Module 4 Facilitator's Guide_Surveillance of Morbidity and Mortality

8/7/2019 Module 4 Facilitator's Guide_Surveillance of Morbidity and Mortality

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THE PHC MAP SERIES OF MODULES, GUIDESAND REFERENCE MATERIALSEach module includes:o a User's guideo a Facilitator's guideo computer programsModule 1 Assessing information needsModule 2 Assessing community health needs and coverageModule 3 Planning and assessing health worker activitiesModule 4 Surveillance of morbidity and mortalityModule 5 Monitoring and evaluating programmesModule 6 Assessing the quality of serviceModule 7 Assessing the quality of managementModule 8 Cost analysisModule 9 Sustainability analysisManager's guides and referenceso Better management 100 tipso Problem-solvingo Computerso The computerised PRICOR thesaurus

Design & Layout:Desktop Publishing,Firsf Printing:Second Printing:

Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva, andThongchai Sapanuchart, Somboon Vacharotai Foundation,BangkokHelene Sackstein, FranceMarilyn J. Murphy, Suracha Suntarasut, Somboon Vacha-rotai Foundation, Bangkok, Thailand and Atthapon Tanoi,Dept. of Medical Sciences, ThailandIn 1993 by Thai Wattana Panich, Bangkok, Thailandln L997 by Veteran Organization Printing Co.,Ltd., Thailand

Fu6ished by the Aga Khan Foundation USA, Suite 700,1901L Street N.W., tv\hshingtonDC" USA Aaaino*t copies are arnilable at the Somboon \hcharotai Foundation, 101Boromratchonanee Road, Glingchar\ Bangkok 10170, Thaland Fax.(662) M&-ffi2


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ISBN: 1-882839-18-8Library of Congress Catalog Number: 93-70733


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Dedicated toDr. Duane L. Smith (7939-1992) ,Dr. Wlliam E. Steeler (7948-7992)and all other health leaders, monagers and workerswho follow their example in the effort to bring quality healthcare to all in need.

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The Primary Health Care Management AdvancementProgramme has been funded by the Aga Khan FoundationCanada, the Commission of the European Communities,the Aga Khan Foundation U.S.A., the Aga KhanFoundation's head office in Geneva, the Rockefeller Foun-dation, the Canadian International Development Agency,Alberta Aid, and the United States Agency for Interna-tional Development under two matching grants to AKFUSA. The first of these grants was, "Strengthening theManagement, Monitoring and Evaluation of PHC Pro-grams in Selected Countries of Asia and Africa" (cooper-ative agreement no. OTR-0158-A-00-8161-00, 1988-1991); and the second was "Strengthening the Effective-ness, Management and Sustainability of PHC,/Mother andChild Survival Programs in Asia and Africa" (cooperativeagreement no. PCD-0158-A-00-1102-00, 199I-19941.The development of Modules 6 and 7 was partially fundedthrough in-kind contributions from the Primary HealthCare Operations Research project (PRICOR)of the Centerfor Human Services under its cooperative agreement withusArD (DSPE-6920-A-00-1048-00).r: This support is gratefully acknowledged. The viewsand opinions expressed in the PHC MAP materials arethose of the authors and do not necessarily reflect thoseof the donors.All PHC MAP material(written and computer files) isin the public domain and may be freely copied anddistributed to others.


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ContentsFOREWORD . 1SESSION T INTRODUCTION AND OVERVIEW ... ...... 7

Tiansparencies4-7: Workshopobjective ........134-2: Surveillance . ... .. . .L44-3: Limitationsof surveillance ... ....154-4: Surveillancemethods ......164-5: Steps in setting up a surveillance system . .. ...L7SESSION 2: SPECIFY OBJECTMS ANDDEFTNE SURVETLLANCE DATA (STEPS 1 AND 2l .. . . . ..19'liansparencies4-6: Session2:Objectives..... ........244-7: Informationforsurveillanceobjectives.... .....254-8: Sources of possible indicators . . . .28

SESSION 3: SPECIFY SURVEILLANCE METHODS ANDDATA COLLECTTON PROCEDURES (STEPS 3 AND 4) .. . . .. ..29Tiansparencies4-9: Session 3: Objectives . . . . . .. .. .. ..324-10: Data sources ....-...334-11: Substeps for designing collection procedures . .. .. .. ..344-12: Rules for recording cases .........35

4-13:Types of instruments ......36

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SESSION 4: COLLECT, REPORT ANDANALYSE THE DATA (STEPS 5 AND 6) ... ..37'liansparencies4-1.4:Session 4: Objectives ......4L4-15:'liaining topics ......424-16: Supervision requirements .. . .....434-17: Possible data patterns . ....M4-18: Factors influencing number of cases reports . . .45

SESSION 5: INVESTIGATE CAUSATION (OPTIONAL)(STEP 7l ... .....47'liansparency4-19: Session 5: Obiective ... ....49

SESSION 6: DEVELOP AN ACTION PLAN ANDPRESENT REPORTS (STEPS 8 AND 9) ... .........51'liansparencies4-20:Session6:Objective .. .....554-2L: Action plan components .... .....564-22:Guidelines for preparing reports ........57

Module 4: FG; contents


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ForewordWhat is the purpose of the Facilitator's guide?

