In the previous section, we looked at the objective and the appropriate methods for that objective in terms of educating villagers. In this section, we're going to take another objective which has to do with the village health workers or the CDDs, learning to carry out a census. One of the important sub-objectives of that objective was estimating the number of Ivermectin tablets that are needed. The CDDs or the villagers themselves need to report this back to the health center so they in turn can order enough supply for all the villagers. The census can involve simply having a village notebook or exercise book, and going around we they said. Possibly with the CDDs and village leaders house to house, and on each page, writing down the name and age of the, the household members. So, at the end of this second session, hopefully the CDDs will outline the procedures for conducting a village census. Other sub-objectives include a definition of the census. that means counting everybody who is physically present, even those, such as farm laborers, who may be from another tribe or another area, but are physically present at the time of the distribution and at the time the simulium are out biting people. we want to count people who are physically living there. this is important, because we found that people tend to perceive of membership of the household of all people. whether they've gone to the city to work two years ago or not, whether they're attending secondary school in another town, people see them members of the household. And if we count those of course we'll require too many tablets. On the other hand, people may not count small children. They may not consider them real people or adults yet. So we have to really ensure that the CDD knows who is a member of that village and the member of that household. And thereby take steps to encourage accuracy and completeness. So after completing the census, the next sub-objective would be estimating the number of eligible people and calculating the number of tablets needed. Eligible, again, as we've mentioned, would be people who are at present not pregnant, not sick, and are over five years old. So, a sub-objective requires that the CDD have knowledge of the eligibility criteria. As we said before, they should be able to list or state those three criteria, and then calculate the number of, of tablets. And there is a formula of two point something tablets per, per person that can help them come to those numbers that they need. In terms of training methods to get this content across. Again, it would be very simple to lecture the CDDs. This is what a census is. This is how we do it. Step by step by step. Outline these things. Maybe we could pass out a flow chart or draw something on the board using a flip chart or a chalkboard. we might then sit down with the trainees, with a pencil and paper and get them to calculate numbers and tablets. Those that at least can read and write. The thing is, if you do that, you'll encounter certain problems back in the field. We found that after initial training, several discrepancies were found in terms of the final result. Normally, if you use the eligibility criteria, you would expect that approximately 85% of the residents of the village would be eligible, and that would be the maximum number that could be treated. In some villages, when we got reports back, we found that over 100% had been treated. Some fell way below the acceptable of 65%. WHO has done some computer modeling and found that if over these 15 years, 65% of the village population consistently took this drug, then it would be controlled to an acceptable levels. So we don't want coverage to fall below 65% of the total population. So, when these figures were found, we were concerned. And then having conducted followup coverage surveys as way of double checking, found that many times the coverage from house to house surveys differed from what was reported based on the village census that was submitted. So that told us that there were, were problems. This is an example of course of the evaluation of the effect of training, and we'll be talking about that in our later lectures. We discussed with villagers with village leaders, with the trainees themselves to find out what were the problems, and some of it had to do with local perceptions. There were concerns about census and about counting people. some weren't sure if maybe the government was trying to tax them [LAUGH] and they were worried about being counted. In some villages, there was a taboo about counting children. If you count your blessing, the, the you know, the deities may take them away from you. So you don't want to count children. in some villages relatives living outside were, were still considered members, and so they were listed on the census forms. In other areas, neighbors came from another village that were not part of the program to take the drugs even though they were not technically members. Even in a case in Uganda, people in some war-torn areas of DRC will come across the border when they heard these drugs are available. And since they had relatives on the Uganda side, no one questioned them. But again that would create coverage figures of over 100%, and they were still considered village members. And so, again, the issue of training methods, we realized had to be more interactive. We should have been involved with more guided discussion. Asking people to talk about they know who is a member of the village, what a village looks like. where are the boundaries, who is included? In the picture, we can see what looks like could be two distinct settlements. They could be one. We don't know until we actually ask the people on the ground how they define their own settlements. Part of the discussion could be again, raising questions. Do