THE PHC MAP SERIES OF MODULES, GUIDES AND REFERENCE MATERIALS Each module includes: a User's guide a Facilitator's guide computer programs Module 1 Assessing information needs Module 2 Assessing community health needs and coverage Module 3 Planning and assessing health worker activities Module 4 Surveillance of morbidity and mortality Module 5 Monitoring and evaluating programmes Module 6 Assessing the quality of service Module 7 Assessing the quality of management Module 8 Cost analysis Module 9 Sustainability analysis Manager's guides and references Better management: 100 tips Problem-solving Computers The computerised PRICOR thesaurus Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva and Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok, Thailand Co-Editors: Jennifer Sharples, Colin De'Ath, Bangkok, Thailand Design & Layout: Helene Sackstein, France Desktop Publishing: Marilyn J. Murphy, Suracha Suntarasut, Somboon Vacharotai Foundation, Bangkok, Thailand Printing: Thai Wattana Panich, Bangkok, Thailand Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W., Washington DC and the Aga Khan Foundation, P.O. Box 6179, 1211 Geneva 6, Switzerland. Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan Foundation (United Kingdom) in London; and AKF offices in Dhaka, Bangladesh; Delhi, India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal; and Dar-es-Salaam, Tanzania; the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand SURVEILLANCE OF MORBIDITY AND MORTALITY MODULE 4 FACILITATOR'S GUIDE Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B. Steeler (1948-1992) and all other health leaders, managers and workers who follow their example in the effort to bring quality health care to all in need. The Primary Health Care Management Advancement Programme has been funded by the Aga Khan Foundation Canada, the Commission of the European Communities, the Aga Khan Foundation U.S.A., the Aga Khan Foundation's head office in Geneva, the Rockefeller Foundation, the Canadian International Development Agency, Alberta Aid, and the United States Agency for International Development under two matching grants to AKF USA. The first of these grants was "Strengthening the Management, Monitoring and Evaluation of PHC Programs in Selected Countries of Asia and Africa" (cooperative agreement no. OTR-0158-A-00-8161-00, 1988-1991); and the second was "Strengthening the Effectiveness, Management and Sustainability of PHC/Mother and Child Survival Programs in Asia and Africa" (cooperative agreement no. PCD-0158-A-00-1102-00, 1991-1994). The development of Modules 6 and 7 was partially funded through in-kind contributions from the Primary Health Care Operations Research project (PRICOR) of the Center for Human Services under its cooperative agreement with USAID (DSPE-6920-A-00-1048-00). This support is gratefully acknowledged. The views and opinions expressed in the PHC MAP materials are those of the authors and do not necessarily reflect those of the donors. All PHC MAP material (written and computer files) is in the public domain and may be freely copied and distributed to others. Contents FOREWORD 1 SESSION 1: INTRODUCTION AND OVERVIEW 7 Transparencies 4-1: Workshop objective 13 4-2: Surveillance 14 4-3: Limitations of surveillance 15 4-4: Surveillance methods 16 4-5: Steps in setting up a surveillance system 17 SESSION 2: SPECIFY OBJECTIVES AND DEFINE SURVEILLANCE DATA (STEPS 1 AND 2) 19 Transparencies 4-6: Session 2: Objectives 24 4-7: Information for surveillance objectives 25 4-8: Sources of possible indicators 28 SESSION 3: SPECIFY SURVEILLANCE METHODS AND DATA COLLECTION PROCEDURES (STEPS 3 AND 4) 29 Transparencies 4-9: Session 3: Objectives 32 4-10: Data sources 33 4-11: Substeps for designing collection procedures 34 4-12: Rules for recording cases 35 4-13: Types of instruments 36 SESSION 4: COLLECT, REPORT AND ANALYSE THE DATA (STEPS 5 AND 6) 37 Transparencies 4-14: Session 4: Objectives 41 4-15: Training topics 42 4-16: Supervision requirements 43 4-17: Possible data patterns 44 4-18: Factors influencing number of cases reports 45 SESSION 5: INVESTIGATE CAUSATION (OPTIONAL) (STEP 7) 47 Transparency 4-19: Session 5: Objective 49 SESSION 6: DEVELOP AN ACTION PLAN AND PRESENT REPORTS (STEPS 8 AND 9) 51 Transparencies 4-20: Session 6: Objective 55 4-21: Action plan components 56 4-22: Guidelines for preparing reports 57 Foreword What is the purpose of the Facilitator's guide? The Facilitator's guide contains a suggested workshop design for use by individuals who will help PHC managers and staff learn how to use the Primary Health Care Management Advancement Programme (PHC MAP) series. There is a Facilitator's guide for each module in the PHC MAP series. What information does it contain? Each Facilitator's guide contains instructions for conducting a workshop on one of the modules in the PHC MAP series using