The Facilitator's guide contains a suggested workshop design for use byindividuals who wili help PHC managers and staff learn how to use thePrimary Health care Management Advancement Programme (PHC MAP)series. ih"t" 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 workshopon one of the modules in the PHC MAP series using the informationcontained in the User's guide.The instructions are irranged in one to two hour sessions. The numberof sessions depends on the amount of information and/or the number ofsteps contained in the User's guide. The first page of each session lists,"rrio., objectives, major topic headings, time required, and materials andequipmen[. The following pages describe the instructional activities inoutline form.The outline is divided into lwo columns. The right-hand columnindicates what the facilitator says or does to conduct the session' Theleft-hand column lists the handouts, overhead transparencies, or othermaterials neededto support the activity. Copies of these materials, suitablefor duplication, appeaiit ttt" 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 tointroduce the PHC MAP series and explain its importance to PHCprogrammes, present an overview of the workshop, explain the purpose ofih"--odrl", review specific terms or concepts used in the module, and

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acquaint the participants with the organisation and content of the User'sguide.The final session of each workshop contains activities designed to reviewkey points of the User's guide, if appropriate, help participants prepare anaction plan, and brings the workshop to a formal conclusion. The sessionsin between present the steps required to accomplish the purpose of themodule and provide an opportunity for participants to apply those stepsto their own programmes.Each workshop is designed to be given on consecutive days, uninter-rupted except for breaks, meals, and rest, if the workshop is longer thanone day. It is recognised, however, that situations vary and the PHC MAPmodules will be used singly or in combination by individuals and or-ganisations in the field and on university campuses. Therefore, it isexpected that the workshops described in the Facilitator's guides will beadapted to fit a range of cirtumstances. Indeed, those who f-acilitate PHCMAP workshops are encouraged to make adaptations to meet the needsof participants andlor specific PHC programmes.Who can be a facilitator?

Ideally, the person who serves as facilitator has training and experiencein the fields of public health, management, planning, and evaluation, as wellas sampling and survey design. It is recommended that this person also beskilful in working with smallgroups.The facilitator should be someone from outside the PHC programme,perhaps from another agency or a university. As a person with no directinterest in the programme, the facilitator can be neutral in disagreementsthat 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 andexpefience as a full participant in the work of the group.It is also recommended that a facilitator have a full set of PHC MApUser's guides and Facilitator's guides. It is sometimes necessary, in thecourse 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 managesPHC programmes or other population-based health programmes in eitherthe public or private sector. An example of a PHC management team inthe public sector is the core staff of a district ranging from 100,000 to300,000 in size of population served.

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An example oI a PHC management team in the private sector is thecore staff of an NGO that provides PHC services to a specific populationin a given geographic area. The average size of the service population mayrange from 40,000 to 60,000, but may be as small as 10,000 or more than100,000. 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 managementsystems and procedures based on this analysis.

If feasible, teams from several districts or from several PHC programmeswithin a given NGO, may work simultaneously with one facilitator tocomplete a module. It is recommended that one facilitator work with nomore than four teams or 20 people at one time.What does the facilitator do?

Understands the needs of participants. If the facilitator is workingwith one PHC programme, the most efficient way to gather informationabout participants and the programme in which they work is to meet withthe PHC director to determine:. the nature of the PHC programme (services provided, size and descriptionof area served, number and type of facilities, number and qualificationsof staff, community involvement, computer capability, strengths, majorproblems, etc.). if information needs have been clearly identifiedr previous staff training in management information systems or relatedtopics. 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 andFacilitator's guide for Module 1 and consider options for workshop delivery.. The purpose of Module 1 is to help participants select priority informationneeds and to review some basic concepts underlying managementinformation systems. Depending on participant background, the amountof time available, and the need to establish priorities among managementinformation needs, Module 1 can be presented in its entirety, limited toLevel 1 Quick start, limited to the PHC MAP systems framework, or inModule 4: FG; foreword


