Zaf CH 20 01 Operational Guidance 2012 Eng South Africa DL Imci Facilitator Manual Colour

DISTANCE LEARNING COURSE
IMCI
Integrated Management of
Childhood Illness
FACILITATOR GUIDE
Temporary Draft
East Cape
South Africa 2012
World Health Organization

Department of Paediatrics and Child Health:ELHCx
1
CONTENTS . .
WHAT IS IN THIS GUIDE?

This guide explains course structure, expectations for facilitators, and the outlines for 4 face-to-face
meetings. The guide describes materials and activities used in learning. This includes visual aids,
IMCI videos, role plays, demonstrations, group activities, assessments, and practice sessions.
PART ONE ......................................................................................................................................... 4

PLANNING & PREPARING FOR IMCI DISTANCE LEARNING COURSE ................................................... 4
1. INTRODUCTION ............................................................................................................................................................................... 5
2. REVIEWING IMCI - KEY POINTS ..................................................................................................................................................... 6
3. THIS DISTANCE LEARNING COURSE .............................................................................................................................................. 9
4. PREPARING TO BE A FACILITATOR ..............................................................................................................................................21
5. HOW TO USE THIS GUIDE .............................................................................................................................................................26
PART TWO ...................................................................................................................................... 27
ORIENTATION & INITIATION ........................................................................................................... 27
SECTION OVERVIEW & PROPOSED AGENDA .................................................................................................................................29
CHECKLIST OF MATERIALS ................................................................................................................................................................30
REGISTRATION & PREPARATIONS ...................................................................................................................................................31
SECTION 1 - INTRODUCTION & COURSE OVERVIEW ....................................................................................................................32
SECTION 2 - CREATING A WELCOMING ENVIRONMENT ..............................................................................................................38
SECTION 3 - CAUSES OF CHILDHOOD ILLNESS ...............................................................................................................................42
SECTION 4 - THE IMCI STRATEGY .....................................................................................................................................................46
SECTION 5 – CLINICAL PRACTICE .....................................................................................................................................................64
SECTION 6 – USING IMCI WITH THE SICK YOUNG INFANT ..........................................................................................................67
SECTION 7 – GOOD COMMUNICATION & COUNSELLING SKILLS ................................................................................................75
SECTION 8 – NEXT STEPS ..................................................................................................................................................................90
ANNEX 1ST MEETING: ORIENTATION ...............................................................................................................................................95
1. SAMPLE COURSE REGISTRATION FORM ....................................................................................................................................96
2. SAMPLE PARTICIPANTS LIST ........................................................................................................................................................97
3. PLANNING & MANAGING STUDY GROUPS................................................................................................................................98
4. TABLE OF CLINICAL SIGNS ......................................................................................................................................................... 100
PART THREE .................................................................................................................................. 102
REVIEW & PRACTICE 1 .................................................................................................................. 102
MEETING OBJECTIVES .................................................................................................................................................................... 103
SECTION OVERVIEW & PROPOSED AGENDA .............................................................................................................................. 104
CHECKLIST OF MATERIALS ............................................................................................................................................................. 105
REGISTRATION & PREPARATIONS ................................................................................................................................................ 106
SECTION 1 – OVERVIEW ................................................................................................................................................................. 107
SECTION 2 – REVIEW SELF-STUDY PHASE 1 ................................................................................................................................ 110
SECTION 3 – ASSESS & CLASSIFY THE SICK CHILD (PART 1) ...................................................................................................... 112
SECTION 4 – CLINICAL PRACTICE .................................................................................................................................................. 116
SECTION 5 – ASSESS & CLASSIFY THE SICK CHILD (PART 2) ...................................................................................................... 119
SECTION 6 – INTEGRATING TREATMENT, COUNSELLING THE CARETAKER, AND FOLLOW-UP ........................................... 123
SECTION 7 – NEXT STEPS ............................................................................................................................................................... 132
PART FOUR ................................................................................................................................... 136
REVIEW & PRACTICE 2 .................................................................................................................. 136
1.1 INTRODUCTION ........................................................................................................................................................................ 137
1.2 OBJECTIVES & STRUCTURE ..................................................................................................................................................... 138
SECTION OVERVIEW & PROPOSED AGENDA .............................................................................................................................. 142
2
SECTION 1 – WELCOME & REVIEW OF IMCI AND INTRODUCTION HIV/ART Module .......................................................... 146
SECTION 2a – REVIEWING THE SELF STUDY PHASE 2 (20min) ................................................................................................. 153
SECTION 2b – INTRODUCING HIV/AIDS....................................................................................................................................... 154
SECTION 3 – ASSESS & CLASSIFY HIV STATUS............................................................................................................................. 157
SECTION 4 – CLINICAL DEMONSTRATION & PRACTICE ............................................................................................................. 168
SECTION 5 – INFANT FEEDING ...................................................................................................................................................... 169
SECTION 6 – TREATMENT & PREVENTATIVE PROPHYLAXIS ..................................................................................................... 175
SECTION 7 – INTRODUCE ANTIRETROVIRAL TREATMENT ........................................................................................................ 178
SECTION 8 – NEXT STEPS ............................................................................................................................................................... 184
PART FIVE ..................................................................................................................................... 187
SYNTHESIS & ASSESSMENT ........................................................................................................... 187
PROPOSED AGENDA ....................................................................................................................................................................... 189
OVERALL ASSESSMENT-GRADING PARTICIPANTS FOR PASS/FAIL.......................................................................................... 193
PLUS .................................................................................................................................................................................................. 193
Clinical Summative assessment at in about 6 weeks to confirm competence to practiceASSESSMENT—GRADING
PARTICIPANTS FOR PASS/FAIL...................................................................................................................................................... 193
ASSESSMENT—GRADING PARTICIPANTS FOR PASS/FAIL ........................................................................................................ 194
SECTION 1 - INTRODUCTION & REVIEW OF IMCI ....................................................................................................................... 195
SECTION 2 – REVIEW SELF-STUDY ................................................................................................................................................ 200
SECTION 3 – REVIEWING IMCI FOR HIV....................................................................................................................................... 202
SECTION 4 – CLINICAL DEMONSTRATION & PRACTICE ............................................................................................................. 204
SECTION 5 – ASSESSMENT BY SKILLS STATIONS ........................................................................................................................ 205
SECTION 6 – MULTIPLE-CHOICE EXAMINATION......................................................................................................................... 211
SECTION 7 – NEXT STEPS & FORMAL CLOSING .......................................................................................................................... 212
PART SIX ....................................................................................................................................... 214
LOCAL CLINICAL SUPPORTIVE MEETINGS ...................................................................................... 214
SECTION 1 – MEETING OBJECTIVE................................................................................................................................................ 215
SECTION 2 – CARRYING OUT THE MEETINGS ............................................................................................................................. 215
PART SEVEN.................................................................................................................................. 216
FINAL LOCAL CLINICAL SUMMATIVE MEETING.............................................................................. 216
SECTION 1 – MEETING OBJECTIVE................................................................................................................................................ 217
SECTION 2 – ASSESSMENT PROCESS AND FORMS FOR CLINICAL ASSESSMENT ................................................................... 217
ANNEX .......................................................................................................................................... 221
REGISTRATION FORM—FINAL SYNTHESIS MEETING ................................................................................................................ 222
ASSESSMENT TOOLS....................................................................................................................................................................... 224
COURSE EVALUATION .................................................................................................................................................................... 239
PROFORMA LETTER — SUPPORT REQUEST FOR COURSE ........................................................................................................ 240
ANSWER KEYS ................................................................................................................................................................................. 242
MODULE 1 - GENERAL DANGER SIGNS ....................................................................................................................................... 243
POST-COURSE MONITORING ........................................................................................................................................................ 248
FACILITATOR GUIDE – Distance learning course on IMCI 3

DRAFT updated August 2011
PART ONE
Planning & preparing for
IMCI distance learning
course
4
1. INTRODUCTION
The Integrated Management of Childhood Illness (World Health Organization, United Nations
Children's Fund) guidelines offer simple, effective methods to manage the leading causes of serious
illness and mortality in young children. Since IMCI was developed in the early 1990s, over 100
countries have adopted IMCI and adapted the guidelines for country needs. Thousands of healthcare
providers have been trained in IMCI. Wide implementation of IMCI has improved quality of care and
has contributed to reductions in childhood mortality.
You are part of an exciting initiative to train even more health workers in IMCI through a distance
learning course developed by the WHO.
COURSE OBJECTIVES
At the end of this distance learning course, participants will be able to:
■ Implement integrated case management for common health problems in sick young infants
and children, including the initiation of Anti Retroviral Treatment.
■ Use the IMCI chart booklet and recording forms in clinical practice
■ Counsel caretakers on home treatment, feeding, well child care, and disease prevention
WHY DISTANCE LEARNING?

Traditional IMCI courses have required health workers to travel and spend two weeks in classroom
and inpatient/outpatient practice sessions. This was a barrier for some healthcare providers to
participate in the training.
Distance learning integrates study into clinical practice. Participants learn on their own time, at their
own pace, and in their own clinical facilities.
Effective distance learning requires participants to study and practice on their own, but also work
with mentors and colleagues. Your role as the course facilitator is critical to ensuring that distance
learning is effective and participants will use IMCI tools in their home clinics.
HOW IS THIS COURSE STRUCTURED?

This distance learning course is intended to last 4 months. The facilitator is expected to organize 4
face-to-face meetings: an orientation meeting, 2 review and practice sessions, and a final synthesis
meeting. In addition local IMCI facilitators will need to be organized to give clinical support and
assessment meetings at a convenient local venue between face to face meetings, and also carry out a
summative assessment of the clinical skills at a meeting at a convenient local venue 6 weeks after the
last face to face meeting.

2. REVIEWING IMCI - KEY POINTS
■ Integrated case management means that health workers assess all aspects of the child’s
health. Integrated management looks at common health issues, feeding and nutrition,
immunizations, and other problems.
■ IMCI focuses on the most common health problems in children, particularly those that are the
most important causes of health. These include acute respiratory infections, diarrhoea,
malaria, measles, malnutrition, and HIV.
■ IMCI is designed for first-level settings such as community clinics, health centres, or
outpatient facilities at a hospital. Doctors, nurses, and other health professionals who see sick
infants and children can use IMCI.
■ Guidelines are age-specific. A sick young infant is up to 2 months of age. A sick child is 2
months up to 5 years of age. This means a child has not reached his or her fifth birthday.
■ IMCI includes instructions to do the following:

 Check clinical signs that indicate severe illness. These are general danger signs in sick
children, and signs of severe disease and bacterial infection in young infants.
 Assess for symptoms and signs of common illnesses and causes of death.
 Assess a child’s nutrition, immunization status, and feeding
 Classify each condition and identify treatment
 Decide on appropriate treatment for all conditions
 Teach caretakers how to care for a child at home
 Counsel caretakers to solve feeding problems
 Advise caretakers about when to return to a health facility
 Provide follow-up care when the infant or child returns
■ IMCI classifications are action-oriented. They determine if a child should be urgently referred
to another health facility, treated at the first-level facility, or safely managed at home.
■ Treatments are identified with action-oriented classifications, rather than exact diagnosis. The
treatments cover the most likely diseases represented by each classification.
Flow charts on the following two pages demonstrate the IMCI process for sick young infant and
sick child. These flow charts appear throughout the course and modules as a learning tool.

