We've just been talking about some sample objectives for training community directed distributors and [UNKNOWN] control. Now we will see some of the appropriate methods that can be used to train people to achieve those objectives. One of our objectives was educating villagers about the threat and problem of onchocerciasis. And sub-objectives, or specific tasks, involved in that, you need to spell those out, is, at the end of the first session, the CDDs will state the signs. And symptoms and complications of onchocerciasis. Can see here, the skin rashes associated with it that cause terrible itching and make it difficult for farmers to do their work. their skin conditions include rashes, leopard skin, white patches where the skin is, atrophy. rough patches and, and nodules where the adult worms live under the skin. Eventually they also include visual impairment leading to blindness. So spelling out again in more detail once you've set the main objective making sure that the specific tasks or content is spelled out clearly so that you yourself know where you're going and what you want the trainees to, to learn. Again, as part of the objective for educating the villagers is another sub-objective would deal with explaining the cause of onchocerciasis. As we can see in the picture, the fast flowing river. Rocks where the black fly might lay its eggs and when the water splashes up at the beginning of the rainy season, these eggs would hatch. The picture here shows a drawing to, to demonstrate the Simulium fly taking a blood meal. And the small little white things are representative of the microfilariae that the fly in ingests. These develop within the fly, and after some days, would be infective to the next person the fly bites. So again, the content of this objective and sub-objective are, being able to identify the fly as the vector. the fast-flowing rivers as the environment where the fly lives and breeds. And mention of the tiny worms or microfilariae that are the parasites that cause the damage and are spread from person to person by the fly. Another aspect of educating the villagers requires that the CDD describe the aspects of the ivermectin treatment. The picture here shows a village gathering where CDDs are measuring people, handing out drugs, keeping the records. So it's become a village event. Villagers need to know and therefore the CDD needs to explain the appearance of the tablets. These are small white tablets. the frequency of administration, which is once a year. The benefits of the tablets, keeping blindness at by and also the side effects, that are, are temporary and not everyone suffers from them, but people need to be warned. Then, looking at these areas of content, these specific tasks. We then want to think about, what are the methods that are appropriate for getting this information across. So the methods for the sub-objective on recognition of signs and symptoms. Recognize first that this is basically a knowledge objective, therefore it would be easy for us to prepare a lecture in simple English, or the local language. And list out for the them the signs, symptoms, and complications. We could even enhance this with learning materials such as photographs and posters. But as we said before, we want learning to be active and participatory, and this approach would not achieve that goal. What we can do to make these knowledge content areas more interesting is to use methods such as brainstorming to build on local knowledge. We can ask people what they know about the disease. We should, of course, find out what the local name is and in Yoruba in Nigeria it's called narum which literally means, fire from the heavens. Because it feels like you've been attacked by something like that, that causes all the itching and discomfort. So we can ask people do they know anyone that has it? How do you know they have it? What are some of the problems that people that narun experience? We can have the trainees share experience that they may have because many people in the village including themselves probably have it. Friends and relatives have it without mentioning other peoples names though. So we can get them to actually contribute to their own training by sharing their own knowledge. And what we have found over the years is that there are many instances, because people live in dynamic area and live with these diseases day in and day out, they're quite knowledgeable about these signs, symptoms, the, the behavior of these different diseases. Another aspect of appropriate training methods would be developing and identifying and using indigenous communication methods. We were having a session one time, and one of the elder people, when he was talking about Narun, said, aha, Ajaka Oko. Well, what does that mean? Then he recited a whole poem about the disease that was in keeping with what the Yoruba have in terms of praise songs or praise poetry for people. But they also use such poetry as a way of identifying disease's conditions, situations, towns trees, etcetera. Each, item has, has a poem that really identifies it. And, the Yuruba writing is in red, and I'm not going to try to pronounce everything. But the poem starts off with a series of sentences, statements, onchocerciasis [INAUDIBLE] with spots all over the body. [BLANK_AUDIO] Who is entering? Please don't step on me. Again, the poem continues that narum is the disease that stops a child from hoeing, that kills the penis, that spoils the body with rashes, groping about with hands on the ground. What this does is provide a series of snapshots about what it's like to have the disease. Clearly, this signs and symptoms, such as spots, blindness are inherent in this poem. A local belief about narwyn causing impotence and infertility is expressed. The idea of who's entering, please don't step on me, shows that the person in