the information contained in the User's guide. The instructions are arranged in one to two hour sessions. The number of sessions depends on the amount of information and/or the number of steps contained in the User's guide. The first page of each session lists session objectives, major topic headings, time required, and materials and equipment. The following pages describe the instructional activities in outline form. The outline is divided into two columns. The right-hand column indicates what the facilitator says or does to conduct the session. The left-hand column lists the handouts, overhead transparencies, or other materials needed to support the activity. Copies of these materials, suitable for duplication, appear at the end of the session in which they are first used. Some transparencies are used in more than one session. How are the workshops organised? The first session of each workshop contains activities designed to introduce the PHC MAP series and explain its importance to PHC programmes, present an overview of the workshop, explain the purpose of the module, review specific terms or concepts used in the module, and acquaint the participants with the organisation and content of the User's guide. The final session of each workshop contains activities designed to review key points of the User's guide, if appropriate, help participants prepare an action plan, and brings the workshop to a formal conclusion. The sessions in between present the steps required to accomplish the purpose of the module and provide an opportunity for participants to apply those steps to their own programmes. Each workshop is designed to be given on consecutive days, uninterrupted except for breaks, meals, and rest, if the workshop is longer than one day. It is recognised, however, that situations vary and the PHC MAP modules will be used singly or in combination by individuals and organisations in the field and on university campuses. Therefore, it is expected that the workshops described in the Facilitator's guides will be adapted to fit a range of circumstances. Indeed, those who facilitate PHC MAP workshops are encouraged to make adaptations to meet the needs of participants and/or specific PHC programmes. Who can be a facilitator? Ideally, the person who serves as facilitator has training and experience in the fields of public health, management, planning, and evaluation, as well as sampling and survey design. It is recommended that this person also be skilful in working with small groups. The facilitator should be someone from outside the PHC programme, perhaps from another agency or a university. As a person with no direct interest in the programme, the facilitator can be neutral in disagreements that may arise and help the group members resolve an issue objectively. Having an outside person as facilitator also allows the programme director, who usually has a leadership role, to contribute his or her knowledge and experience as a full participant in the work of the group. It is also recommended that a facilitator have a full set of PHC MAP User's guides and Facilitator's guides. It is sometimes necessary, in the course of completing one module, to refer to information in another module. Who should participate in the workshop? The primary audience for the PHC MAP series is the team that manages PHC programmes or other population-based health programmes in either the public or private sector. An example of a PHC management team in the public sector is the core staff of a district ranging from 100,000 to 300,000 in size of population served. An example of a PHC management team in the private sector is the core staff of an NGO that provides PHC services to a specific population in a given geographic area. The average size of the service population may range from 40,000 to 60,000, but may be as small as 10,000 or more than 100,000. In either case, the management team should have: the knowledge and skills needed to complete the steps in the module the time and resources required to collect and analyse the required data the authority to plan and implement improvements in management systems and procedures based on this analysis. If feasible, teams from several districts or from several PHC programmes within a given NGO, may work simultaneously with one facilitator to complete a module. It is recommended that one facilitator work with no more than four teams or 20 people at one time. What does the facilitator do? Understands the needs of participants. If the facilitator is working with one PHC programme, the most efficient way to gather information about participants and the programme in which they work is to meet with the PHC director to determine: the nature of the PHC programme (services provided, size and description of area served, number and type of facilities, number and qualifications of staff, community involvement, computer