3. THIS DISTANCE LEARNING COURSE
HOW WAS THIS COURSE ADAPTED IN-COUNTRY?

This distance learning course is based on the WHO/UNICEF generic IMCI materials.
When countries adopt IMCI, they adapt the clinical guidelines to:
■ Cover the most serious childhood illnesses typically seen at first-level health facilities,
■ Make the guidelines consistent with national treatment guidelines and other policies,
■ Make the guidelines realistic for implementation in the health system and by families caring
for children in their home.
Countries may use their IMCI guidelines to make technical adaptations to this course’s materials.
Consistency with national IMCI approaches and current clinical guidelines are essential to the success
of this course.
COURSE STRUCTURE
The course structure is outlined in the chart below, and further detailed in the course calendar.
The long bars show the participants’ time for self-study, practice in clinic, and learning with others.
The 4 boxes demonstrate the timing of the 4 face-to-face meetings.
Distance learning course structure

Orientation Review & practice Review & practice Final synthesis Optional
Additional
1st face-to-face 2nd face-to-face 3rd face-to-face 4th face-to-face
Modules in future
Meeting meeting meeting meeting eg update,
new information
(1 day) (1 day) (1 day) (1 day) (1 day)
3-4 6-8 4 weeks

weeks weeks
Self-study phase 1 Self-study phase 2 Self-study phase 3

(Modules 1 & 2) (Modules 3-7) (Module 8)
Practice IMCI in clinic, using Chart Booklets and recording forms Application of clinical skills
Review with study groups
Work with mentors
Clinical Formative Clinical Formative Clinical Formative Clinical

Assessment Assessment Assessment Summative
Local Site Local Site Local Site Assessment
IMCI Facilitator IMCI Facilitator IMCI Facilitator Local Site
about 4 months 6 weeks

COURSE CALENDAR
The course calendar below details course activities, and is also provided to the participants.
Facilitators should fill in the dates and meeting locations for your course.
COURSE CALENDAR – about 4 months total
Sessions Objectives Location Date
 Introduce IMCI process
 Distribute learning materials &
Orientation
introduce content to Modules 1 and 2
1st face-to-face ____________ _________
 Review distance learning course
meeting Meeting place (1 day)
structure & expectations
 Provide clinical practice
 Read modules
 Self-assessment exercises in modules
as you read
 Practice in clinic and record cases on
Self-study phase 1
recording forms in logbook _________
Modules 1 & 2 Home facilities
 Hold study group discussions (3-4 weeks)
 Maintain contact with mentors &
facilitators
 Complete assessment exercises in
logbook
 Meet with local IMCI facilitator to see Convenient
Clinical Support _________
PHC child clients using IMCI – “sign off” local venue
meeting 1 (1 day)
2 seen patients with patients
• Review progress & issues in self-study
Review & practice 1 • Examine cases from clinical practice ____________
_________
2nd face-to-face • Introduce content from upcoming Meeting place
(1 day)
meeting modules can be on-site
• Provide clinical practice
 Read modules
as you read
Self-study phase 2
Modules 3-7 Home facilities
 Hold study group discussions (8-9 weeks)
facilitators
logbook
meeting 2 (1 day)

_________
3rd face-to-face • Introduce content from upcoming Meeting place
(1 day)
 Read modules
as you read
Self-study phase 3
Module 8 -9 Home facilities
 Hold study group discussions (3-4 week)
facilitators
logbook
meeting 3 (1 day)
• Examine cases from clinical practice
Final synthesis  Review content from all modules
____________
4th face-to-face  Provide clinical practice _________
Meeting place
meeting  Individual action plans for continued (1 day)
Can be on site
learning
 Course assessment (skills stations and
written exam)
 Meet with local IMCI facilitator 6
Convenient
Clinical Summative weeks after 4th face to face to see PHC _________
local venue
assessment child clients using IMCI as final clinical (1 day)
with patients
assessment
FACE-TO-FACE / CLINICAL MEETINGS

Course facilitators will hold 4 face-to-face meetings with participants AND local IMCI facilitators will
hold 3 clinical support meetings plus 1 clinical summative meeting with participants.
During the face to face meetings, facilitators will present new IMCI content and provide
practice/demonstrations in a clinical setting. Your constructive feedback during these meetings is
critical to effective mentorship, particularly in a distance learning format.
During the clinical support meetings local IMCI facilitators will meet with the participants at a
convenient local venue that has adequate patient numbers and see patients with the participants – 2
patients will be recorded and “signed off” for each participant for each meeting to be submitted as
part of course work in addition to recording forms of patients seen without facilitator present.

A final summative assessment meeting of clinical skills will be carried out by the local IMCI facilitators
with the participants at a convenient local venue 6 weeks after the final face to face meeting and will
be required to be assessed as adequate along with attendance of meetings and successful
completion of the modules and final MCQ assessments to allow the participant to receive a
certificate of competence.
In the 2nd , 3rd and 4th meetings, facilitators will also focus on any challenges from the previous self-
study modules and issues from clinical practice.
1st meeting—Orientation
The first is an orientation to IMCI, course structure, and materials. Participants will be given their
self-study modules. Facilitators will use videos and clinical demonstrations to introduce IMCI for the
sick child and young infant.
MEETING LEARNING OBJECTIVES

At the end of this meeting, participants should be able to:
■ Explain the objectives and structure of this distance learning course, including the
importance of clinical practice, mentors, and study groups
■ Identify key causes of childhood mortality
■ Explain the purpose of integrated case management
■ Describe the major steps in the IMCI process (ASSESS, CLASSIFY & IDENTIFY TREATMENT,
TREAT, COUNSEL THE PARENT, and PROVIDE FOLLOW-UP CARE)
■ Demonstrate how chart booklets and recording forms are job aids for the IMCI process
■ Recognize the general danger signs in children
■ Identify important care for young infants
■ Explain the importance of assessing for signs of severe disease and feeding problems in
young infants
■ Describe how a welcome environment is important for case management
■ Explain and demonstrate key communication skills
■ Plan self-study, group study, and clinical practice for Modules 1 and 2
1st Clinical Support Meeting

Participants in suitable sized groups will meet ½ way between the 1st and 2nd face to face with a local
IMCI facilitator at a convenient local venue that has adequate patient numbers and see patients with
the participants. Each participant should see 2 patients will be recorded on the normal recording
form and must be “signed off” by the IMIC Facilitators. These forms are in the participants logbook
and will be submitted as part of the participants course evaluation.

2nd meeting—review and practice 1
The second face-to-face meeting is an opportunity to review the self-study process thus far and
practice skills. This meeting can be arranged on-site in order to practice clinical skills (e.g. district
hospital, tertiary facilities central to participants). Facilitators will arrange opportunities for clinical
demonstration and practice.
Participants should bring completed Modules 1 and 2 recording forms and written exercises to
review in a plenary discussion and with the facilitators. This session will also introduce content from
modules 3 - 7.

■ Demonstrate skills from Modules 1 and 2 in a clinical setting
■ Explain and demonstrate how to use IMCI chart instructions to assess, classify, and treat main
symptoms and conditions in a sick child (cough or difficult breathing, diarrhoea, fever,
malnutrition, and anaemia).
■ Plan self-study, group study, work with mentors, and clinical practice for remaining modules
2nd Clinical Support Meeting

Participants in suitable sized groups will meet ½ way between the 2nd and 3rd face to face with a local
3rd meeting—review and practice 2

The third face-to-face meeting is an opportunity to review the self-study process thus far and
practice skills. This meeting can be arranged on-site in order to practice clinical skills (e.g. district
hospital, tertiary facilities central to participants). Facilitators will arrange opportunities for clinical
demonstration and practice.
Participants should bring completed Modules 3 to 7, recording forms and written exercises to review
in a plenary discussion and with the facilitators. This session will also introduce content from module
8 and 9.

■ Demonstrate skills from Modules 1 to 7 in a clinical setting
■ Explain and demonstrate how to use IMCI chart instructions to assess, classify, and treat main
symptoms and conditions in a sick child specifically including the HIV / ART skills and
knowledge.
■ Plan self-study, group study, work with mentors, and clinical practice for remaining modules

3rd Clinical Support Meeting
Participants in suitable sized groups will meet ½ way between the 3rd and 4th face to face with a local
4th meeting—final synthesis

All participants will return 3-4 weeks later for the final synthesis meeting. This meeting will conclude
the course. It should take place about 4 months after the first Orientation meeting.
This meeting will review how participants are using IMCI in their clinics, and address problem areas.
Facilitators will arrange opportunities for clinical demonstration and practice.
Participants complete an assessment and receive certificates of completion. All participants will be
asked to create individual action plans. These will include plans for continued skills development,
refresher training, seeking mentorship, using IMCI in the clinic, and disseminating information to
supervisors and colleagues.

■ Explain and demonstrate IMCI clinical process with sick children and young infants
■ Demonstrate good use of IMCI charts and recording forms in clinical practice
■ Design an individual action plan for using IMCI and continuing to improve skills
Final Clinical Summative Assessment
About 6 weeks after the final face to face meeting the local IMCI facilitators will arrange to meet
participants in suitable sized groups at a convenient local venue that has adequate patient numbers
and see patients with the participants. 2 patients will be seen individually with the facilitator who will
assess them against the standard IMCI practice process and will decide if they are able to practice
this clinical consultation skill safely and correctly. The will inform the course director of the outcome
of this assessment.
If the participant has submitted all the module logbook work including MCQ’s, Facilitators
observed clinical practice recording forms, individual clinical consultation recording forms
successfully; has passed the final face to face assessment (4th face to face) and has been clinically
assessed as safe and competent at the summative clinical assessment – they will be issued with a
certificate of competence as an IMCI (+ Child NIMART) practitioner.
If not, certificates of attendance or completion may be issued as appropriate at the course

directors discretion dependent on the attendance and completion of the required course works.

PARTICIPANT SELF-STUDY MODULES & LOGBOOK
The facilitator will give participants the self-study modules during the first orientation meeting. The
modules are detailed below.
SELF-STUDY MODULES
1 General danger signs
Identifying signs of severe illness in sick children
2 Care of the sick young infant
Using the IMCI strategy with sick young infants
3 Cough or difficult breathing
Assess, classify, and treat cough or difficult breathing in sick child
4 Diarrhoea
Assess, classify, and treat diarrhoea and dehydration in sick child
5 Fever
Assess, classify, and treat fever in sick child
6
Ear problems
Assess, classify, and treat ear problems in sick child
7 Malnutrition and anaemia
Assess nutritional status and address malnutrition, anaemia, or
feeding problems
8 HIV/ART
Assess classify and treat children with HIV infection
9 Cosider TB/ Assess Immunisation & Other
Assess and classify TB/ Immunisation and Other Problems
Participants should complete Modules 1 and 2 between the 1st and 2nd face-to-face meetings.
Participants are encouraged to complete the modules at their own pace.
Participants should complete Modules 3 and 7 between the 2nd and 3rd face-to-face meetings.
Participants should complete Module 8 and 9 between the 3rd and 4th face-to-face meetings.

What is in the self-study modules?
The modules include reading material, recommendations for DVD clips, video practices, and self-
assessment exercises. The self-assessment exercises have an answer key in each module so
participants can check their own answers.
What is the logbook?

The logbook is given with the self-study modules. It is an important course material for participants
to record exercises and cases that facilitators will check.
The logbook has a section for each module. For each module, participants should do the following in
their logbook:
■ WRITTEN EXERCISES: these exercises are similar to the self-assessment exercises in each module.
Participants are not given an answer key to these exercises. They are expected to complete them
on their own and submit the logbook to you at each meeting.
Each module has about 20 multiple-choice and true/false questions in the logbook. You have an
answer key for each module in Annex. You can use this key to mark exercises at the face-to-face
meetings. .
■ RECORDING FORMS: participants should use the material they are learning during self-study
phases and record cases that they see in their clinic. Facilitators should recommend a certain
number of recording forms to be filled out for each module. Participants will submit these forms
at the 2nd , 3rd and 4th meetings. Facilitators will review these forms to identify any problem areas
and use them as part of the course assessment. Problem areas can be reinforced with additional
information, demonstration, or clinical practice.
In addition some of the recording forms are to be used with an IMCI facilitator present at clinical
support meetings between face to face sessions to ensure adequate support is provided. These
signed off recording forms also need to be submitted
Participants should also use their logbook to record questions during self-study, difficult cases they
see, experiences or reflections from using IMCI in the clinic, or other course notes.