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summary form as contained in the first session of the Facilitator's guidesfor Modules 2 through 9.. If information needs have not been clearly identified and participantshave no background in systems, then Module 1 should be presented infull. The selection of the next module willdepend upon priorities set bythe participants as they complete the steps in Module 1.. If information needs have been clearly identified and participants haveno background in systems, then that portion of Module I can be addedto the first session of the selected module.. If information needs have been clearly identified and participants have abackground in systems, then the overview of PHC MAP in the selectedmodule will be sufficient.Understands the content of the selected module. Read the User'sguide and Facilitator's guide for the selected module and consider optionsfor workshop delivery.. Depending upon the length of the module and the availability of staff fortraining, the workshop sessions may be presented as described in theFacilitator's guide, or workshop sessions may be delivered at intervals (forexample, 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 modulecould be presented in the workshop and the application of the procedureto 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 isparticularly applicable to Module 2.which requires development of aquestionnaire, selection of a survey sample, training of data collectors,and data collection. These steps cannot actually be carried out within thetime limits of the workshop as contained in the Module 2 Facilitator'sguide.. Other options are possible depending upon the circumstances of eachsituation.Determines what programme information, if any, is needed forcompletion of the module. For example, census data and lists of households

are required to complete some of the steps in Module 3.

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Determines the most appropriate people to attend the workshop. Forexample, 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 managerand make decisions regarding the most appropriate option and participantselection. Also determines if the needed information is available and if itis not. the alternatives for obtaining the information.Notifies participants of the date, time, and purpose of theworkshop and confirms attendance. Initial notice of the meeting may comefrom the PHC manager, with follow-up by the facilitator'Prepares the agenda, using as a model the sample in session 1of theFacilitator's guide for the selected module.Inspects the room where the workshop willbe held and answers thesequestions:

Is the room targe enough to seat all the participants?Can chairs and tables be arranged in a variety of ways; all participantsaround 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?

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aaaaa. 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 inthe Facilitator's guide for the selected module, and makes the necessaryadaptations. Refer to the appropriate User's guide for content.Duplicates the worksheets and other handouts as indicated inthe Facilitator's guide and obtains the necessary equipment.Conducts the workshop as planned.Provides follow-on assistance, if appropriate.

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Session 1: Introduction and overviewObjectives:

Session outline:

Materials:

Equipment:

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 qualita-tive surveillance.. Explain how surveillance data contribute toPHC programme planning.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)

Module 4 User's guideHandout 4-1: Sample AgendaTiansparency 4-I: Workshop objectiveTiansparency 4-2: SurveillanceTiansparency 4-3: Limitations of surveillanceTiansparency 4-4: Surveillance methodsTiansparency 4-5: Steps in setting up a sur-veillance systemFlip chart, stand, markers, masking tape, over-head projector and screen

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I. Introduction (3O minutes)

Name tagsor place cardsFlip chart

Note: Omit Section I if youhaue presented Mod-ule 7, or some other module, immediately prior tothe presentation of Module 4A. OPENING REMARKSr Introduce self and other staff, as necessary.. Explain your role in the workshop.. If you do not know the participants, ask eachone to state his or her name, position title, andjob location.Note: I the group is larger than 6 or 8, you maywish to haue them u)ear name tags or place cardswith their nqmes at places where they are sitting.. Ask each participant to complete this sen-

tence:'As a result of attending this workshop,I expect . . ." and write their responses on theflip chart.o When all responses have been recorded, saythat you will return to this list after giving anoverview of the workshop.B. OVERVIEW OF PHC MAP. Explain why information is important orPHC programmes.. Summarise PHC MAP programme, includ-ing:Purpose of PHC MAPTitle and purpose of each module and othermaterials.. Make the following points about PHC MAP:Has been field tested and revised toensureuse fulness to PHC programme staff.



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Modules can be used in any sequence.Materials can, and should, be adapted to fita particular situation.The procedures outlined in the modules canbe adopted as routine monitoring activities ina PHC programme.. Explain why MAP is being introduced in thisPHC programme.Note: The specit'ic programme and should pro'

uide the onsurers to these questions:Why are we doing this workshop?What do we expect to achieue?It may be appropriate t'or the PHC manager tomake these remarks.II. Overview of workshop (1O minutes)

'Iiansparency 4-1:Workshop objectiveHandout 4-l Sampleagenda

. Review the workshop objectives.. Distribute and review the workshop agenda,describing the activities that will take place toaccomplishthe workshop objectives.o Review the expectations contributed by par-ticippants at the beginning of the session.Indicate which ones will be met and whichones will not and why.Suggest, if possible, alternatives for meet-ing expectations that will not be met in thisworkshop.. Ask for questions or comments.