capability, strengths, major problems, etc.) if information needs have been clearly identified previous staff training in management information systems or related topics resources available for training (time, space, equipment) possibility for subsequent technical assistance to workshop participants. Understands the content of Module 1. Read the User's guide and Facilitator's guide for Module 1 and consider options for workshop delivery. The purpose of Module 1 is to help participants select priority information needs and to review some basic concepts underlying management information systems. Depending on participant background, the amount of time available, and the need to establish priorities among management information needs, Module 1 can be presented in its entirety, limited to Level 1: Quick start, limited to the PHC MAP systems framework, or in summary form as contained in the first session of the Facilitator's guides for Modules 2 through 9. If information needs have not been clearly identified and participants have no background in systems, then Module 1 should be presented in full. The selection of the next module will depend upon priorities set by the participants as they complete the steps in Module 1. If information needs have been clearly identified and participants have no background in systems, then that portion of Module 1 can be added to the first session of the selected module. If information needs have been clearly identified and participants have a background in systems, then the overview of PHC MAP in the selected module will be sufficient. Understands the content of the selected module. Read the User's guide and Facilitator's guide for the selected module and consider options for workshop delivery. Depending upon the length of the module and the availability of staff for training, the workshop sessions may be presented as described in the Facilitator's guide, or workshop sessions may be delivered at intervals (for example, every morning for a certain number of days, one session per week, or one day per week for three or four weeks). If follow-on technical assistance is available, the content of the module could be presented in the workshop and the application of the procedure to the PHC programme could be conducted on the job. Participants could plan steps in the workshop, complete them on the job, and bring the results to the next workshop session. This approach is particularly applicable to Module 2 which requires development of a questionnaire, selection of a survey sample, training of data collectors, and data collection. These steps cannot actually be carried out within the time limits of the workshop as contained in the Module 2 Facilitator's guide. Other options are possible depending upon the circumstances of each situation. Determines what programme information, if any, is needed for completion of the module. For example, census data and lists of households are required to complete some of the steps in Module 3. Determines the most appropriate people to attend the workshop. For example, Module 7 is best completed by those responsible for planning, training, supervision, logistics, and other management services. Discusses the delivery options and participants with the PHC manager and make decisions regarding the most appropriate option and participant selection. Also determines if the needed information is available and if it is not, the alternatives for obtaining the information. Notifies participants of the date, time, and purpose of the workshop and confirms attendance. Initial notice of the meeting may come from the PHC manager, with follow-up by the facilitator. Prepares the agenda, using as a model the sample in Session 1 of the Facilitator's guide for the selected module. Inspects the room where the workshop will be held and answers these questions: Is the room large enough to seat all the participants? Can chairs and tables be arranged in a variety of ways; all participants around one table; participants in groups of three or four at smaller tables? Is the lighting adequate? Can temperature and humidity be controlled? Is there an electrical outlet for an overhead projector? Is a microphone necessary for everyone to hear and to be heard? Are toilets conveniently located? Is the site convenient to parking, restaurants and public transportation? Are supporting facilities available and convenient: duplication, word processing, computers? Prepares notes to conduct the workshop using the session outlines in the Facilitator's guide for the selected module, and makes the necessary adaptations. Refer to the appropriate User's guide for content. Duplicates the worksheets and other handouts as indicated in the Facilitator's guide and obtains the necessary equipment. Conducts the workshop as planned. Provides follow-on assistance, if appropriate.Session 1: Introduction