SUPPORT DURING SELF-STUDY
Participants should involve others in their learning process. These individuals can help explain
reading material, facilitate opportunities to see cases or clinical signs, and help with any challenges.
Supporters are particularly important for effective distance learning.
This course has several components:
• STUDY GROUPS: facilitators should help participants form study groups during the
Orientation meeting. Study groups will depend on participants' home locations.
The study group is a very important element to distance learning. It provides participants
with an opportunity to meet regularly to review content, answer questions, explain confusing
topics, and practice skills together as necessary. Groups should meet regularly (e.g. weekly or
twice a week) during self-study. In the Annex there is a section on advice for planning and
managing study groups. The participants’ modules book has the same information.
• MENTORS: participants will be asked to identify mentors that they can approach during self-
study. These mentors should be IMCI-trained healthcare providers or more experienced
professionals that can explain cases, challenging material, or the IMCI process. Mentors can
be colleagues, in-charge officers, or other professionals outside of a participant's facility (e.g.
at the district hospital).
• IN-CHARGE OFFICERS: in-charge officers are the doctors or nurses responsible for clinical
service in the facility. Participants should debrief in-charge officers after each face-to-face
meeting. In-charge officers should be aware of the IMCI guidelines and tools that participants
will be using in the clinic.
• COURSE FACILITATORS: Facilitators should be clear with participants about corresponding

and expectations during the self-study phases. This will depend on your arrangements as a
facilitator. Participants should know in what situations they should contact you (e.g. only
when there is an issue, when they need clarification on material) and how you are best
reached (e.g. mobile, email, what times of day).
The facilitator should also be prepared to advise participants on how to seek support in their
home facilities. These situations will vary depending on the arrangements made for each
participant.
• OFF-SITE PRACTICE: course facilitators will arrange for participants to attend meetings with
local IMCI facilitators at convenient nearby sites which have adequate suitable patients
numbers to support supervised consultations on one occasion between each face to face
meeting.

ASSESSMENT OF PARTICIPANTS
There are several opportunities to assess participants' skills development and comprehension.
Participants are assessed by:
1. Clinical cases on recording forms in their logbooks: should demonstrate effort to use IMCI
in their clinical practice.
2. Written exercises in logbook: should demonstrate an understanding of material from study
modules. Facilitators should mark these exercises during the face-to-face meetings. The
answer key is in Annex.
3. Final course assessment: participants should perform well in the course assessment during
the 4th face-to-face meeting. The final assessment includes skills stations, including written
cases and video exercises.
4. Final clinical assessment: Participants in suitable sized groups will meet 6 weeks after the
4th face to face with a local IMCI facilitator at a convenient local venue that has adequate
patient numbers and see patients with the participants. Each participant should see 2
patients and will be assessed against standard IMCI care levels as to ability to carry out IMCI
care. If the they are assessed as adequate this will be recorded ans used with the other in
course assessments and tasks as evidence to support the issuing of a certificate of
competence as an IMCI (including child NIMART) primary care practitioner.
Participants should bring their logbooks to the 2nd , 3rd and 4th face-to-face meetings. When
facilitators review logbook exercises and recording forms, it is important to mark work for correct
answers and also identify any common problem areas. Facilitators should focus on correcting these
problem areas during the 2nd , 3rd and 4th face-to-face meetings.
CHART OF ASSESSMENTS
Participants are provided with the following chart detailing all assessments. Facilitators should
explain to participants how they are to be assessed in the course.
Activity Objectives of assessment Submission date

nd
Module 1 2 face-to-face
1  Record checking sick children for general danger signs
recording forms meeting
Module 2  Record examples of assessing, classifying, treating, 2nd face-to-face
2
recording forms counselling, and following up sick young infants meeting
Written exercises  Complete, on your own, logbook exercises for modules 1 and 2nd face-to-face
3
for Modules 1-2 2. You will have practice exercises in the modules as you read. meeting
Module 3  Record example of IMCI process with assessing, classifying, 3rd face-to-face
4
recording forms and treating cough in your clinic meeting
Module 4  Record example of assessing, classifying, and treating fever in 3rd face-to-face
5
recording forms your clinic meeting
Module 5  Record example of assessing, classifying, and treating 3rd face-to-face
6
recording forms diarrhoea in your clinic meeting

Module 6  Record example of assessing, classifying, and treating 3rd face-to-face
7
recording forms malnutrition and anaemia in your clinic meeting
Written exercises  Complete, on your own, logbook exercises for modules 3-7. 3rd face-to-face
8
for Modules 3-7 You will have practice exercises in the modules as you read. meeting
Module 8  Record example of assessing, classifying, and treating 4th face-to-face
7
recording forms malnutrition and anaemia in your clinic meeting
Written exercises  Complete, on your own, logbook exercises for modules 3-7. 4th face-to-face
8
for Modules 8 You will have practice exercises in the modules as you read. meeting
Final course  Assesses your ability to use the IMCI process with sick children During 4th face-to-
9
assessment and young infants face meeting.
Clinical Final  Assess your ability to use the IMCI process on sick children and 6 weeks after 4th
10
Assessment young infants in the clinical setting face to face meeting
WHAT DO PARTICIPANTS RECEIVE WHEN COMPLETING THE COURSE?

If a participant's skills development is satisfactory, participants will be awarded a certificate of
completion. This will certify that participants are trained in Integrated Management of Childhood
Illness through a distance learning course offered through the WHO and the national government.
In addition if the final clinical assessment is deemed safe and adequate a certificate of competence
will be issued. This will certify that in addition to successfully completed the in course process of
assessment that they have been assessed in practice and are considered competent to practice IMCI
(including child NIMART) in primary care settings.
If a person attends the course and submits the required course work but is not deemed safe for
practice and does not fulfill the knowledge criteria they may be issued a certificate of attendance at
the discretion of the course director.

COURSE EVALUATIONS
It is important for facilitators to gather feedback on the distance learning process, course materials,
and use of IMCI in clinics.
Participant evaluations at the end of each face-to-face meeting can identify gaps in the course or
learning process. Evaluations can also recommend changes for the facilitators.
Facilitators should also provide feedback to those who are planning the distance learning courses at
regional and national levels. It is particularly useful for facilitators to share any good practices,
course logistics issues, or other.
AFTER THE COURSE

After participants finish the course, there are two parts of follow-up:
1. In the final face to face meeting, participants will create individual action plans. These are
their personal plans for continued learning (skills advanced and refresher training),
implementing IMCI in the clinic, working with IMCI mentors, and disseminating tools in their
home facilities.
2. 6 weeks after the final face to face a summative assessment will be made by a local IMCI
facilitator which in addition to being and assessment visit will offer support opportunity.
3. In the months following the course, participants will be mentored in the implementing IMCI in
clinical practice by local MCWH Managers, NIMART Mentors and Clinic Supervisors.

4. PREPARING TO BE A FACILITATOR
Who should facilitate this course?

Course facilitators should have already completed the IMCI case management course and the IMCI
facilitator course in your country. The appropriate facilitator will be a seasoned clinician with an
ability to teach, a strong knowledge of clinical practice and national policies. In addition they should
have received orientation in the distance based format which may be in the form of a formal
presentation but ideally in the form of mentored facilitation by an experienced distance based IMCI
facilitator.
The facilitator should have a strong willingness to facilitate discussion and Your role is to
learning. The facilitator should be a mentor in addition to an instructor. facilitate learning
Support and guidance from a facilitator is critical if a distance learning by providing
course is going to build clinical capacity. encouragement,
information, and
How will you be trained? guidance—while
prompting your
As a facilitator of this course, you will be expected to have previously
students to
completed the courses in IMCI case management and IMCI course
develop their
facilitation. Course directors should participate in a one day orientation in
abilities.
facilitating the IMCI distance learning course. This orientation is important
to review the critical tasks you will be responsible for in the distance learning process, which is quite
different from the traditional IMCI courses.
Facilitators and course directors should also co-direct / facilitate a dIMCI course with an experienced
dIMCI facilitator /course director.
How many facilitators are required?

It is recommended that there are 2 facilitator (one of whom should be the course director – they may
be local facilitators /course directors) for every 16-20 participants in the course.
In addition local IMCI Facilitators will be needed to provide the clinical support training and
assessment meetings at a local venue – recommended 2 local facilitators for every 16-20
participants.
Who are your participants?

This course is designed for health professionals who manage children at first-level facilities. This
includes nurses, nurse assistants, and clinical health workers.

What should you expect from participants?
In order to complete this course, participants are expected to:
• Read all self-study materials
• Practice IMCI in their own PHC facilities and complete logbook work as requested
• Practice IMCI in a convenient local facility with IMCI facilitators.
• Attend 4 face-to-face meetings
• Take part in the post face to face 6 week summative assesment
• Demonstrate eager participation in the course
• Seek out mentorship
• Learn with others as much as possible
• Notify facilitators, study groups, and mentors if you are going to be late for a meeting
• Practice with normal ethnical and professional conduct standards of the facilities
Before the course begins, participants and in-charge officers should understand that the course is a
significant commitment of time and attention. Participants will be out of clinic for each face-to-face
meeting. They will need time to study and practice IMCI in their clinic.
Ideally, in-charge officers will offer encouragement to participants who are trying to improve their
clinical skills. The course is also beneficial for these in-charge officers. They can learn content from
the study modules even if they cannot attend the face-to-face meetings.
What does a facilitator do?

As a facilitator, you do four basic things:
1. YOU INSTRUCT
 Explain content in full. Provide engaging learning examples and draw from clinical
experiences to relate content to clinical practice.
 Answer questions in full and as they occur.
 Provide constructive feedback.
 During meetings, ensure that participants understand what is expected from a module,
exercise, discussion, or activity.
 Diversify the learning process to emphasize content in different ways. Present content so
that participants:
o hear about content,
o read reinforcement materials on slides or in their participants materials,
o see video or photo examples,
o practice through role plays, demonstrations, or clinical practice,
o reinforce lessons with constructive feedback, group discussions, and questions
 Identify gaps in a participant's understanding or skills. Provide additional explanation and
practice opportunities to reinforce and improve.
 Revisit the learning objectives to ensure that all have been met.

 Model good clinical and communication skills during face-to-face meetings and clinical
practice sessions or demonstrations.
 Ensure that participants understand expectations for completing the course materials,
integrating skills into clinical practice, and working with others during their self-study.
 Give participants concrete advice, examples, and practice on integrating IMCI into their
own clinical practice.
2. YOU MOTIVATE
 Affirm and acknowledge participants' correct answers, constructive teamwork, and
personal improvements and progress.
 Engage participants in your meetings. Bring the material alive. Introduce exciting and
dynamic activities. Share (and encourage participants to share) clinical experiences and
reflections.
 Encourage participants to ask questions and clarifications so that they can move forward
in self-study without confusion.
 Eliminate any learning obstacles like noisy learning environments, low lighting, and
distractions from mobile phones.
 Ensure that participants are supported during their self-study and are receiving
mentorship (e.g. IMCI mentors, colleagues, course facilitators, group study).
 Encourage ownership during self-study and practice.
3. YOU MANAGE
 Plan ahead for the 3 face-to-face meetings. Outline your delivery notes, obtain all
necessary materials, and prepare required content.
 Monitor each participant's progress. The success of this course, as with most adult
learning, is linked to the facilitator's abilities to assess participant needs, and use materials
and activities that will address these needs. This should be ongoing throughout the
course. You can monitor progress by asking direct questions, reviewing participants' work
(e.g. recording forms, written exercises), and observing during practice sessions. Ideally
facilitators will also administer a pre-training needs assessment.
 Provide on-site mentorship, or facilitate participants' mentors as required during self-
study phases.
4. YOU ASSESS
 Each participants needs to be assessed for competence as outlined above

 How does a facilitator accomplish these tasks?
 Show enthusiasm for the course material and the participants' learning process
 Give the course your undivided attention. Do not work on or discuss unrelated matters, or
use your mobile phone and email during the sessions or breaks. Encourage the participants
to do the same. It is important that you are available to mentor participants during breaks.
 Be attentive to participant needs and questions. Be available to participants and encourage

them to come to you with questions or feedback
 Promote a friendly, cooperative relationship through active listening and affirmations (e.g.
"yes, I see what you mean," or "that is a good question")
 Observe participants as they work, and offer help if you notice someone not engaged
 Encourage participants to ask questions or seek clarification with open-ended questions

(e.g. “what questions do we have about chest indrawing?” instead of “does anyone have a
question?”) and relate to their challenges.
 Give enough time to answer questions - so that you and the participant are satisfied
 Use this guide as an outline for materials, content, and flow. This guide has a great deal of
information and support for you. Do not be apprehensive.
 Bring the content alive with your own inputs and experiences. Do not read directly from
the slides or your notes. These are only intended to be useful references.
 Encourage participants to share experiences, questions, and feedback – do not lead the
show.
 Be respectful, and promote a respectful learning environment. Do not allow anyone to

condescend or embarrass another, and be mindful that you do not do this as facilitator.
 Reach out to participants to engage them in the material or check their understanding.
However, do not directly call on participants to answer questions like in a traditional
classroom. This might embarrass them if they do not know the answers. If you have direct
questions for a participant, or want to reinforce that he or she understands content, reach
out during individual time.