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III. Purpose of module 4 (1O minutes). Explain that the purpos of Module 4 is tohelp PHC programme staff set up and operatea local surveillance system, using simple andinexpensive tools.. Discuss the value of collecting surveillancedata and how it relates to other modules in thePHC MAP series.

IV. Module 4 User's guide (1O minutes)Module 4 User's guide o Distribute a User's guide to each participanl. Highlight key sections of the User's guide.. Quick start, with a computer prograrune.Introduction to surveillance principles.. Step-by-step directions for designing and

operating a surveillance system.Appendices containing blank worksheetsand other reference material that will be usedin the workshop.References, glossary and list of acronymsand abbreviations.V. Definitions, purposes and principles (3O minutes)

liansparency 4-2Sur'.reillance

Module 4, User's guide,page 3

. Define surveillance and discuss its purposesin PHC programmes.Distinguish between quantitative andqualitative surveillance.Stress the importance of collecting onlynecessary data.Refer participants to the example in theUser's guide, discuss the example, and askthem if the data represented are the result ofquantitative or qualitative surveillance.



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'liansparency 4-3:Limitations ofsurveillance

Tiansparency 4-4:Surveillance methods

Tiansparency 4-5:Steps in setting up asurveillance system

Discuss some limitations of surveillance.o Discuss the principles of an ellective surveil-lance system as participants follow alcing intheir User's guide.. Explain the four surveillance methods rec-ommended in this module, and the advantagesand disadvantages of each.. Review briefly the steps in Module 4, includ-ing expected outcomes.o Ask for questions or comments on the defini-tions and principles, the module as a whole,and the workshop itself.

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SAMPLEAGENDA MODULE 4*Session 1(1 hr, 30 mins)

Session 2(1 hr, 45 mins)Session 3(1 hr, 20 mins)

Session 4(1 hr, 40 mins)Session 5(1 hr, 20 mins)Session 6:(1 hr, 20 mins)

Introductionand overviewSpecify objectivesand define surveillance data

(Steps 1 &.2)Speficy surveillancemethods and dat-a collectionprocedures(Step 3 & 4)Collect, report and analysethe data(Step 5 & 6)

Investigate causation(Optional)(Steps 7)Develop an action plan andpresent reports(Step 8 & 9)

'For an actual presentation, substitute the appropriate clock hours in the first column,

Module 4: FG: session L handout 4-1


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WORKSHOP OBJECTIVEDesign and operate a surveillancesystem using the principles, stepsand materials contained in Modu\e 4

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SURVEILLANCESu rveillance of morbidity andmortality is the collection andanalysis of selected health andvital events to:

identify, investigate, control epidemicsidentify populations at riskconfirm disease control prioritiesevaluate input of activities on incidenceand prevalence

- monitor trendsModule 4: FG; session 1; transparency 42


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LIMITATIONS OFSURVEILLANCELabour intensive activityTabulation and analysis are timeconsumingLimited to a few key indicatorsSevdral years of data collection is nec-essary to identify trendsDifficult to assess impact if populationis small, or if no control group

o Reporting of surveillance data is often'incomplete



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SURVEILLANCEMETHODSo Routine reporting system

Sentinel reporting systemSurveys and special studiesCase or outbreak investigationMtal registration systemsCensus

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STEPS IN SETTING UP ASURVEILLANCE SYSTEMStep L Specify objectivesStep 2: Define data to collectStep 3: Specify method(s)Step 4: Develop data collection andreporting proceduresStep 5: Collect and report dataStep 6: Analyse dataStepT: Investigate causation

(optional)Step 8: Develop an action PlanStep 9: Prepare and present rePorts



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Session 2: Specify objectives and definesurveillance data (Steps I and 2)Obiectives:

Session outline:

Materials:

Participants will be able to follow the directionsin the Module 4 User's guide to:. Specify the purpose, scope, and time period ofthe surveillance; the users of the surveillanceinformation; the target group; the type andfrequency of surveillance.o Determine what data the system will collect,how frequently, from which source, and usingwhich procedure.I. Introduction (5 minutes)Il. Specify the objectives of the surveillance (40mintes)III. Define the surveillance data to collect (60

minutes)Module 4 User's guideTiansparency 4-6t Session 2: ObjectivesTiansparency 4-7: Information for surveil-lance objectives'liansparency 4-8: Sources of possible in-dicatorsHandout 4-2: Worksheet for specifyingobjectivesHandout 4-3: Worksheet for specifyingsurveillance procedures

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20Equipment Flip chart, stand, markers, masking tape, over-heal projector and screen



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I. Introduction (5 minutes)Tiansparency 4-6:Session 2 Objectives o Review the session objectives.. Describe briefly the session activities.