and overview Objectives: Participants will be able to: Explain the purpose of Module 4. Define surveillance as used in Module 4. Name at least two purposes of surveillance. Distinguish between quantitative and qualitative surveillance. Explain how surveillance data contribute to PHC programme planning. Session outline: I. Introduction (30 minutes) II. Overview of workshop (10 minutes) III. Purpose of Module 4 (10 minutes) IV. Module 4 User's guide (10 minutes) V. Definitions, purposes and principles (30 mi<->nutes) Materials: Module 4 User's guide Handout 4-1: Sample Agenda Transparency 4-1: Workshop objective Transparency 4-2: Surveillance Transparency 4-3: Limitations of surveillance Transparency 4-4: Surveillance methods Transparency 4-5: Steps in setting up a surveillance system Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (30 minutes) Note: Omit Section I if you have presented Module 1, or some other module, immediately prior to the presentation of Module 4 A. OPENING REMARKS Introduce self and other staff, as necessary. Explain your role in the workshop. If you do not know the participants, ask each one to state his or her name, position title, and job location. Note: If the group is larger than 6 or 8, you may wish to have them wear name tags or place cards with their names at places where they are sitting. Ask each participant to complete this sentence: "As a result of attending this workshop, I expect . . ." and write their responses on the flip chart. When all responses have been recorded, say that you will return to this list after giving an overview of the workshop. B. OVERVIEW OF PHC MAP Explain why information is important or PHC programmes. Summarise PHC MAP programme, including: Purpose of PHC MAP Title and purpose of each module and other materials. Make the following points about PHC MAP: Has been field tested and revised toensure use fulness to PHC programme staff. Modules can be used in any sequence. Materials can, and should, be adapted to fit a particular situation. The procedures outlined in the modules can be adopted as routine monitoring activities in a PHC programme. Explain why MAP is being introduced in this PHC programme. Note: The specific programme and should provide the answers to these questions: Why are we doing this workshop? What do we expect to achieve? It may be appropriate for the PHC manager to make these remarks. II. Overview of workshop (10 minutes) Review the workshop objectives. Distribute and review the workshop agenda, describing the activities that will take place to accomplishthe workshop objectives. Review the expectations contributed by particippants at the beginning of the session. Indicate which ones will be met and which ones will not and why. Suggest, if possible, alternatives for meeting expectations that will not be met in this workshop. Ask for questions or comments. III. Purpose of module 4 (10 minutes) Explain that the purpose of Module 4 is to help PHC programme staff set up and operate a local surveillance system, using simple and inexpensive tools. Discuss the value of collecting surveillance data and how it relates to other modules in the PHC MAP series. IV. Module 4 User's guide (10 minutes) Distribute a User's guide to each participant. Highlight key sections of the User's guide. Quick start, with a computer programme. Introduction to surveillance principles. Step-by-step directions for designing and operating a surveillance system. Appendices containing blank worksheets and other reference material that will be used in the workshop. References, glossary and list of acronyms and abbreviations. V. Definitions, purposes and principles (30 minutes) Define surveillance and discuss its purposes in PHC programmes. Distinguish between quantitative and qualitative surveillance. Stress the importance of collecting only necessary data. Refer participants to the example in the User's guide, discuss the example, and ask them if the data represented are the result of quantitative or qualitative surveillance. Discuss some limitations of surveillance. Discuss the principles of an effective surveillance system as participants follow along in their User's guide. Explain the four surveillance methods recommended in this module, and the advantages and disadvantages of each. Review briefly the steps in Module 4, including expected outcomes. Ask for questions or comments on the definitions and principles, the module as a whole, and the workshop itself. SAMPLE AGENDA MODULE 4* Session 1 (1 hr,, 30 mins), Introduction and overview Session 2 (1 hr,, 45 mins), Specify objectives and define surveillance data (Steps 1 & 2) Session 3 (1 hr,, 20 mins), Speficy surveillance methods and data collection procedures (Step 3 & 4) Session 4(1 hr,, 40 mins), Collect,, report and analyse the data (Step 5 & 6) Session 5(1 hr,, 20 mins), Investigate causation (Optional) (Steps 