What materials will you require to facilitate this course?
All facilitators will require the following resources for this distance learning course. Parts 2-4 of this
guide include specific material lists for each of the three face-to-face meetings.
1. This facilitator guide, which includes a chapter for each meeting

This facilitator guide provides key information for each meeting. There is more information
about this guide on the following page.
2. PowerPoint presentation slides for each face-to-face meeting

PowerPoint slides are designed as a training tool during your meetings with participants.
However, do not rely heavily on these slides. They are meant to provide visuals and key points
only.
These may be used as slides, may be printed as participant materials, or both. In settings
where a projector or computer screen is not available, photocopies of key slides should be
provided to participants.
3. IMCI training DVD

This video demonstrates clinical practice and signs. It provides opportunities for practice.
Videos can be used to stimulate group discussion, or revisit problem areas. Each participant
should be given a DVD with their self-study modules if possible. The modules recommend
video segments to watch as they read.
4. Participant self-study modules and logbook for distribution

Participant self-study modules are bound in a 2 books. The introduction to this book will
include a review of the IMCI process and course overview. This content will be covered during
the Orientation meeting.
This book should be distributed and explained early in the first face-to-face meeting, and sent
home with participants. The logbook should accompany this book. The logbook includes
written exercises and recording forms that should be completed during the self-study phases.
The logbook will be submitted during the face-to-face meetings for the facilitators to review.
5. IMCI chart booklets for distribution to all

The IMCI chart booklet is an essential tool for this course and IMCI implementation. This
course will use either the WHO "generic" chart booklet or one adapted with national IMCI
guidelines.

5. HOW TO USE THIS GUIDE
This guide contains a chapter for each meeting. Each chapter includes the following information
about the meeting:
1. Meeting objectives
2. Section overview & proposed agenda

Outlines sections of content for the day, and provides agenda timing. Facilitators can take
notes on who will cover each section.
3. Checklist of materials
Materials required for participants and activities during the day. Each sub-section will include
a "reminder" list of materials.
4. Content for the day

Each section of the day’s meeting includes section objectives, activities, and content to be
discussed. The outline includes guidance on when to use materials (e.g. PowerPoint slides and
DVD clips to show, helpful times to use a flipchart).
All activities - be it a video demonstration, written exercises, or content discussion - should

reinforce a learning process:
 Introduce the topic with excitement, and in an engaging manner. Open with
questions that check your participants' experiences or understanding about a
particular topic.
 Reflect and reinforce content, an activity, or a discussion with follow-up questions

and feedback from participants.
 Summarize after a period of questions or discussion.
 Field questions and confirm comprehension at the closing of each sub-topic.
 Transition to the next section.
5. Meeting evaluation
An evaluation form to be distributed at the end of the day.
6. Handouts
Worksheets for distribution to participants if the day's activities, if applicable.

PART TWO
Orientation & Initiation
1st face-to-face meeting
Introduce course and modules 1 & 2.

MEETING OBJECTIVES
Participants meet for their first orientation with the course facilitator and fellow participants.
The facilitator briefs them on the objectives and structure of this distance learning course, introduces
them to the IMCI approach and Chart Booklet, and sets a plan for the self-study period. This self-
study period will include Modules 1 (general danger signs) and 2 (sick young infant).
By the end of the first face-to-face meeting, participants will:
■ Explain the objectives and structure of this distance learning course, including
the importance of clinical practice, mentors, and study groups
■ Identify key causes of childhood mortality
■ Explain the meaning and purpose of integrated case management
■ Describe the major steps in the IMCI process (ASSESS, CLASSIFY & IDENTIFY
TREATMENT, TREAT, COUNSEL THE PARENT, and PROVIDE FOLLOW-UP CARE)
■ Demonstrate how chart booklets and recording forms are job aids for the IMCI
process
■ Recognize the general danger signs in children
■ Identify important care for young infants
■ Explain the importance of assessing for signs of severe disease and feeding
problems in young infants
■ Describe how a welcoming environment is important for case management
■ Explain and demonstrate key communication skills
■ Plan self-study, group study, and clinical practice for Modules 1 and 2

SECTION OVERVIEW & PROPOSED AGENDA
8:00 - 8:30 REGISTRATION
9:00 - 9:30 SECTION 1 PLANNING NOTES

INTRODUCTION & OVERVIEW (30 minutes)
Facilitate introductions, discuss "why are we here?" and
review course objectives, structure, and expectations
CREATING A WELCOME ENVIRONMENT (30 minutes)
Facilitate role play scenario and discussion on emotional needs
of families and patients, and role as health workers to create
welcoming environment
CAUSES OF CHILDHOOD ILLNESS (15 minutes)
Identify key causes of mortality as background for IMCI.
10:15 - 10:30 Tea break (15 minutes)

THE IMCI PROCESS (60 minutes)
Introduce IMCI process, chart booklets, and recording forms.
Facilitate opportunities to practice with video and activities.
11:30-12:30 SECTION 5 PLANNING NOTES
CLINICAL DEMONSTRATION & PRACTICE (60 minutes)
12:30 - 13:15 Lunch (45 minutes)

USING IMCI WITH THE SICK YOUNG INFANT (60 minutes)
Reinforce the IMCI approach with sick young infant. Emphasis
special care for young infant, including feeding.
COMMUNICATION SKILLS (75 minutes, break for tea midway)
Review key communications skills and facilitate role plays to
demonstrate communications skills and practice assessment.

NEXT STEPS (45 minutes)
Review expectations for self-learning.
16:30 CLOSE MEETING PLANNING NOTES

CHECKLIST OF MATERIALS
This is a checklist of suggested materials for the day. Each section of the day's meeting specifies
which of these materials is required during a particular section.
MATERIALS NUMBER  list
For facilitators
Facilitator guide 1 for each facilitator
Module PowerPoint slides 1 file of slides
IMCI DVD 1 DVD (has 2 discs)
IMCI Wall Chart 1 displayed, optional visual aid
IMCI facilitator guide for outpatient
1 for each facilitator
clinical practice
IMCI guide for clinical practice in the
inpatient ward
Projector and/or computer screen For slides and video
Speakers for showing DVD As necessary, if showing on laptop or
other equipment with low sound
Flipchart or large paper 15 large sheets, for wall display
Flipchart markers
Clock or stopwatch for timekeeping -
best if visible to all participants
Masking tape As necessary for displaying
If needed during demonstrations or role
Props or display materials
plays
For everyone (all participants + all facilitators) *
Registration forms 1 for each, sample in Annex
Name tags 1 for each
Participants self-study modules
1 of each book for each
Modules 1-2 & self-study Modules 3-9
Participants log book 1 for each
1 booklet for each, preferably the
IMCI Chart Booklets
national adaptation
IMCI DVD Copies for all participants if available
Handouts for activities 1 copy for each
Copies as necessary for meetings and if
IMCI Recording Forms
extras needed for logbooks
Evaluation form 1 copy for each
1 copy for each - if significant changes
Contact information sheet made during registration, reprint and
distribute during day
Notebooks 1 for each
Pens and pencils 1-2 for each
Supplies for 2 tea breaks and lunch If provided
* Materials should be ready and available for the facilitator to distribute at points during the day.
When the facilitator distributes a particular material, s/he must explain the content in full to the
participants.

REGISTRATION & PREPARATIONS
1. REGISTRATION
All participants should complete a registration form (a sample form is in the Annex). During the
day, these forms should be typed into a list of participants, with complete contact information
for each. This should be distributed to everyone by the end of the day. Facilitators should keep
a copy for their records.
2. MATERIALS FOR DISTRIBUTION AT REGISTRATION (or ready at place settings)

 Note book or paper for notes
 Pens and pencils
 Day’s agenda
 Nametag or nameplate
3. MATERIALS PREPARED AND READY FOR DISTRIBUTION

 Chart booklets
 Copies of IMCI recording forms – both for child and young infant
 Participants’ books of self-study modules
 Participant logbooks
 Printed PowerPoint slides (if you decide to distribute)
 Handouts for activities
 Evaluation forms
 List of participants with contact information (prepared during day and distributed by
closing)
4. EQUIPMENT PREPARATIONS
 Viewing—If you are using PowerPoint slides and showing the IMCI DVD on the same
equipment and projector, you will need to switch between them during the day. If you are
using 1 laptop for both, it is best to have the slides open and the IMCI DVD disc 1 in your
computer and at the main menu. It will be easier to switch between them if both are ready
on the computer. Load IMCI DVD disc 2 at the lunch break.
 Audio—Test all audio equipment. For example, be sure the slides show well on the
projector, that the DVD runs, and sound is adequate with speakers or sound system, etc.
 Lighting—Know where the lighting is if you need to lower lights when showing the DVD

SECTION 1 - INTRODUCTION & COURSE OVERVIEW
TIME - 30 minutes
FACILITATOR SUMMARY
In this section you will facilitate group introductions. Then you will review the course’s structure and
objectives, and the plans for today.
SECTION OBJECTIVES
■ Set a welcoming learning environment during facilitator and participant introductions
■ Introduce concept of distance learning
■ Explain course structure, emphasizing the 3 face-to-face meetings and self-study phases
■ Distribute and review participant self-study modules
MATERIALS
□ PowerPoint slides
□ Participant self-study module books for distribution
□ Flipchart
(1.1) WELCOME PARTICIPANTS
1. Introduce yourself and co-facilitators, describing:

 Your clinical background
 Your experience with IMCI
 Your relevant experience as a trainer and mentor
 How you will serve this role as a course facilitator
2. Invite participants to introduce themselves and record their names on FLIPCHART

 Name
 Workplace and role
 Hopes for this training, or other icebreaker question (i.e. interesting fact about yourself)
(1.2) SET THE STAGE: WHY ARE WE HERE?
1. What is IMCI? Briefly introduce IMCI to set the stage for the course.
 IMCI is a strategy for integrated case management for the most common symptoms and
conditions that cause illness and death in children under 5 years of age.
 IMCI strategy has been adapted in over 100 countries around the world. Thousands of
healthcare professionals have trained to use IMCI in their care.
 The IMCI strategy seeks to improve health worker skills, health systems, and family and
community practices in childcare.

2. What will we be doing together? Introduce distance learning, but will discuss in detail later.
 4 month distance learning course, participants will be studying materials at home,
practicing IMCI in clinics, and working with mentors and study groups as they learn.
 This group will meet three more times.
(1.3) ADMINISTRATIVE ANNOUNCEMENTS

 Ask participants to set ground rules for the day (use FLIPCHART to record suggested ground
rules and display on wall). Emphasize that mobile phones should be turned off, and use
should be limited during breaks. Complete attention is required for the day’s busy schedule
and learning objectives.
 Meeting runs until 4:30pm
 Breaks in morning and afternoon, lunch at 12:30pm. Note if provided.
 Review facilities in this building - toilets, phone and computer access
 Are there any administrative questions for today?
(1.4) DISTRIBUTE PARTICIPANTS SELF-STUDY MODULE BOOKS & LOGBOOK

Explain purpose of books and ask participants to open to key sections with you.
1. STUDY MODULES BOOK

 PART 1 - Course overview: this section mirrors today's review of course structure,
calendar, and expectations. Participants should follow along in book to take notes.
 PART 2 - Introduction to IMCI: this section mirrors today's meeting, so participants
should follow along in this section when discussing the IMCI approach to view graphics
and take notes.
 PART 3 - Self-study modules: you will explain this portion at the end of the day, during
the "Next Steps" section. Flip through modules to highlight topic of each.
2. LOGBOOK: participants will document notes and exercises as you study and practice. Will
review in greater depth at the end of the day.