II. Specify the objectives of the surveillance (4O minutes)

Handout 4-2 Worksheetfor specifying obPctivesTiansparency 4-7,Information forsurveillance objectives

. Explain that the purpose of this step is todecide on and record the objectives of thesurveillance system.. Refer participants to the completed Work-sheets A and B, pages 2O-2L from Module 1(ifdone) to review their overall informationneeds.

Note: If Module t hos not been completed, decidenow as a group what the overall information needsare for thePHC programme.r Remind participants that what they chooseto monitor should be based on overall pro-gramme goals, but will not be able to covereverything.r Review and discuss the categories of infor-mation needed to formulate specific surveil-

lance objectives.. Distribute the worksheet and direct partic-ipants to complete it in small groups for theircatchment area. Refer participants to thesample completed worksheet on page 11, Mod-ule 4 for guidance as needed.Note: Groups of 4-5 participants are recommen'ded if the group is large to increase opportunityfor indiuidual participation. If more than onePHC is represented, groups should be t'ormed onthe bosis of programme.



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. Facilitate discussion of the completed work-sheet.Ask a spokesperson from one group toreport the items checked for purpose withsupporting arguments.Invite other groups to report on differencesand help participants reach consensus on anydifferences.Repeat 1 and 2 for other sections of theworksheet.. Ask for questions and comments.

Ill. Define the surveillance data to collect (6O minutes)

Handout 4-3:Worksheet for specrfuingsurveillance methods

. Explain that this step will help determineprecisely which data the surveillance systemwill collect, how frequently, from which source,and using which procedure.. Distribute the worksheet and explain eachsection as the participants (working in groupsassigned in II above) complete the first threecolumns on the worksheet. State that thesecond part of the worksheet will becompleted in Step 3.r Direct participants to enter target groupsidentified in Step 1 in the first column.. Discuss considerations for completingcolumn 2:MortalityCause of deathRefer participants to Table 3 on page 22for causes that can be determined by inter-view.Review verbal autopsy approach in Ap-pendix E.# Module 4: FG; session 2


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'Iiansparencv 4=&Sflrces of possibleindicators

Revlew Appendix D for a discussion offeasibility of determining cause of maternaland childhood deaths.MorbidityRefer participants to Table 2,paget9,Iora list of priority diseases.Refer participants to Appendix B formore detailed information.Cause of diseaseHow much information should be col-lected?. Suggest sources for specifying indicatorswhich are entered in the first column.. Ask for questions and comments.

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SESSION 2zOBJECTIVES1. Decide on and record the objectives ofthe surveillance system2. Determine data to be collected andfrequency, source(s), and procedure(s)

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INFORMATIONFORSURVEILLANCEOBJECTIVESo Purpose(s)o Userso Scopeo Target groupso Cases and/or causeso Other topicso Time period and frequencyModule 4: FG; session 2; transparency 4-7


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WORKSHEET FOR SPECIFYINGOBJECTIVES OF SURVEILLANCEPURPOSE(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 - CommunityGovernment officials PHC Staff - CDC'_ Supervisors_ Donors

SCOPE- Geographic area(s):

Other:Other:

_ Programme service(s):TARGET GROUP(s)- Children l month - Women 15-59 yrs- Children 12-23 months - Married women 15-49 yrs_ Children 1-4 yrs

-Pregnant women

_ Children 5 yrsCASES_ Mortality_ MorbidityTIME PERIOD:

Other:CAUSES OTHER_ Mortality - Specify: -- Morbidity - Specif:

FREQUENCY:'Local communicable disease centre

Module 4: FG; session 2; handout 4-2


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Module 4: FG: session 2: handout 4-3


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SOURCES OF POSSIBLEINDICATORSModule 1Appendix B

Module 5



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Session 3: Specify surveillance methods

Materials:

Equipment:

and data collection procedures (Steps 3and 4)Objectives: Participants will be able to follow the directionsin the Module 4 User's guide to:. Specify surveillance methods for each of theindicators selected in Session 2.