the poem is blind. they're groping about with their hands on the ground. So these types of poems people recognize, they understand. They even start to contribute their own ideas, their own proverbs. It's a way of stimulating discussion, people appreciate it and one nice thing, when you use these kinds of methods they model for the village health worker how he or she can go back to the community and perform this education so the method serves two purposes. One it's a local communication method that they will understand and respond to better than say a lecture. But also it gives them ideas about how to do their job. What are the things we heard people say is also is Oh yes Ko Mo bus stop, it doesn't know bus stop, well what do you mean by that? OK. When you have [UNKNOWN], because of the skin rashes, you're scratching, you're itching, in public, you're, you embarrass yourself, it's so bad you can't stop yourself from scratching. Then somebody says, well, remember, there was an example of a young woman in our village who always wore long dresses. You know, long sleeves, the dress all the way to the ground. Why was that? I remember she had serious rashes on her skin. Finally she had to move to Lagos to avoid embarrassment and find a husband there. Because no one in the village would marry her. They'd say oh yea she has this terrible disease. She's scratching. It might spread to people even though it doesn't spread that way. But people are not sure, and also because they believe it causes infertility who would want to marry a person with Onco because they might not be able to have children. So people using these local proverbs and phrases, and poems, gets people involved, and they can contribute their own ideas. When we start to do brainstorming, we ask people, how does someone get narun? Then all kinds of ideas come out. Eating yarin, it's a vegetable that some people are allergic to. Eating groundnuts, eating cheese. Groundnuts, again, it's not clear why, but some people feel there's an allergy involved there. When you ask about eating cheese they say, Oh, yes. The nomadic flood people who have cattle and produce cheese, they have a lot of narun, /g, of course, they're exposed to the flies, but they don't know that, so the local villagers might think it's eating the cheese that causes this. Some say oh no, we're born with these tiny kokoro or insects inside us. Some people say oh yeah, you need some of these kokoro to be fertile but too much causes infertility and impotence. So people give their own ideas and again the idea of itching, the idea of tiny insects which could be the microflare, so there's some overlap between their local beliefs and what is actually scientifically correct. as we said before they may associate it with the fulani but then the fulani are out and exposed more to the simulium flies than others. So the next logical step is to take these beliefs and sort them out to see which ones are scientifically correct and emphasize those. Say well what we know about [UNKNOWN] is that yes it does have the itching, it does have the spots on the skin as in the poem. there are certain people that get it more because their out and exposed. What are they exposed to? And then you can introduce the idea of the simulium bites. So it's important to build on local knowledge, not to criticize it. And when you're doing training in a local setting again by stressing the local knowledge, it shows respect, it creates interest and it gives people ideas to go back to their village and continue. their role as village health workers or in this case community directed distributors. This process of building on local knowledge has health belief synthesis. We know that not all local beliefs are accurate but they're often logical. Said before their allergic reaction causes itching to a certain vegetable. Well itching also comes with [INAUDIBLE], there's a connection. The observation that for many people have a lot of oncho, but that again is associated with their lifestyle and work out in the fields with the cattle where the flies would be biting them. We can compare the idea of kokoro, tiny insects in the body, with the microfilariae, and in fact what we did at the one training was to take one of our lab attendands with us, do skin snips. Of some of the trainees looked at it under the microscope and they could see the microfilariae area, so that reinforced their local knowledge. And finally coming to the point where we want to talk about controlling these kokoro, controlling these microfilariae you get to the issue of annual ivermectin distribution. So in conclusion, what we have is a situation by drawing out the trainees. What we've done is create a situation where knowledge flows not from the trainers per se but from the trainees, and building on that local knowledge the trainer can guide the trainees to learn new knowledge. And be then ready through the steps that we've taken, the methods we've used to go back and model those methods to do education and training back in the village. When you wrap up a session, when you conclude a session, you want to draw people out again to have discussion this helps us evaluate. So you can ask questions and continue the learning process, asking some of the participants from our discussion, what are the main signs and symptoms again that we've talked about for oncho? Would somebody please summarize the problem facing someone with onchocerciasis? And then finally we can draw on the local beliefs and ideas that have been mentioned that are actually connected to scientific fact. And use those to re emphasize those and encourage the village health workers to repeat those when they go back to the village try to educate people. In our next section we will look at the second objective that we outlined before, which was the skill of taking the village census.