(1.5) COURSE OVERVIEW
Direct participants to follow along in PART 2 Course Overview of their books.
1. Review objectives of this distance learning course (SLIDE 2)
2. Why distance learning? (SLIDE 3)

3. Review course structure in chronological order - (SLIDE 4) details below
1. ORIENTATION – first face-to-face
meeting (today)
 Introduction to IMCI Orientation Review & practice Review & practice Final synthesis Optional
Additional
 Introduction to course 1st face-to-face
Meeting
2nd face-to-face
meeting
3rd face-to-face
meeting
4th face-to-face
Modules in future
eg update,
meeting
new information
structure, expectations, and (1 day) (1 day) (1 day) (1 day) (1 day)
self-study materials 3-4

weeks
6-8
weeks
4 weeks

2. SELF-STUDY PHASE 1 Practice IMCI in clinic, using Chart Booklets and recording forms Application of clinical skills
When & where: for the next 3-4 weeks
at your home facility
Work with mentors
 Complete modules 1 and 2 –
Clinical
read modules, and complete Clinical Formative
Assessment
Clinical Formative
Assessment
Local Site
Clinical Formative
Assessment
Local Site
Summative
Assessment
Local Site
self-assessment exercises as you IMCI Facilitator
about 4 months
IMCI Facilitator
6 weeks
IMCI Facilitator Local Site
read
 Practice what you have learned from the modules in your clinic. Record cases in your
logbook.
 Complete exercises in logbook. These will be assessed at the next meeting.
 Meet regularly with study groups. These groups will be important to discuss problems,
review questions, and practice together. We will form study groups at the end of the
day.
 Identify and meet with mentor(s) trained in IMCI
 Stay in contact with course facilitators – outline expectations for staying in touch with
facilitators, including when they should contact you (e.g. weekly check-ins, or only when
they have a problem) and how they should contact you (e.g. mobile, email).
3. REVIEW & PRACTICE 1 – second face-to-face meeting

When & where: give participants date & location for them to fill in on their calendars in
participants book
 Facilitators and participants will meet for 1 day. The meeting should be arranged for on-
site practice, for example in district hospital or centrally located facility.
 Review progress with modules 1 and 2 and practice in clinics. Focus will be on problem
areas, challenging or interesting cases from the clinic, and confusing material.
 Facilitators will collect logbooks to mark written exercises and review recording forms
from clinical practice.
 Introduce content from modules 3-7 and any additional modules
 Practice IMCI together and work on any problem areas
4. SELF-STUDY PHASE 2
When & where: for following 8-9 weeks in home facility
 Complete remaining modules and self-assessment exercises
 Practice in clinic, using Chart Booklets and recording forms
 Complete exercises in logbook
 Continue to work with mentors on using IMCI, or when you need help or want to

practice material from the modules
 Continue to study with groups
3. REVIEW & PRACTICE 2 – third face-to-face meeting

When & where: give participants date & location for them to fill in on their calendars in
participants book
 Facilitators and participants will meet for 1 day. The meeting should be arranged for on-
site practice, for example in district hospital or centrally located facility.
 Review progress with modules 3 tp 7 and practice in clinics. Focus will be on problem
areas, challenging or interesting cases from the clinic, and confusing material.
 Facilitators will collect logbooks to mark written exercises and review recording forms
from clinical practice.
 Introduce content from module 8
 Practice IMCI together and work on any problem areas
4. SELF-STUDY PHASE 2
When & where: for following 3-4 weeks in home facility
 Complete remaining module and self-assessment exercises
 Practice in clinic, using Chart Booklets and recording forms
 Complete exercises in logbook
 Continue to work with mentors on using IMCI, or when you need help or want to
practice material from the modules
 Continue to study with groups
5. FINAL SYNTHESIS – fourth face-to-face meeting

When and where: give participants date & location for their calendars
 Facilitators and participants will meet for 1 day at location
 Review self-study progress and clinical practice, to identify problem areas that need
more practice
 Practice IMCI together and work on any challenging topics
 Create personal action plans for continued study and integration of IMCI in your facility
 Course assessment & certification
What questions do we have about the course structure?
4. Reiterate objectives for today’s Orientation meeting (SLIDE 5)

(1.6) REINFORCE KEY PRINCIPLES
■ Effective distance learning requires significant motivation, time, and energy
■ Effective distance learning requires participants to practice in the clinic and use IMCI tools
■ Effective distance learning requires participants to involve others in their study, and should
reach out to mentors, study group members, colleagues, and in-charge officers. A great deal
of learning happens through feedback and problem solving together.
( Slide 6 )
(1.7) TRANSITION TO NEXT SESSION PLEASE NOTE

We’ll begin our day by discussing the
important role of good communication in  To succeed in dIMCI you need to devote time,
effective case management of children. energy and committment – you need to be
motivated!
Depending on your set-up for the following  To succeed you need to practice seeing children and
role play, facilitators may choose to not using the IMCI tools
provide an introduction to the scenario, but to  Working with others makes learning and skill
lead right into it to catch participants’ development happen – work with colleagues,
mentors and groups – if you don’t know -> seek!!
attention.

SECTION 2 - CREATING A WELCOMING ENVIRONMENT
TIME - 30 minutes
FACILITATOR SUMMARY
In this section, facilitators will act out two short scenarios to stimulate discussion. The two scenarios
show a health worker greeting a mother at the clinic. In the first scenario, the health worker does not
make the mother feel welcome. In the second scenario, he greets the mother and asks more
questions about the child. These scenarios should focus on greeting a caretaker and making them
feel welcome and secure. Section 7 this afternoon will explain more communication skills in a clinical
assessment.
Facilitators do not need to introduce this section formally. Leading right into the scenario catches
participants’ attention. Sample scenarios are detailed below, but facilitators can adapt the scene as
long as the objectives are achieved.
ROLE PLAY OBJECTIVES

■ Emphasize that good communication skills with families create a welcoming and enabling
environment for case management.
■ Engage participants emotionally into the scenario scene. This is an opportunity to grab their
attention and start the day off with an energetic session.
MATERIALS
□ Role play script
□ Props (e.g. blanket rolled as baby, scarf or other dress to distinguish mother, 2 chairs)
□ Flipchart
(2.1) SCENARIO & DISCUSSION
Timing: 10 minutes
Summary: This scenario shows a health worker that does not welcome a mother to the clinic.
The health worker does not seem interested. As a result, the mother remains quiet.
The health worker does not obtain very much information about the child.
Scenario
The health worker is standing in the clinic talking with colleagues. It is afternoon, and they are
talking about closing the clinic in an hour.
A young mother (Sara) comes in holding a baby wrapped in a blanket. Sara begins to cry and
says her child is sick.
The health worker takes her aside to see what the problem is. The health worker tells her that it
is better to come in the morning with serious problems.
The health worker sits Sara down, but he sits on the other side of the table. The health worker
asks what the problem is. Sara says the child is not feeding well, and that he is acting sick.
The health worker lifts the blanket to look at the child. He says he is underweight. The health
worker does not take the child to examine.
The health worker is writing notes and does not look up at Sara or the baby. The health worker
asks what Sara is feeding him. Sara says she feeds him milk diluted with water.
The health worker asks if Sara breastfed. Sara says she breastfed for the first few months, but
also gave cow’s milk and water. The health worker says that it is dangerous to mix feeding like
that.
Analysis points for facilitators

 The health worker does not make Sara feel welcome at the clinic. He tells her to bring
the child in earlier.
 The health worker does not greet the mother. For example, by asking her name, the
child’s name, or the child’s age.
 The health worker sits on the other side of the table, away from the mother and child.
 The health worker does not examine the child.
 The health worker could make Sara upset by telling her that the way she is feeding is
dangerous. Even if the health worker is concerned about the mixed feeding, it must
be explained without judgement. The health worker should also ask for more
background information about why Sara is feeding this way.
Reaction questions – record key responses on FLIPCHART and summarize discussion

 What did you observe about the scenario?
 What information did we learn about the baby? About the mother and her situation?
 Each of these pieces of information – which ones did the healthcare provider discover
by asking and listening?
 How could this healthcare worker have done the scenario differently to make the
mother feel more welcome?
 How many of us are parents, or have cared for a child? What did you feel when a child
you were caring for became ill?
 What did you want from your healthcare provider when you took the child in?

(2.2) SCENARIO TWO & DISCUSSION
Timing: 10 minutes
Summary: This scenario should show a health worker taking steps to welcome the mother. As
a result, the health worker should learn more information about the child’s health
conditions and the household’s living situation.
Scenario
The health worker is in his clinic room. He is organizing supplies on the table. A young mother
(Sara) comes in holding a baby wrapped in a blanket.
Sara looks scared. She says her child is sick. The health worker asks her to sit. He pulls a chair
next to her. He says that he will help Sara and her baby today.
When he asks questions, he looks at Sara and the baby. He listens to her responses.
He asks the child’s name and age. Sara says her baby is Elias, and he is 7 months old. He asks
Sara what Elias’ problem is. She says that Elias is not eating well.
He asks her to describe the feeding problem. Sara says that Elias is not gaining weight and
sometimes will not eat. She says that today he is not eating anything at all. This is why she is
scared.
He asks Sara what she feeds Elias. Sara says cow’s milk with water. He asks if she breastfeeds
or gives formula. Sara says she cannot afford formula. She says that she did breastfeed but
thought Elias was not getting enough milk because he stayed small.
He tells Sara that it was important for her to bring Elias to the clinic. He tells Sara that she was
very good to bring him in today when he stopped feeding.
Analysis points for facilitators

 The health worker is waiting in the clinic room. He is prepared with materials.
 The health worker greets Sara and asks her to sit. He sits beside her. This body
language and a warm welcome can help establish a sense of trust and care. It also
helps calm a mother in a very emotional situation.
 The health worker reassures Sara that he will help her today. He praises Sara for
bringing Elias to the clinic.
 The health worker asks the child’s name and age.
 The health worker asks about Elias’ problem and listens to Sara’s response. He asks
more detailed questions about the feeding. This encourages Sara to speak.

Reaction questions – record key responses on FLIPCHART and summarize discussion
 What did you observe in this scenario?
 What did the health worker improve from the previous scenario?
 What additional information did we learn about the baby?
 What do you do in your clinic to make families feel welcome? Do you have any useful
examples to share with the group?
■ Caretakers are very emotional when a child is sick.

■ Healthcare providers play a critical role in creating a welcoming environment. It is important
to be sensitive to families’ and children’s emotional needs and personal situations.
■ Good communications skills build rapport and trust with caretakers. This helps the caretakers
share more information about the child’s illness and the household situation.
■ Reinforce lessons from the second scenario. For example, asking open-ended questions,
sitting next to the mother, making personal contact by asking names and about their
situation, listening to the mother’s responses.
(2.4) TRANSITION TO NEXT SECTION
These scenarios emphasize the critical roles we have in creating welcoming environments for our
patients and their caretakers. These environments help us obtain more information and allow for
better case management.
Now we will take a step back and look at what causes many of these families to bring their children
into our clinics. In other words, what are the health problems that we are trying to address as health
workers? Then we will learn how IMCI is a strategy for managing these common health problems.