. Design data collection procedures.I. Introduction (10 minutes)IL Select the surveillance methods (30 minutes)III. Develop the data collection and reportingprocedures (40 minutes)Module 4 User's guideTiansparency 4-9: Session 3: Objectives

Tiansparency 4-4: Surveillance methodsTiansparency 4-10: Data sourcesTiansparency 4-tl: Substeps for designingcollection proceduresTiansparency 4-I2: Rules for recording casesTiansparency 4-13: Types of instrumentsFlip chart, stand, markers, masking tape, over-head projector and screen

Session outline:



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I. Introduction (1O minutes)'Iiansparency 4-9:Session 3: ObjectivesUser's guide

. Review session objectives.. State that this session covers Steps 3 and 4in designing and operating a surveillance sys-tem and includes completion of columns 4, 5and 6 on the worksheet for specifying thesurveillance procedures and will guide partic-ipants in developing the data collection proce-dures and instruments.

lI. Select the surveillance methods (3O minutes)Handout 4-3:Worksheetfor specifyingsurveillance procedures

'Iiansparency 4-10:Data sources'Itansparency 4-4:Surveillance methods

. Explain that more than one surveillancemethod can be used, and that the methods canbe modified to better suit the needs of theprogramme.o Instruct participants to return to Handout4-3, and explain considerations for columns4 and 5 as they complete them.Frequency of data collection/reporting de-pends on routine or priority indicators.Primary and secondary data sources.. Review the possible methods and advantagesand disadvantages of each as presented inSession 1.. Facilitate the discussion as participantsselect the appropriate methods.. Ask for questions and comments.



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III. Develop the data collection and reporting procedures (4Ominutes)Tiansparency 4-11:Substeps for designingdata collection procedures

User's guide

Tiansparency 4-12:Rules for recording casesTiansparency 4-13,Types of instruments

r Review the substeps involved in designingdata collection procedures.. Explain that every disease that willbe moni-tored requires a case definition to ensure thatall healthworkers use the same definitions andcriteria.Refer participants of Appendix B for ex-amples of standard and lay definitions of com-mon diseases.Review important rules for identifying andrecording cases.. Explain the three types of instruments usedin surveillance, and what circumstances war-rant the use of each, relerring participants toexamples of each in the User's guide whenappropriate.

RegistersSurvey questionnairesCase investigation

. Ask participants to examine daily clinicaltreatment records, CHW activities registers orother forms used in their PHC programmeand determine whether those forms supply thedata they have specified on their worksheet.e Direct participants to indicate how the formsshould be modified to correct anv deficienciesthey find.. Ask for questions and comments.



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SESSION 3: OBJECTIVES1. Select surveillance methods2. Design collection procedures



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DATA SOURCESPrimary

o Secondary

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SUB-STEPS FORDESIGNING COLLECTIONPROCEDURESDevelop operational definitions of casesDevelop or revise the datacol lect ion/ r ecording instrumentsPretest the instruments



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RULES FOR RECORDINGCASESo Avoid double-countingo Only count those cases that have beendiagnosed by a health workero Count current cases only

Module 4: FG; session 3; transparency 4-12 #


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TYPESOF INSTRUMENTSRegisters

Survey questionnairesCase investigation



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Session 4: Collect, report and analysethe data (Steps 5 and 6)Objectives:

Session outline:

Materials:

Equipment:

Participants will be able to follow the directionsin the Module 4 User's guide to:. Plan surveillance activities for their PHC pro-gramme, based on the methods selected andprocedures developed.. Plan the analysis of their surveillance data.I. Introduction (10 minutes)II. Collect and report the data (30 minutes)IIL Analyse the data (60 minutes)Module 4 User's guideTiansparency 4-L4:Tiansparency 4-15:Tiansparency 4-16:Tiansparency 4-17:Tiansparency 4-18:Flip chart, stand, markers, masking tape, over-head projector and screen

Session 4: ObjectivesTiaining topicsSupervision requirementsPossible data patternsFactors inf luencing num-ber of cases reported



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I. Introduction (1O minutes)Tiansparency 4-14:Session 4: Objectives

. Review session objectives.. Explain that this session will guide partici-pants in planning the collection, reporting andanalysis of their data.II. Collect and report the data (3O minutes)

Tiansparency 4-15:Tiaining topics

Tiansparency 4-16:Supervision requirements

. Explain the importance of good training andsupervision of staff involved in data collection,tabulation, and reporting for a successful sur-veillance system.r Review who should be trained and ask par-ticipants to review the worksheet for specify-ing surveillance procedures and list who willbe involved in collecting, tabulating, and re-porting their data.. Review the recommended training topics.

Note: Point out the special requirementsfor caseinuestigations but explain them fully only if it is amethod chosen by participants in the workshop.. Discuss what types of supervision will beneeded, and facilitate a discussion of anyspecial supervision needs participants foreseefor their surveillance method(s).. Discuss what is meant by quality controlandassist participants to plan as a group ways ofensuring a level of quality for their chosenmethod(s).. Discuss data collection, tabulation, and re-porting requirements for each type of surveil-lance method, stressing those which wereselected in Step 1.Module 4: FG; session 4


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. Ask for questions and comments.III. Analyse the data (6O minutes)

Tiansparency 4-17:Possible data oattems

Tiansparency 4-18:Factors influencingnumber of cases reported

Note: lf possible, prouide a set of actual or hy-pothetical surueillance data for participants towork from.. Remind participants about the importance ofanalysis at each level of the surveillance sys-tem.. Review ways of tabulating surveillance dataand refer participants to an example of eachin the User's guide.