all the members of your village live here? Who traveled? Why do they travel? Where and when, and for how long? Who stays around most of the time? More discussion will help us get an idea of the structure of the village, the normal population. And we can then, based on this help guide the trainees to a more realistic definition and understanding of why we need to have a more accurate picture of the people who are physically present in order to get enough tablets so that either everybody would be treated, and or none would be wasted. So, further discussion questions to get people to think about who is around and when they're around. We can ask them what are some of the occasions or reasons. Why we count people in the village. They may say well, when we have fundraising, we want to build a school or do some project, we do need to know who is present. All the you know, the adults who have income that we can count on, or the number of children if we're building a school. So they can think about these examples and why it's important to get accurate numbers. We can ask you know, from our experience, are there some people that you consider members of the village even if they aren't present, even if they don't live here? Are there some people who we don't like to count? And we found that besides children, sometimes migrant workers. They're not part of us. Of course they're part of the disease transmission process, and they're living you know, in, in the farm village for the meantime. And so, even though they're not related, they're still part of the, the treatment process. After getting this discussion going and getting feedback, and getting people actively involved in defining who is a member, who is not, who is living there, who is not. A brief mini-lecture can summarize the issue of eligibility, and the need for counting people accurately to get, make sure everybody who could get the disease And who would then be in a position to, to transfer it to another person if a fly bites them. To get all these people counted you know, you can build on, through a mini lecture, what people have already been talking about. We can then have a small group exercise or small group discussion, where after going through this trainees can be broken into small groups, and they can develop a plan for how they can accurately count people. Given local taboo's, given fears, given local beliefs, how they can get get an effective census. So they can, people who are actually living there, they can come up with ideas, and then the groups can report back and this can be debated in a planary session. So here again, instead of the original approach we had about lecturing on census. We discovered through trial and error that it would have been more appropriate to have a more interactive approach where trainees share their ideas about what is a census, and do their own problem solving to come up with the best way to do it, given their culure in their villages. After we've gotten ideas from them about what would be appropriate ways of conducting the census, we can either have a demonstration or role play. We can of course demonstrate how to use the notebook to record family data. But more importantly, the trainees themselves can do a role play of going from house to house. A couple of trainees can be the CDD, and other trainees can pretend they're household members, and they can do a role play showing how they would approach. And then of course with a role play, it's important for the rest of the trainees to watch as an audience and then give feedback how they might do it better. And then possibly even have a second running of the role play with different people showing how they think it should be done. So again, practice learning through doing. Finally, after people have had a chance to do it in a controlled setting, in the training setting where there's less problem with taking risks, now they feel confident that they understand the census idea. That they've practiced it through role play. The next step would be to go to a nearby village where they can actually conduct a census. Should be a village where at least one or two of them are from so that they're not strangers. And they can actually conduct that village census and see in a practical sense what the problems are. Calculate the number of tablets needed based on a real census, then discuss the experiences. Afterwards, learning lessons, then again, educating themselves. Over and over again, we do want to stress that the trainee's themselves are an important resource for learning. And as much as possible, we need to design learning experiences where they can try things out. They can share their knowledge. They can evaluate and assess their own experiences and teach each other. So, in summary, what we've been talking about in terms of training methods, is that the methods we choose should maximize participation and experience. Experience the new roles that the trainee will take up after the training. Even when we're talking about issues such as knowledge, we can make it more active through brainstorming and sharing of local experiences. skills can be active. Skill learning can be made active through practical sessions like laboratories, field projects. Attitudes, learning new attitudes values can be incorporated into active discussions and role plays where people can try out experiences and see for themselves, how their attitudes affect their jobs. Finally, we would want to be sure that our methods account for local culture factors. Not only in terms of people's beliefs, for example, the beliefs about counting children. But also identifying local training, educational communication methods, such as the poetry songs that people use to communicate about health ideas, and incorporate those into our training method.