SECTION 3 - CAUSES OF CHILDHOOD ILLNESS
TIME - 15 minutes
FACILITATOR SUMMARY
In this section, you will present data and discuss causes of childhood illness and mortality. This
provides a context for the course by describing the problem. In this next section, you will introduce
IMCI as a strategy for solving this problem. This section provides an outline for you, but you will be
expected to bring your own expertise to guide the discussion. You should also provide relevant data
from your region, country, province, or district.
OBJECTIVES
■ Emphasize that the majority of children die from preventable causes. These include acute
respiratory infections, diarrhoea, malnutrition, measles, malaria, HIV, and perinatal causes.
■ Emphasize that children often suffer from overlapping conditions. Malnutrition and HIV are
particularly common underlying causes of other illness.
■ Explain how factors of inequity cause higher childhood mortality in rural communities and
poorer households.
MATERIALS
□ PowerPoint slides (need adaptation if you are including slides on national or local data)
□ Flipchart

(3.1) LOCAL CAUSES OF MORTALITY
Group discussion: What causes illness and death in the children we see in our facilities? (Slide 7)
It is best for the group to think about causes and discuss

what they see in their facilities before showing them actual
data, which might be surprising for some.
Suggested presentation method: on FLIPCHART draw a pie

chart, similar to SLIDE 7 that roughly represents the major
causes of childhood mortality in your country or region. Ask
participants to fill the chart in. As they suggest causes of
death, fill them in the correct proportion.
(3.2) COMPARING TO GLOBAL DATA
1. DISCUSSION: how does global data (SLIDE 8) compare to what we have discussed about our
area? (Slide 9) What surprises us?
2. Review data and make any clarifications as required.
You will need to explain how underlying causes like malnutrition and HIV contribute to illness and
mortality. For example:
When children are missing key nutrients, it impacts their physical and mental development. It can
cause poor growth and immune function. HIV/AIDS reduces a child’s immune function.
Proportion children dead by 5yrs : E Cape

Basis Burden of
Disease 2000
Alive
project
Leading causes of death in children under 5yrs of age

Low Birth Wt
Dead
Diarrhoeal Dis
LowerRespTractInf
SevereMalnutrition
Neonatal Infection
Birth Asphyxia/trauma
Cong Heart Dis
Road Traffice Accident
HIV
Bacterial Meninigitis
Fires
Neural Tube Defects
Septicaemia
Tuberculosis
Homicide/violence
Drowning
Cot Death
Downs Syndrome
Rest Cong GIT disorder
Cong Syphyillis

(3.3) INEQUITY & HEALTH
Briefly discuss how inequity impacts child health. This discussion should provide a context for health
problems outside of the clinic. This discussion should introduce the topic that inequity is important
when looking at the different levels of health between groups.
Most health workers will be familiar with the economic, social, cultural, and political environments
where they work. It is important to relate these bigger issues to how caretakers seek healthcare
services and care for the child in their home.
1. DISCUSSION: globally, childhood mortality is high in rural areas and among poorer households
(SLIDE 9, and also in participants’ modules book PART 2, section 1)
a. Why is this? What are the factors that contribute?

Some factors that could come into the discussion:
• rural transportation
• fewer clinics in rural areas How does inequity relate to health?
• access to health information
• access to education, especially
for women Table: child mortality per 1,000 live births (Source UNICEF 2006)
• food insecurity due to poverty, Richest 40% 67
access to food, poor farming,
Poorest 60% 107
drought and weather
• poverty, few employment Urban 69
opportunities Rural 105
• women's ability to make
Female 93
decisions in the home and
community Male 96
• lack of basic supplies like clean
0 20 40 60 80 100 120
water or sanitation services
b. For those of us working in urban settings, how does this relate to your patients?
2. SUMMARIZE: now that we have discussed these factors, how would we define inequity?
Inequity is the uneven distribution of health caused by conditions that may be avoidable, as well
as unjust and unfair. For example, the differences in health are due to a group's social class.
How does it impact health in children? What other inequities impact health in our area? (e.g.
gender, disparities between racial, ethnic, or religious communities)

(3.4) REINFORCE KEY POINTS (SLIDE 10)
■ Most children die of preventable causes Key points about child mortality
■ Major killers of children under 5 are
1. Most children die of preventable causes
neonatal conditions, diarrhoea, and 2. Major killers of children under 5
pneumonias 1. Neonatal conditions - infections, asphyxia,
prematurity. Babies with low birthweight account
■ Malnutrition and HIV are widespread for 70% of all newborn deaths.
underlying causes 2. Diarrhoea
3. Pneumonias
■ It is important to consider the wider 3. Malnutrition is an underlying cause in up to 50% of
environment of our patients and families' under-5 deaths
4. HIV is an underlying causes in many countries
lives when thinking about child health. 5. Economic, social, political, and cultural factors
There are many factors that impact a child's impact child health. Poorer households and rural
communities have higher child mortality.
health and ability to seek services. There are
wide inequities between certain groups.
What questions do we have?
(3.5) TRANSITION TO NEXT SECTION (SLIDE 11)
We have seen that children often die from

preventable, overlapping causes.
IMCI is a strategy that addresses the major, common

causes of illness and death that we have discussed in
this section.
Many children die from overlapping causes.

Integrated case management examines children for
all common health issues.
In the next session, we will begin to see how the IMCI How does IMCI try to address child mortality?
strategy is designed to focus on the most common
symptoms of childhood illness. (SLIDE 12) IMCI focuses on most common symptoms of
childhood illness
STOP FOR TEA BREAK (15 MINUTES)

SECTION 4 - THE IMCI STRATEGY
TIME - 60 minutes
FACILITATOR SUMMARY
This section is the most important of the day. You will introduce the IMCI strategy, which is the
foundation for the entire course. It is critical that participants are very clear on the IMCI process and
the use of Chart Booklets and recording forms before they begin their self-study.
There is a lot of information in this section. Explain the material. Encourage participants to follow
along and take notes in their Chart Booklets and their module A PART 2: INTRODUCTION TO IMCI.
Assess their comprehension by asking questions and presenting examples.
OBJECTIVES
■ Explain the IMCI strategy and the meaning of integrated case management
■ Introduce the IMCI process - assess, classify, identify treatment, treat, counsel the caretaker,
and provide follow-up care.
■ Demonstrate how Chart Booklets and recording forms are supporting tools in the clinic.
■ Introduce general danger signs in sick children.
■ Provide opportunities to practice the IMCI process with video.
MATERIALS
□ Chart Booklets for distribution
□ Copies of (sick child) recording forms for distribution – 2 for each participant
□ IMCI DVD disc 1
□ Flipchart
(4.1) OPENING: What is IMCI? What is integrated case management?

■ IMCI is the Integrated Management of Childhood Illnesses. This means that the IMCI
approach does not look at one symptom, or only at what the parent tells you is the problem.
■ In your normal clinical practice, you might only evaluate a child for the problem that they
present with – for example, diarrhoea. However, by only focusing on this one presentation,
we might miss that the child also has a fever and is malnourished.
■ Instead, IMCI assesses all children and infants for the major causes of childhood illness and
death. We saw in the last slide (SLIDE 12) that these include diarrhoea, cough and difficult
breathing, fever, and malnutrition.
■ By assessing children and infants for all major health issues, we provide more holistic care.
We can identify issues that we might not have, if we only treated the symptoms that the child
presents with, or what the caretaker tells us about. There might be more issues, and IMCI
gives us instructions about how to look for these issues.

(4.2) INTRODUCE THE IMCI PROCESS
Integrated case management might sound confusing. The important thing you need to know is the
IMCI strategy has a very specific process that walks you through examining children, identifying their
health problems, and giving appropriate treatment.
You will also have an important tool to use in your clinic called the Chart Booklet. It is a series of
charts with instructions that walk you through IMCI. We will review this in a few minutes.
1. Let's review the IMCI process (SLIDE 13)
Participants should follow along using the flow charts in their modules book PART 2, section 2.
Using IMCI, every time a child under 5 comes into your clinic, you will do the following:
 GREET caretakers, ask why they are
bringing the child to the health clinic,
and if this is an initial or follow-up
visit.
 ASSESS for signs of severe illness that

will require an urgent referral. These
signs depend on the age group, and
we will learn more about that soon.
 ASSESS for common main symptoms

by asking the caretaker questions and
making your own observations about
the child. You will assess a child for
signs of common health problems,
and also for underlying health problems like malnutrition, poor feeding, HIV, and immunization
status. The symptoms you look for also depend on the age group, which we will learn about.
When you ASSESS:

 ASK the caretaker is the child has a certain problem. We ASK questions for more information,
if we need it.
 LOOK, LISTEN, and FEEL to observe certain signs in a child, for example: LOOK to see if a child
is unconscious, LISTEN for signs of respiratory distress, FEEL for swelling.
What’s the difference between a sign and symptom?

 The child will present with a symptom like a fever, diarrhoea, or a cough. This is the
presenting complaint that the child or the caretaker tells you.
 In order to determine the cause of this symptom, we assess for a number of signs. Signs are
smaller pieces of information. In the symptom cough, you will look for the sign of fast
breathing.

 Based on what signs the child shows, you will use IMCI charts to CLASSIFY the severity of the
illness. The charts are colour coded RED, YELLOW, and GREEN by severity, and instruct us on
what action to take.
 What do these colours remind us of in our everyday lives? Streetlights directing traffic.
 RED – the condition is very serious and requires urgent referral
 YELLOW – the condition can be treated in the clinic
 GREEN – can be treated in the home
 On these charts there is a TREATMENT column that will IDENTIFY TREATMENT for each
condition. It will list all of the necessary treatments, and tell you which ones are urgent.
 Based on all of the conditions you identify, you will TREAT the child for everything.
 You will then COUNSEL the caretaker on providing treatment if the home, if necessary, and on
feeding and other care. You will counsel on when to bring the child back to the clinic.
 When the child returns to the clinic, IMCI provides instructions on FOLLOW-UP CARE.
(4.3) DISTRIBUTE CHART BOOKLET AND RECORDING FORM

Now that we have seen the IMCI process, let's look at two important IMCI tools.
*DISTRIBUTE CHART BOOKLETS AND RECORDING FORMS (1 COPY SICK INFANT, 2 COPIES SICK
CHILD)*
The IMCI Chart Booklets is a job aid – a book of charts with instructions on IMCI. These booklets are
used all over the world, and in our country we will be using copies of the (generic WHO or nationally
adapted) Chart Booklet revised in (year).
The second tool, the IMCI recording form, allows you to take notes as you use your Chart Booklets.
In this discussion, it is useful to relate the form to your clinical experience and emphasize that it is an
intuitive form to use with the Chart Booklets.

(4.4) USING THE AGE-APPROPRIATE CHART
There are two sections in your Chart Booklet because charts are specific for two age groups. (SLIDE
14, participants have same flow chart in book PART 2, section 3).
*Open to both sections (sick child, sick young infant) with the participants so they know where to
locate in their booklets*
If the child is:

■ age up to 2 months - considered a young infant
■ age 2 months up to 5 years - considered a child
What does “up to 5 years” mean? The child has not reached his/her fifth birthday; same for “up to 2
months.”
PRACTICE: ask participants what charts used

for a child:
o 6 weeks old? Sick young infant
o 2 months old? Sick child
o 4 years and 11 months? Sick child
o 5 years old? Not included
SUMMARIZE age-appropriate charts

■ The IMCI process that we just reviewed is the same for both groups. With both groups:
o ASSESS for serious signs,
o ASSESS for main symptoms and other health problems,
o CLASSIFY and IDENTIFY TREATMENT
o TREAT for all conditions
o COUNSEL the caretaker, and
o PROVIDE FOLLOW-UP CARE
■ The different sections of charts are important because children and young infants differ in
the signs and symptoms you assess, and in some treatments.
■ This is why it is critical that you must immediately determine the child's age.
■ We will focus on the sick child now, and will learn more about the young infant this
afternoon.

(4.5) HOW DO WE USE OUR CHART BOOKLETS & RECORDING FORMS?
Now we will review how Chart Booklets and recording forms are useful tools for integrated case
management.
Let’s picture a child and mother coming into our clinic room. We will walk through our Chart
Booklets and recording forms.
Open your chart booklet to the first page of the sick child, and take out a recording form for the
sick child.
1. First, we need some important information about the child, and why they are visiting. This is
above the chart, and at the top of your recording form.
■ To review, what is the first thing we want to know before we begin our assessment?
The child’s age, so we know what assess and classify charts to use. Let us say we are
dealing with a child, so we will stay in this section.
■ We ASK this mother why she is bringing the child to the clinic: what are the child's problems?
■ We want to know: is this an initial or follow-up visit for this problem?

 If this is the child's first visit for this episode of an illness or problem, then this is an
initial visit.
 If the child was seen a few days ago for the same illness, this is a follow-up visit. During
a follow-up visit, a health worker determines if the treatment given during the initial visit
is helping the child. You will learn how to conduct follow-up visits in your self-study
modules.
■ We record weight and temperature.