Summary tablesDisease chartsMaps and chartsNote: The User's guide includes some int'orma-tion on computing rates and ratios t'or large popu-lations. lnclude this int'ormation only if appro-priate t'or the participonts in the workshop.. Explain that the purpose of analysis is toidentify patterns and, possibly, causes of dis-

eases or death.Present possible data patterns and whatthey might indicate.Explain that sentinel systems allow formore detailed analyses, such as correlation.Point out that changes in disease patternsmay reflect a change in health status or achange in the quality,/amount of surveillance.Review the major factors that can influencethe number of cases reported.Suggest other analyses that participantsmay wish to perform.



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User's guide . Refer participants to the tables, charts, andmaps on pages 38-41and ask them to analysethem for patterns and what they might indi-cate about health status or the surveillancesystem.Nole: If possible pnide additional surueillancedata shafing difierent pattems to giw partici-ponts more practice in analysing data.. Ask for questions or comments.



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SESSION 4: OBJECTIVESPlan surveillance activities for theirPHC programmePlan the analysis of their surveillancedata

Module 4: FG; session 4; transparency 4-I4


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TRAININGTOPICSo purpose and value of surveillancehow to recognise and classify diseaseso how to record datahow to summarise and report datahow to determine need for furtherinvestigation



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SUPERVISIONREQUIREMENTSSupervisors should be sure that inter-viewers:

Follow up on all designated cases anddeathsFollow up on all incomplete answers

o Encourage probingWrite all responses downUse local language or dialectSummarise and verify answers

Nlodule 4: FG; session 4; transparency 4-16


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POSSIBLE DATAPATTERNSSpikesClustersTiendsSystematic variations



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EACTORS INFLUENCINGNUMBEROFCASESREPORTEDcompleteness of reportingseasonal variationepidemics or outbreakscoverage

other factors

oo



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Session 5: Investigate causation(optional) (Step 7l

Objectives:

Session outllne:

MaterialsrEquipment:

Participants will be able explain what is involvedin conducting investigations to determine thecause of certain diseases, health problems, ordeaths.L lntroduction (5 minutes)II. Caseloutbreak investigations (15 minutes)III. Verbal autopsies (25 minutes)Module 4 User's guideTiansparency 4-L9: Session 5: ObjectiveFlip chart, stand, markers, masking tape, over-head projector and screen



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48iffi#ilI. Introduction (5 minutes)

Tiansparency 4-19'Session 5: Objectives. Review session objective.. Remind participants that investigatingcausation requires special training, is time-consuming and is done on a selective basis.

II. Case/outbreak investigations (15 minutes)Module 4 User's guide,page 46 . Review general guidelines for conducting acase or outbreak investigation.. Refer participants to Appendix C and explaineach section of the prototype form.. Explain that a form will be needed for eachcase selected for investigation.. Explain that analysis of this information will

help to identify the main cause of the problemand plan preventive action.. Ask for questions or comments.III. Verbal autopsies (25 minutes)

Module 4 User's guide,page 46 . Review general guidelines for conductingverbal autopsies and refer participants to Ap-pendix D for further information and guide-lines.. Refer participants to Appendix E and reviewprotocols for child and maternal death inves-tigations.. Explain that analysis of this information willalso help to identify the main cause of theproblem and plan preventive action.. Ask for questions and comments.



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SESSION 5: OBJECTIVEParticipants will be able to explainwhat is involved in conductinginvestigations to determine thecause of certain diseases, healthprobleffis, or deaths



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Session 6: Develop an action plan andpresent reports (Steps 8 and 9)Objectives:

Session outline:

Materials:

Equipment:

Participants willbe able to follow the directionsin the Module 4 User's guide to develop actionplans to prevent unnecessary disease and deathbased on the surveillance data collected.I. Introduction (10 minutes)IL Develop an action plan (20 minutes)III. Prepare and present reports (30 minutes)IV. Next steps (15 minutes)V. Conclusion (10 minutes)Module 4 User's guideliansparen cy 4-20: Session 6: ObjectiveTiansparency 4-2I: Action plan componentsTiansparency 4-22: Guidelines for preparing

reportsHandout 4-4: Worksheet for developingaction plansFlip chart, stand, markers, masking tape, over-head projector and screen



