going to do, we have to think about the tasks involved in preparing the oral rehydration solution. The health worker also needs to be able to assess the signs of dehydration, to find out if a child, for example, the eyes are sunken, there's no tears, the child is thirsty, a sunken fontanelle in a small child. The health worker needs skills to ask the mother or caregiver, whoever brings the child, about the child's condition. So these are some of the tasks involved in managing a child that comes to the clinic who has diarrhea. A fourth step, is to determine the extent of dehydration, then developing an appropriate treatment plan. Including starting oral rehydration at the clinic and of course treating the patient according to that plan, which would in addition involve teaching the mother, or caregiver how to continue the care at home. The health worker would then refer severe cases to the higher referral hospital, possibly if they have to set up intravenous drip. The other issues that the health worker needs to be able to do in this whole process is identify whether the child has other problems. If there's in addition to diarrhea, there may be fever, there may be blood or mucus in the stool. There's fever, the child may have dysentery, and that would require additional medical treatment. Part of the whole process of managing a child with diarrhea is recording the information in the patient register. And then on a monthly basis compiling that information, submitting reports. So these are some of the steps involved in the task of managing children with diarrhea and dehydration. By looking at these steps carefully, it's possible to analyze the task, figure out where the health worker is performing them well, where there may be difficulties, and use that as a basis for training. So we want to examine each task carefully then see if it's being performed as expected. Then we need to look at the tasks carefully and subdivide them into subtask competencies or steps. If the health worker is going to assess a child for referral to another clinic what are the steps? What are the steps involved in assessing the level of dehydration? How about checking the skin? Checking the eyes? Et cetera. All of these steps need to be spelled out clearly so we can see if the whole skill of assessing level of dehydration is being performed. In addition to identifying the steps we need to know, and figure out what knowledge, what attitudes are needed to carry out each step, each task along the way. For example, in terms of mixing the local salt, sugar solution, the knowledge of the exact ingredients, the measurements in the local situation, the attitudes about teaching this to the mothers in terms of what kind of approach the health worker is taking, being aware of mother's attitudes. For example, we found in many communities in Nigeria that mothers are skeptical about sweet fluids, putting sugar in things, because they believe that sugar can cause diarrhea to become a more serious disease, actually progress into dysentery and be more harmful to the child. So we need to be aware of all these things and find out if the health worker is aware, so that he or she has this information, has this knowledge, and is able to communicate effectively to mothers. Let's look in more detail at the task in terms, task number nine in the list we reviewed, in terms of recording the patient data in a register. Let's look at the context of that. This should be done during the provision of services. It should not wait until evening when the clinic closes. The health worker won't remember the details to put down. So this is something that should be an ongoing part of the service. The components of this task include writing on forms, filling in a register, writing down information about a patient, the patients response to treatment. So we need to look carefully at the forms that are provided and the case note requirements and see what information is needed and where it should be recorded . The skills involved in carrying out this task include writing, spelling, possibly calculation. How much fluid was given to the child, what was the child's weight, et cetera. Knowledge that's required to carry out this task. What are the specific information needed on the forms? Why is this information important? And then attitudes and appreciation of the importance of recording data, monitoring children's progress, looking at clinic attendance over time, identifying people that may need follow up. So, the importance of recognizing the importance that the health worker needs to appreciate the value of data recording. At this point it's necessary for us to remember our earlier concern about involving trainees in the process of their own training. Again this diagnostic process, finding out what trainees need to learn, should involve them. This task analysis is not something that an external consultant comes in and watches them, writes down things and then goes and designs a training program. It's important for the trainees also to be involved in this task analysis. They can observe each other, they can sit and discuss the task. What parts are difficult, what parts are easy, where do they need additional information? What parts they often forget? The observer can have the standard observation checklist about things that should be done. It may turn out that many of the workers forget a certain step. Writing information down, or checking the child's temperature before they carry out the activities. And if this type of thing is observed it should be discussed among the potential trainees so that they can think about what is missing, what is important for their training. This information, observing, analyzing the tasks, the diagnostic information, again, can be shared or should be shared with the training committee, so that they can discuss these tasks, identify the areas that need updating, and again, bring in the viewpoint of the trainees. Again, since attitude are such an important part of practicing a skill, the training committee with representatives from the trainees can talk about the difficulties that they experienced. Maybe they feel that what information they provide on record forms is not valued or appreciated when they forward their reports. So these kinds of concerns can come out and be highlighted and incorporated into the training design. We will be looking at more specific methods and sources of information in our next section.