2. Next, we ASSESS.
You see the top of the coloured chart reads: ASSESS, CLASSIFY, & IDENTIFY TREATMENT (SLIDE 15)
Under the ASSESS column you will see

instructions to:
■ Assess children for general danger
signs, which we will discuss in a few
minutes.
■ Assess for main symptoms and other
conditions. On the first page here we
have the symptom cough or difficult
breathing.
Instructions in the ASSESS column tell us what

signs to ASK about, or LOOK, LISTEN, and FEEL for.
 We ASK about the child’s symptoms, and then ASK further details if clarification needed.
 We LOOK, LISTEN, and FEEL to make our own observations
REINFORCE ASSESS – Let’s see how the ASSESS charts relate to our recording forms. Look at your
ASSESS column for cough & difficult breathing, and the section on cough & difficult breathing on your
form.
 What is an example of a sign we will ASK about?
 What is an example of a sign we will LOOK or LISTEN for?
When you use your recording form to take notes as you ASSESS, you can check "YES" on signs you
see, or circle them. You do not have to circle anything if the child does not show the sign.

3. With these signs, we CLASSIFY using our Chart Booklet.
Under the CLASSIFY column you will match the SIGNS a child shows with a classification under the
CLASSIFY AS column. Demonstrate this on chart.
As a reminder, can you tell me what the colour coding means?

■ What does a red classification mean? most serious health problems, immediate action and
referral to the hospital
■ A yellow classification? can be managed within the clinic, because they require attention but
do not have the same risk of death as the severe classifications in the red section
■ A green classification? the child can be managed at home and the clinic can handle follow-up
care
Let’s practice the CLASSIFY column. We see there is a SIGNS column, which directs us to CLASSIFY
AS. As you walk through examples below, ask questions to be sure participants comprehend.
Let’s look at the chart on this page for the symptom cough and difficult breathing.
■ If the child only shows the sign fast breathing, how do we classify? What colour is the
classification? What does this tell us about action? Pneumonia; yellow, treat in clinic
■ What if we observe the signs fast breathing and lethargy? Very severe pneumonia or disease;
red, urgent pre-referral treatment and refer
Let’s turn to the next symptom, diarrhoea. Look at the first chart for dehydration.
■ What if we observe the signs lethargy and a very slow skin pinch? Severe dehydration; red,
urgent pre-referral treatment and refer
■ If a child is restless but shows no other signs? No dehydration; green, home treatment
■ What if the child is restless, but drinks eagerly, and shows no other severe signs? Some
dehydration; yellow, treat in clinic
How do you use your form with the chart? (SLIDE 16)
Always immediately CLASSIFY each symptom Assess & classify on recording form
and write your classification on the form
before you move to the next symptom on
your chart, and the next section on your form.
4. IDENTIFY TREATMENT

The TREATMENT column on our chart recommends an appropriate treatment for each classification.
It also tells you where to treat—referral, clinic, or at home.
We record this on the back of our recording forms (SLIDE 17).
Let’s look at the chart for the symptom cough and

Identify treatment
difficult breathing
■ If we classify pneumonia, what are the
identified treatments we would record?
■ What if we classify cough or cold?
We have been looking at the first symptom, cough and difficult breathing. After we ASSESS,
CLASSIFY, and IDENTIFY TREATMENT for this symptom, we move to the next one and repeat the
process.
Let’s flip through the Booklet to see everything we will assess for with a sick child. Flip through
each symptom and condition.
Main symptoms-
■ Next is diarrhoea
■ Fever
■ Ear problems
And then we check for other health issues-
■ Malnutrition and anaemia
■ HIV infection
■ Consider TB
■ Status for immunizations, Vitamin A, and deworming
■ Finally we ask about other problems
REMEMBER: The signs and symptoms are different for the young infant, which we will review this
afternoon.
5. TREAT

After we have gone through all of the symptoms and conditions, we use this TREAT THE CHILD
section to determine how we will treat. (SLIDE 18)
■ When a child has more than one Treat the child

classification, you must look at more than
one table to find the appropriate
treatments.
■ You will write the treatments identified for

each classification on the reverse side of
the case recording form.
■ If you have classified several conditions

and identified several forms of required treatment, you will need to review all of these and
decide on the appropriate treatment for the child.
Facilitator: offer your own experiences about using the form to record treatment & referrals, how did
you use this in your own clinic? What is most useful?
PRACTICE – provide an example to connect the “TREATMENT” column on the classification charts
with content in the TREAT THE CHILD section.
For example, a few minutes ago we looked at the charts for classifying dehydration with diarrhoea.
We looked at some dehydration from diarrhoea, which was a yellow classification to be managed in
the clinic. Let’s look back at that row on the chart. We see it requires Plan B for treating
dehydration. Let’s flip to Plan B in our TREAT THE CHILD section.
6. COUNSEL THE CARETAKER (SLIDE 19)

Once we have determined treatment we will COUNSEL THE CARETAKER with instructions in the next
section COUNSEL THE MOTHER.
■ Counselling will review (a) instructions for home treatment, (b) instructions for follow-up care,
and (c) overall counselling on feeding, good care in the home, and disease prevention.
■ Review a counselling example from the
COUNSEL THE MOTHER chart. Relate to an Counsel the caretaker
example from treatment.
■ For many sick children, you will assess feeding
write the results on the bottom of the case
recording form.
■ You will record the earliest date to return for
follow-up on the back of the case recording
form.
7. PROVIDE FOLLOW-UP CARE

■ Several treatments in the ASSESS AND CLASSIFY chart include a follow-up visit. At a follow-up
visit you can see if the child is improving on the drug or other treatment that was prescribed.
■ You will have recorded the earliest date to Provide follow-up care
return for “follow-up” on the reverse side
of the case recording form.
■ The TREAT THE CHILD chart includes a

section on GIVING FOLLOW-UP CARE with
instructions for conducting each type of
follow-up visit. Headings in this section
correspond to the child’s previous
classification(s). (SLIDE 20)
■ During follow-up you will re-assess the child's conditions to see if they are:
 Improving
 Worsening
 The same
Then you will do a full re-assessment to check for other conditions.
■ You will use a second recording form for this assessment - see on our recording form where
we will check “follow up visit” this time.

8. Review ANNEX contents of Chart Booklet -explain sections briefly to orient participants on the
reference materials available.
Any questions about the Chart Booklet and recording forms? What questions do we have about
using these tools on the job?
SUMMARIZE: KEY POINTS ABOUT THE CHART BOOKLET & RECORDING FORM
■ Study these tools closely as you read your self-study modules. For example, as you read about
diarrhoea in a child, follow along in your Chart Booklet and form so you can picture how the
material will apply in your clinical practice, and you can picture the process.
■ Take these tools to your in-charge officer to show him/her how you will use them in the clinic.
■ The more you practice with the Chart Booklet and form, the quicker you will learn the process
and get comfortable using these tools correctly in your clinical room.
■ If it makes you more comfortable, you can tell the caretaker that you will be taking notes as
you ask questions and speak with him/her.

(4.7) GENERAL DANGER SIGNS
Now that we have seen how our two important tools work – the CHART BOOKLET and the IMCI
RECORDING FORM – we will begin to learn the specific signs and symptoms we will assess and
classify.
REMEMBER our first step in assessing is to look for signs of serious illness that will require referral.
We said that these signs are different for the sick young infant and the sick child.
Now we will look at those signs for the sick child, called GENERAL DANGER SIGNS. This afternoon
we will discuss the same signs for the sick young
infant. (Slides 22 & 23)
Disc 1 GDS
1. First let’s see these GENERAL DANGER SIGNS in real clinics.

Showing the video first is a useful way of bringing the signs to life, and then you will reinforce by
describing them.
PLAY IMCI DVD “General danger signs” (disc 1, 4 minutes)

■ Instructions for participants: open your Chart Booklets to the first chart for the sick child –
general danger signs are the first chart. Take out a recording form for the sick child – general
danger signs are the first box.
■ Facilitation: lower lights as needed
2. Let’s review the GENERAL DANGER SIGNS and answer any questions we have (SLIDE 24)
ASK - Is your child able to drink or breastfeed?
■ A child has the sign “not able to drink or General Danger Signs
breastfeed” if the child is not able to suck or 1. ASK: is child unable to drink or breastfeed?
swallow when offered a drink or breast 2. ASK: does the child vomit everything?
milk. 3. ASK: has child had convulsions during the current
■ When you ask the mother if the child is able illness, or LOOK: is child convulsing now?
 Muscles are contracting, arms and legs stiffen, and child may
to drink, make sure that she understands lose consciousness or cannot respond
the question. If she says that her child is not 4. LOOK: is child lethargic or unconscious?
able to drink or breastfeed, ask her to  Child doesn't respond or show interest, cannot be wakened if
unconscious. Eyes might be open.
describe what happens when she offers the Signs of very serious illness, if 1 or more urgently refer
child something to drink. For example, is
the child able to take fluid into his mouth and swallow it? If you are not sure about the
mother’s answer, ask her to offer the child a drink of clean water or breast milk. Look to
see if the child is swallowing the water or breast milk.
■ A child who is breastfed may have difficulty sucking when his nose is blocked. If the
child’s nose is blocked, clear it. If the child can breastfeed after the nose is cleared, the
child does not have the danger sign, “not able to drink or breastfeed.”
ASK - Does your child vomit everything?

■ A child who is not able to hold anything down at all has the sign “vomits everything” -
everything that goes down comes back up. A child who vomits everything will not be
able to hold down food, fluids, or oral drugs. A child who vomits several times but can
hold down some fluids does not have this general danger sign.
■ When you ask the question, use words that the mother understands. Give her time to
answer. If the mother is not sure if the child is vomiting everything, help her to make her
answer clear. For example, ask the mother how often the child vomits. Also ask if each
time the child swallows food or fluids, does the child vomit? If you are not sure of the
mother’s answers, ask her to offer the child a drink. See if the child vomits.
ASK - Has your child had convulsions?

■ During a convulsion, the child’s arms and legs stiffen because the muscles are
contracting. The child may lose consciousness or not be able to respond to spoken
directions.
■ Ask the mother if the child has had convulsions during this current illness. Use words the
mother understands. For example, the mother may call convulsions “fits” or “spasms.”
■ What is the local word(s) we would use to explain a convulsion?
LOOK - is the child is lethargic or unconscious?
■ A lethargic child is not awake and alert when she should be. The child is drowsy and
does not show interest in what is happening around her.
■ Often the lethargic child does not look at his mother or watch your face when you talk.
The child may stare blankly and appear not to notice what is going on around him. A
child might have his eyes open but still be lethargic or unconscious.
■ An unconscious child cannot be wakened. He does not respond when he is touched,
shaken, or spoken to.
■ Ask the mother if the child seems unusually sleepy or if she cannot wake the child. Look
to see if the child wakens when the mother talks or shakes the child or when you clap
your hands.
■ Note: If the child is sleeping and has cough or difficult breathing, count the number of
breaths first before you try to wake the child.

3. Let’s practice using our recording forms to assess for GENERAL DANGER SIGNS.
Use one of the recording forms for the sick child that we handed out earlier. I will read a case aloud.
As I read, record information on your form like you would with a child in your clinic.
(Slide 25)
Read this script aloud as participants fill in recording forms. Speak slowly and clearly.
A grandmother named Victoria brings her grandson into your clinic. She says his name is Biki,
He is 7 months old. You take Biki’s temperature and it is 37 degrees Celsius. You weigh him
and he is 9 kg. You ask her what Biki’s problem is. She tells you that he isn’t feeding well. You
ask if she is coming to the clinic for the first time with this problem. She says they have come
to this clinic before, but this is the first time for this feeding problem.
You ask Victoria if Biki is able to drink anything or breastfeed. She tells you his mother has
passed away, so she gives him milk. She said that he does not feed very well. Starting this
morning, he is too weak and will not take the milk when she tries to give it. You ask her to
describe this. She says that his head leans back and he won’t open his mouth for the cup of
milk. The milk just dribbles onto his face.
You ask Victoria if he is vomiting everything. She says no, because he is not drinking anything
today. She said when he took milk yesterday, he did not vomit. You ask Victoria if he is having
(local word for convulsions) or fits while he has been unwell. She says no.
You sit Biki up on Victoria’s lap and unwrap his blanket so you can watch him better. Biki looks
very tired and lays back into Victoria’s arms. As you snap your fingers and move your hand in
front of Biki, his eyes follow you. You ask Victoria to speak to Biki, and when she says “hi baby
Biki!” down to him, he moves his face to look up at her.
Let’s review your recording forms and see what you found for general danger signs (SLIDE 26)
■ How does your form compare to
this form?
■ What questions do we have
about Biki’s case? Do we have
questions about the decision on
the general danger signs?
■ What questions do we have
about the recording form?
Conclude general danger signs by

reminding participants that they will
complete Module 1 on general danger
signs before the next meeting. Ask participants to flip to Module 1 with you.