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I. Introduction (1O minutes)Tiansparency 4-20:Session 6: Obiective

. Review session objective.r Give a brief overview of session activities.II. Develop an action plan (2O minutes)

Tiansparency 4-21:Action plan componentsModule 4 User's guide,page 48Handout 4-4: Worksheetfor developing actionplans

. Explain that surveillance data is used to planways to prevent unnecessary disease anddeath.. Review options for developing solutions to anidentified problemModules 4 and 6Problem-solving guideBrainstorming with staff, community repre-sentatives, and others. Review what should be included in an actionplan once a viable solution is found.. Refer participants to the example at the bot-tom of the page.e Direct participants to complete the work-sheet for one action based on the analysis oftables, charts, and maps in Session 4.. Ask one or two participants to read theirexample aloud and invite other participants tocomment on its appropriateness, clarity, andfeasibility for the stated analysis.. Ask for questions and comments.



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lII. Prepare and present reports (30 minutes)

Trans;nrency 4-22:Guidelines for preparingreports

. Remind participants that although the datagenerated by the surveillance system proposedin this module should address the concerns ofsession 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 docu-mentation.. Ask for questions or comments.IV. Next steps (15 minutes)

. Briefly summarise the steps in this moduleand the outcomes of each step.. Direct participants to review their completedworksheets and write down the actions thatthey need to take when they return to the jobto:Complete the worksheets {or objectives forsurveillance and for surveillance methods.Develop data collection procedures.

Implement or improve surveillance of mor-bidity and mortality in their PHC programme.. Ask each participant (or participant team) tobriefly describe the actions they will take whenthey return to their jobs. (The format on Hand-out 4-4 is appropriate for this action plan).



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V. Concluslon (10 minutes)Flip chart ofa


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SESSION 6: OBJECTIVEDevelop action plans to preventun necessary disease and deathbased on surveillance data



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ACTION PLANCOMPONENTSO WHATO WHOO WHEN


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GUIDELINES FORPREPARING REPORTSo Review original objectiveso Review tables, charts, and mapso Prepare a short explanatory of eacho Order them in logical sequ enceo number of cases

.o number of deathso number of trendsDiscuss major issuesSummarise actions planned or taken

ooModule 4: FG; session 6; transparency 4-22


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PHC MAP MANAGEMENT COMMITTEEDr. Ronald Wilson . Aga Khan Foundation, Switzerland (Co-Chair)Dr. Jack Bryant . Aga Khan University, Pakistan (Co-Chair)Dr. William Steeler o Secretariat of His Highness the Aga Khan, France (Co-Chair)Dr. Jack Reynolds . Center for Human Services, USA (PHC MAP Director)Dr. David Nicholas r Center for Human Services, USADr. Duane Smith . Aga Khan Foundation, SwitzerlandDr. Pierre Claquin . Aga Khan Foundation, SwitzerlandMn Aziz Currimbhoy ' Aga Khan Health Service, PakistanMr. Kabir Mitha . Aga Khan Health Service, IndiaDr. Nizar Verjee . Aga Khan Health Service, KenyaMs. Khatidja Husein . Aga Khan University, PakistanDr. Sadia Chowdhury . Aga Khan Community Health Programme, BangladeshDr. Mizan Siddiqi . Aga Khan Community Health Programme, BangladeshDr. Krasae Chanawongse . ASEAN Institute for Health Development, ThailandDr. Yawarat Porapakkham . ASEAN Institute for Health Development, ThailandDr. Jumroon Mikhanorn . Somboon Vacharotai Foundation, ThailandDr. Nirmala Murthy . Foundation for Research in Health Systems, IndiaPHC MAP TECHNICAL ADVISORY COMMITTEEDr. Nirmala Murthy . Foundation for Research in Health Systems, India (Chair)Dr. Krasae Chanawongse . ASEAN Institute for Health Development, ThailandDr. Al Henn . African Medical and Research Foundation (AMREF), formerly ofthe Harvard Institute for International DevelopmentDr. Siraj-ul Haque Mahmud . Ministiy of Planning, PakistanDr. Peter Tugwell . Faculty of Medicine, University of Ottawa, CanadaDr. Dan Kaseje . Christian Medical Commission, Switzerland, formerly of theUniversity of Nairobi, KenyaKEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICESDr. Jack Reynolds (PHC MAP Director)Dr. Paul Richardson .Dr. David NicholasDr. Wayne StinsonMs. Maria Francisco

Dr. Neeraj KakMs. Lori DiPrete BrownMs. Pam HomanDr. Lynne Miller-FrancoMs. Mary Millar


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Documents

Module 4 Facilitator's Guide_Surveillance of Morbidity and Mortality