7) Session 6:(1 hr,, 20 mins), Develop an action plan and present reports(Step 8 & 9) *For an actual presentation, substitute the appropriate clock hours in the first column. WORKSHOP OBJECTIVE Design and operate a surveillance system using the principles, steps and materials contained in Module 4 SURVEILLANCE Surveillance of morbidity and mortality is the collection and analysis of selected health and vital events to: identify, investigate, control epidemics identify populations at risk confirm disease control priorities evaluate input of activities on incidence and prevalence monitor trends LIMITATIONS OF SURVEILLANCE Labour intensive activity Tabulation and analysis are time consuming Limited to a few key indicators Several years of data collection is necessary to identify trends Difficult to assess impact if population is small, or if no control group Reporting of surveillance data is often incomplete SURVEILLANCE METHODS Routine reporting system Sentinel reporting system Surveys and special studies Case or outbreak investigation Vital registration systems Census STEPS IN SETTING UP A SURVEILLANCE SYSTEM Step 1: Specify objectives Step 2: Define data to collect Step 3: Specify method(s) Step 4: Develop data collection and reporting procedures Step 5: Collect and report data Step 6: Analyse data Step 7: Investigate causation (optional) Step 8: Develop an action plan Step 9: Prepare and present reports Session 2: Specify objectives and define surveillance data (Steps 1 and 2) Objectives: Participants will be able to follow the directions in the Module 4 User's guide to: Specify the purpose, scope, and time period of the surveillance; the users of the surveillance information; the target group; the type and frequency of surveillance. Determine what data the system will collect, how frequently, from which source, and using which procedure. Session outline: I. Introduction (5 minutes) II. Specify the objectives of the surveillance (40 mintes) III. Define the surveillance data to collect (60 minutes) Materials: Module 4 User's guide Transparency 4-6: Session 2: Objectives Transparency 4-7: Information for surveillance objectives Transparency 4-8: Sources of possible indicators Handout 4-2: Worksheet for specifying objectives Handout 4-3: Worksheet for specifying surveillance procedures Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I.Introduction (5 minutes) Review the session objectives. Describe briefly the session activities. II. Specify the objectives of the surveillance (40 minutes) Explain that the purpose of this step is to decide on and record the objectives of the surveillance system. Refer participants to the completed Worksheets A and B, pages 20-21 from Module 1 (if done) to review their overall information needs. Note: If Module 1 has not been completed, decide now as a group what the overall information needs are for the PHC programme. Remind participants that what they choose to monitor should be based on overall programme goals, but will not be able to cover everything. Review and discuss the categories of information needed to formulate specific surveillance objectives. Distribute the worksheet and direct participants to complete it in small groups for their catchment area. Refer participants to the sample completed worksheet on page 11, Module 4 for guidance as needed. Note: Groups of 4-5 participants are recommen<->ded if the group is large to increase opportunity for individual participation. If more than one PHC is represented, groups should be formed on the basis of programme. Facilitate discussion of the completed worksheet. Ask a spokesperson from one group to report the items checked for purpose with supporting arguments. Invite other groups to report on differences and help participants reach consensus on any differences. Repeat 1 and 2 for other sections of the worksheet. Ask for questions and comments. III. Define the surveillance data to collect (60 minutes) Explain that this step will help determine precisely which data the surveillance system will collect, how frequently, from which source, and using which procedure. Distribute the worksheet and explain each section as the participants (working in groups assigned in II above) complete the first three columns on the worksheet. State that the second part of the worksheet will be completed in Step 3. Direct participants to enter target groups identified in Step 1 in the first column. Discuss considerations for completing column 2: Mortality Cause of death Refer participants to Table 3 on page 22 for causes that can be determined by interview. Review verbal autopsy approach in Appendix E. Review Appendix D for a discussion of feasibility of determining cause of maternal and childhood deaths. Morbidity Refer participants to Table 2, page 19, for a list of priority diseases. Refer participants to Appendix B for more detailed information. Cause of disease How much information should be collected? Suggest sources for specifying indicators which are entered in the first column. Ask for questions and comments. SESSION 2: OBJECTIVES 1. Decide on and record the objectives of the surveillance system 2. Determine data to be collected and frequency, source(s), and procedure(s) INFORMATION FOR SURVEILLANCE OBJECTIVES Purpose(s) Users Scope Target groups Cases and/or causes Other topics Time period and frequency WORKSHEET FOR SPECIFYING OBJECTIVES OF SURVEILLANCE PURPOSE(s) __Assess needs __Monitor trends __Explain causes __Identify risk factors __Evaluate impact on________ __Identify outbreaks __Other:________________ __Identify unusual events __Other:________________ USER(s) __Board of directors __PHC Manager __Community __Government officials __PHC Staff __CDC* __Supervisors __Other:________________ __Donors __Other:________________ SCOPE __Geographic area(s):_________________________________ __Programme service(s):_______________________________ TARGET GROUP(s) __Children 1 month __Women 15-59 yrs __Children 12-23 months __Married women 15-49 yrs __Children 1-4 yrs __Pregnant women __Children 5 yrs __Other:________________ CASES CAUSES OTHER __Mortality __Mortality __Specify:__ __Morbidity __Morbidity __Specif:__ TIME PERIOD: ____________FREQUENCY:__________ *Local communicable disease centre Step 2: Define the surveillance data to collect Step 3: Select the surveillance methods DATA COLLECTION Target group Mortality/ morbidity/other Indicator Frequency Source Method* *Routine, sentinel, sample survey/special study, case/outbreak investigation, verbal autopsy WORKSHEET FOR SPECIFYING SURVEILLANCE METHODS, , , , SOURCES OF POSSIBLE INDICATORS Module 1 Appendix B Module 5 Session 3: Specify surveillance methods and data collection procedures (Steps 3 and 4) Objectives: Participants will be able to follow the directions in the Module 4 User's guide to: Specify surveillance methods for each of the indicators selected in Session 2. Design data collection procedures. Session outline: I. Introduction (10 minutes) II. Select the surveillance methods (30 minutes) III. Develop the data collection and reporting procedures (40 minutes) Materials: Module 4 User's guide Transparency 4-9: Session 3: Objectives Transparency 4-4: Surveillance methods Transparency 4-10: Data sources Transparency 4-11: Substeps for designing collection procedures Transparency 4-12: Rules for recording cases Transparency 4-13: Types of instruments Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I.Introduction (10 minutes) Review session objectives. State that this session covers Steps 3 and 4 in designing and operating a surveillance system and includes completion of columns 4, 5 and 6 on the worksheet for specifying the surveillance procedures and will guide participants in developing the data collection procedures and instruments. II. Select the surveillance methods (30 minutes) Explain that more than one surveillance method can be used, and that the methods can be modified to better suit the needs of the programme. Instruct participants to return to Handout 4-3, and explain considerations for columns 4 and 5 as they complete them. Frequency of data collection/reporting depends on routine or priority indicators. Primary and secondary data sources. Review the possible methods and advantages and disadvantages of each as presented in Session 1. Facilitate the discussion as participants select the appropriate methods. Ask for questions and comments. III. Develop the data collection and reporting procedures (40 minutes) Review the substeps involved in designing data collection procedures. Explain that every disease that will be monitored requires a case definition to ensure that all healthworkers use the same definitions and criteria. Refer participants of Appendix B for examples of standard and lay definitions of common diseases. Review important rules for identifying and recording cases. Explain the three types of instruments used in surveillance, and what circumstances warrant the use of each, referring participants to examples of each in the User's guide when appropriate. Registers Survey questionnaires Case investigation Ask participants to examine daily clinical treatment records, CHW activities registers or other forms used in their PHC programme and determine whether those forms supply the data they have specified on their worksheet. Direct participants to indicate how the forms should bemodified to correct any deficiencies they find. Ask for questions and comments. SESSION 3: OBJECTIVES 1. Select surveillance methods 2. Design collection procedures DATA SOURCES Primary Secondary SUB-STEPS FOR DESIGNING COLLECTION PROCEDURES Develop operational definitions of cases Develop or revise the data collection/recording instruments Pretest the instruments RULES FOR RECORDING CASES Avoid double-counting Only count those cases that have been diagnosed by a health worker Count current cases only TYPES OF INSTRUMENTS Registers Survey questionnaires Case investigation Session 4: Collect, report and analyse the data (Steps 5 and 6) Objectives: Participants will be able to follow the directions in the Module 4 User's guide to: Plan surveillance activities for their PHC programme, based on the methods selected and procedures developed. Plan the analysis of their surveillance data. Session outline: I. Introduction (10 minutes) II. Collect and report the data (30 minutes) III. Analyse the data (60 minutes) Materials: Module 4 User's guide Transparency 4-14: Session 4: Objectives Transparency 4-15: Training topics Transparency 4-16: Supervision requirements Transparency 4-17: Possible data patterns Transparency 4-18: Factors influencing number of cases reported Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I.Introduction (10 minutes) Review session objectives. Explain that this session will guide participants in planning the collection, reporting and analysis of their data. II. Collect and report the data (30 minutes) Explain the importance of good training and supervision of staff involved in data collection, tabulation, and reporting for a successful surveillance system. Review who should be trained and ask participants to review the worksheet for specifying surveillance procedures and list who will be involved in collecting, tabulating, and reporting their data. Review the recommended training topics. Note: Point out the special requirements for case investigations but explain them fully only if it is a method chosen by participants in the workshop. Discuss what types of supervision will be needed, and facilitate a discussion of any special supervision needs participants foresee for their surveillance method(s). Discuss what is meant by quality control and assist participants to plan as a group ways of ensuring a level of quality for their chosen method(s). Discuss data collection, tabulation, and reporting requirements for each type of surveillance method, stressing those which were selected in Step 1. Ask for questions and comments. III. Analyse the data (60 minutes) Note: If possible, provide a set of actual or hypothetical surveillance data for participants to work from. Remind participants about the importance of analysis at each level of the surveillance system. Review ways of tabulating surveillance data and refer participants to an example of each in the User's guide. Summary tables Disease charts Maps and charts Note: The User's guide includes some information on computing rates and ratios for large populations. Include this information only if appropriate for the participants in the workshop. Explain that the purpose of analysis is to identify patterns and, possibly, causes of diseases or death. Present possible data patterns and what they might indicate. Explain that sentinel systems allow for more detailed analyses, such as correlation. Point out that changes in disease patterns may reflect a change in health status or a change in the quality/amount of surveillance. Review the major factors that can influence the number of cases reported. Suggest other analyses that participants may wish to perform. Refer participants to the tables, charts, and maps on pages 38-41 and ask them to analyse them for patterns and what they might indicate about health status or the surveillance system. Note: If possible, provide additional surveillance data showing different patterns to give participants more practice in analysing data. Ask for questions or comments. SESSION 4: OBJECTIVES 1. Plan surveillance activities for their PHC programme 2. Plan the analysis of their surveillance data TRAINING TOPICS purpose and value of surveillance how to recognise and classify diseases how to record data how to summarise and report data how to determine need for further investigation SUPERVISION REQUIREMENTS Supervisors should be sure that interviewers: Follow up on all designated cases and deaths Follow up on all incomplete answers Encourage probing Write all responses down Use local language or dialect Summarise and verify answers POSSIBLE DATA PATTERNS Spikes Clusters Trends Systematic variations FACTORS INFLUENCING NUMBER OF CASES REPORTED completeness of reporting seasonal variation epidemics or outbreaks coverage other factors Session 5: Investigate causation (optional) (Step 7) Objectives: Participants will be able explain what is involved in conducting investigations to determine the cause of certain diseases, health problems, or deaths. Session outline: I. Introduction (5 minutes) II. Case/outbreak investigations (15 minutes) III. Verbal autopsies (25 minutes) Materials: Module 4 User's guide Transparency 4-19: Session 5: Objective Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I.Introduction (5 minutes) Review session objective. Remind participants that investigating causation requires special training, is time-consuming and is done on a selective basis. II. Case/outbreak investigations (15 minutes) Review general guidelines for conducting a case or outbreak investigation. Refer participants to Appendix C and explain each section of the prototype form. Explain that a form will be needed for each case selected for investigation. Explain that analysis of this information will help to identify the main cause of the problem and plan preventive action. Ask for questions or comments. III. Verbal autopsies (25 minutes) Review general guidelines for conducting verbal autopsies and refer participants to Appendix D for further information and guidelines. Refer participants to Appendix E and review protocols for child and maternal death investigations. Explain that analysis of this information will also help to identify the main cause of the problem and plan preventive action. Ask for questions and comments. SESSION 5: OBJECTIVE Participants will be able to explain what is involved in conducting investigations to determine the cause of certain diseases, health problems, or deaths Session 6: Develop an action plan and present reports (Steps 8 and 9) Objectives: Participants will be able to follow the directions in the Module 4 User's guide to develop action plans to prevent unnecessary disease and death based on the surveillance data collected. Session outline: I. Introduction (10 minutes) II. Develop an action plan (20 minutes) III. Prepare and present reports (30 minutes) IV. Next steps (15 minutes) V. Conclusion (10 minutes) Materials: Module 4 User's guide Transparency 4-20: Session 6: Objective Transparency 4-21: Action plan components Transparency 4-22: Guidelines for preparing reports Handout 4-4: Worksheet for developing action plans Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I.Introduction (10 minutes) Review session objective. Give a brief overview of session activities. II. Develop an action plan (20 minutes) Explain that surveillance data is used to plan ways to prevent unnecessary disease and death. Review options for developing solutions to an identified problem Modules 4 and 6 Problem-solving guide Brainstorming with staff, community representatives, and others Review what should be included in an action plan once a viable solution is found. Refer participants to the example at the bottom of the page. Direct participants to complete the worksheet for one action based on the analysis of tables, charts, and maps in Session 4. Ask one or two participants to read their example aloud and invite other participants to comment on its appropriateness, clarity, and feasibility for the stated analysis. Ask for questions and comments. III. Prepare and present reports (30 minutes) Remind participants that although the data generated by the surveillance system proposed in this module should address the concerns of session objectives and of local PHC managers, it should also be useful at other levels. Review the guidelines for preparing reports. Explain the importance of complete documentation. Ask for questions or comments. IV. Next steps (15 minutes) Briefly summarise the steps in this module and the outcomes of each step. Direct participants to review their completed worksheets and write down the actions that they need to take when they return to the job to: Complete the worksheets for objectives for surveillance and for surveillance methods. Develop data collection procedures. Implement or improve surveillance of morbidity and mortality in their PHC programme. Ask each participant (or participant team) to briefly describe the actions they will take when they return to their jobs. (The format on Handout 4-4 is appropriate for this action plan). V. Conclusion (10 minutes) Review the expectations participants expressed at the beginning of the workshop and ask them to assess informally how well they think those expectations have been achieved. If any were not achieved, ask how the workshop could be improved to make that happen. Thank participants for their time and attention, congratulate them on the effort they put into the workshop, and wish them good luck in implementing their plans. Note: Indicate what follow-on assistance will be available, if appropriate. SESSION 6 OBJECTIVE Develop action plans to prevent unnecessary disease and death based on surveillance data ACTION PLAN COMPONENTS WHAT WHO WHEN GUIDELINES FOR PREPARING REPORTS Review original objectives Review tables, charts, and maps Prepare a short explanatory of each Order them in logical sequence number of cases number of deaths number of trends Discuss major issues Summarise actions planned or taken ACTION TO TAKE(What) DATES(When) OTHER (Where, how, resources) RESPONSIBLE(Who) WORKSHEET FOR DEVELOPING ACTION PLANS