(4.8) SUMMARIZE IMCI PROCESS FOR SICK CHILD
1. First, let’s review the IMCI process for the sick child (SLIDE 27). Participants should view slide or
same flow chart in participants book PART 1, section 2.
As a facilitator, reviewing this flow chart is an important opportunity to look for any confusion and
explain before the activities build on the IMCI process. Check understanding with the following:
■ ASK QUESTIONS, for example,

o Why do you greet the caretaker?
o What is the important information we want to get from the caretaker?
o Why do general danger signs require urgent referral?
o Can someone use their Chart Booklet to explain the ASSESS-CLASSIFY-TREAT process?
o What do red, yellow, and green classifications mean?
o If I have assessed and classified a child’s cough, what do I do next? Use the classification
table to identify the treatments, write the treatments down on the recording form, and
then assess and classify the next symptom. After assessing all symptoms, HIV,
immunizations, and problems, decide what treatments are necessary for all identified
health problems. Decide where this treatment is given—urgent referral, in clinic, or at
home.
o What other important sections of information are in your Chart Booklets?
■ FIELD QUESTIONS and SUMMARIZE any clarifications or discussions

2. POWERPOINT ACTIVITY—REVIEWING RECORDING FORMS
These slides will first appear as a form with health worker notes. Discuss with the group to see
what problems they identify on the form. When you are ready to check answers, click the slides as
if you were moving to the next slide. The comments in red (as seen below) will show on the slide.
■ What problems do we see in this form? (SLIDE 28) This case is a bit of a trick to see if
participants realize they are seeing a sick infant but using the sick child form.
■ What problems do we see in this form? (SLIDE 29) Same process as above.
3. Video demonstration – assessing for general danger signs

PLAY IMCI DVD “Assess general condition” (disc 1, 6 minutes)
■ Instructions for participants: you will evaluate 4 children for the general danger sign
lethargy or unconsciousness. Write your answers down.
■ Facilitation: stop video at 4:15 and discuss participant results before playing the video
answers through

(4.9) REINFORCE KEY POINTS
The facilitator should present review questions to the group and encourage clear responses. Example
questions are below. The questions should cover all key points of the IMCI process to summarize the
session. Use SLIDE 15 to show the classification tables, or other slides as necessary.
■ When do we use IMCI in our clinics? For every sick child under the age of 5.
■ What are the two age groups? Sick young infant (up to 2 months), sick child (2 months up to 5
years)
■ What does “up to 5 years” mean? The child has not reached his/her fifth birthday
■ What charts do we use for a child:
o 6 weeks old? Sick young infant
o 2 months old? Sick child
o 4 years and 11 months? Sick child
o 5 years old? Not included
■ Can someone show us on their chart where the steps for assessing sick children are located?
Have participant come to front and show the boxes in the ASSESS column.
■ What do the ASSESS boxes contain? Instructions on signs to ask, look, listen, and feel for
■ Where do you look first when you classify the child’s illness? You look at the SIGNS column in
classification table to see what signs the child is presenting with. Remember that if the child
has signs from more than one classification, you “classify up” to the more severe.
■ Where are the classifications located? CLASSIFY AS column
■ What do the 3 colours of the classification table mean? Red is an urgent condition, refer.
Yellow is serious but can be treated in the clinic. Green requires home treatment.
■ What happens if a child has signs from both the RED and YELLOW classification boxes? You
always “classify up” to the more severe condition. So you will classify using the red box instead
of the yellow, or the yellow instead of the green.
■ How do we identify treatment for a particular classification? TREATMENT column in
classification table
■ What is the first thing we assess for using IMCI? Signs of severe illness that require urgent
referral.
o In the sick child, these are called general danger signs.
o In the sick young infant, these are called signs of severe disease and possible bacterial
infection.

■ What are the general danger signs for the sick child?
o Not able to breastfeed or drink anything
o Vomiting everything
o Lethargic or unconscious
o Convulsing, or has had convulsions with this illness
■ What do we do if we identify at least 1 general danger sign? If the child has 1 or more danger
signs they require immediate referral. They will need pre-referral treatment in the clinic—
these are the bold treatments listed in the TREATMENT column. Then they must be referred.
■ Each caretaker is asked about main symptoms – what are they? Cough or difficult breathing,
diarrhoea, fever, ear problem
■ After main symptoms, what do you chck for? Malnutrition, anaemia, immunization status,
HIV, and other problems that the caretaker mentions.
(4.10) TRANSITION TO NEXT SESSION

Review plan for moving to clinical practice and then lunch afterwards.
We will now go to the clinic for demonstrations of IMCI. When we return from lunch, we will learn
more about how to use IMCI with the sick young infant.

SECTION 5 – CLINICAL PRACTICE
TIME – 30-60 minutes
FACILITATOR SUMMARY
This section is a critical opportunity to demonstrate IMCI with the sick child. Please refer to the IMCI
facilitator guide for outpatient clinical practice and the IMCI guide for clinical practice in the
inpatient ward for guidance on how to facilitate this time in the clinic. These arrangements will
depend on the facility, case load, and prior agreements with the facility or patients.
SECTION OBJECTIVES
■ Participants see examples of signs of illness in real children, and gain experience and
confidence in using the skills as described on the case management charts.
■ Demonstrate good skills in managing sick children and young infants according to case
management charts
■ Practice assessing, classifying and treating sick children and young infants, and counselling
mothers about food, fluids, and when to return. This clinical session will particularly reinforce
course content on general danger signs, managing the sick young infant, and symptoms
introduced.
■ Observe and mentor participants’ practice, providing constructive feedback about how well
they have performed each skill and guidance about how to strengthen particular skills.
MATERIALS
□ Participants should bring Chart Booklets and recording forms (logbook or copies provided)
□ Any other materials required for clinical setting
(4.1) WHY CLINICAL PRACTICE?

Clinical practice is an essential part of any IMCI course.
Most of the clinical practice in this course will happen at distance, so this practice time with
participants is a critical time to mentor participants in their case management skills and ensure they
can perform them proficiently when they return to their own clinics.
The clinical practice skills should be presented in the order they are being learned in the modules.
This clinical session would demonstrate the IMCI process with the sick child, and general danger
signs if possible.
To make sure that participants receive as much guidance as possible in mastering the clinical skills,
the outpatient facilitator and/or inpatient instructor should give particular attention and feedback to
the skills practiced.

If any participant has difficulty with a particular skill, the facilitator or inpatient instructor continues
working with the participant on that skill in subsequent sessions until the participant can perform the
skill with confidence.
(4.2) OUTPATIENT SESSIONS
Outpatient sessions take place in outpatient clinics. The focus of the outpatient session is to provide
practice of the case management process with sick children. In the next face-to-face meeting, the
clinical practice will include sick young infants.
Outpatient sessions should begin by demonstration of a case. This case should demonstrate all
steps in the IMCI process.
In this outpatient session, participants will:

 see sick children who have been brought to the clinic by caretakers.
 practice assessing and classifying sick children using the chart booklet
 practice identifying the child's treatment by using the TREATMENT column in the classification
tables
 practice treating sick children and young infants according to the TREAT charts
 practice counselling mothers about food, fluids, and when to return according to the
COUNSEL chart.
 practice using good communications skills when assessing, treating and counselling mothers
of sick children
1. DEMONSTRATE a clinical evaluation using IMCI
2. PRACTICE - if possible, assign participants or small groups to a child. Observe while

participants assess and classify the children.
3. MONITOR - conduct rounds to review the children that participants assess and classify.
Have all participants practice assessing some signs, to give them more practice with severe
signs and signs that are difficult to assess.
4. REINFORCE - show participants any additional children with infrequently seen signs.
5. SUMMARIZE - the session, and reinforce participants for new or difficult steps that they did
correctly, and give them suggestions and encouragement to help them improve.

(4.3) INPATIENT SESSIONS
Outpatient sessions should begin by demonstration of a case. This case should demonstrate all
steps in the IMCI process.
Facilitators or inpatient instructors lead small groups in an inpatient ward. The focus of the inpatient
sessions is to practice assessing and classifying clinical signs. Participants have already learned about
general danger signs in sick children, so this can be a focus.
During inpatient sessions, participants will:

 see as many examples as possible of signs of severe classifications from the ASSESS &
CLASSIFY charts, including signs not frequently seen.
 practice assessing and classifying sick children according to the ASSESS & CLASSIFY. This
should focus especially on the assessment of general danger signs, other signs of severe
illness, and signs which are particularly difficult to assess (for example, chest indrawing and
skin pinch).
A designated inpatient instructor should lead all inpatient sessions with small groups of participants.
This instructor may be a facilitator, or another colleague requested to assist with the clinical practice
session.
This will change depending on the arrangements for this on-site meeting, and who will be able to do
necessary tasks in the ward before and during the clinical practice session.
Inpatient instructor tasks include:
Prior to practice session, if possible, selecting children with appropriate clinical signs to be assessed by
participants during the session. Also identify any additional children with infrequently seen signs to
show participants.
2. PRACTICE - assign each participant to a child, or small groups. Observe while participants
assess and classify the children.
3. MONITOR - conduct rounds to review the children which participants have assessed and
classified. Have all participants practice assessing some signs, to give them more practice
with severe signs and signs that are difficult to assess.
AFTER CLINICAL PRACTICE, BREAK FOR LUNCH (45 MINUTES)

SECTION 6 – USING IMCI WITH THE SICK YOUNG INFANT
TIME - 60 minutes
FACILITATOR SUMMARY
This section will continue with the IMCI approach, but focus on IMCI for the sick young infant.
It is important that participants leave the Orientation meeting with a strong understanding of the
IMCI process for both children and infants before they begin self-study.
This section will not cover all Module 2, which participants will complete before the next meeting.
OBJECTIVES
■ Explain why young infants have special care considerations.
■ Emphasize benefits of exclusive breastfeeding.
■ Reinforce the major steps in the IMCI process while emphasizing distinctions in sick young
infant, including signs of serious disease and bacterial infection, different main symptoms,
and the emphasis on infant feeding.
■ Connect IMCI for the sick young infant to the infant charts and recording forms.
■ Introduce assessments for signs of serious disease and for feeding and low weight.
MATERIALS
□ IMCI DVD (disc 2)
□ Flipchart
(5.1) WELCOME TO AFTERNOON SESSION
■ Are there any questions that came up during lunch that I can answer?
■ Tell me what you think so far. What about the IMCI process, or what IMCI tools, do you think
will be particularly useful in your clinic?

(5.2) INTRODUCE THE SICK YOUNG INFANT
1. Can someone remind us how we define a sick young infant? Review specification between child
and young infant, and remind that each has own charts and recording forms.
2. Young infants are special and need special attention. Do you know why? Record answers, and
your notes from content below, on FLIPCHART.
■ Young infants have special characteristics that must be considered when classifying their
illness. Young infants differ from older infants and children in the way they manifest signs
of infection.
■ They become sick and die very quickly from serious bacterial infections. Severe infections
are the most common serious illness during first 2 months of life. Infections are particularly
dangerous in low birthweight infants.
■ They frequently have only general signs such as difficulty in feeding, reduced movements,
fever or low body temperature.
■ Lower chest indrawing is different in young infants. Only severe lower chest indrawing is an
important sign of severe disease. Mild chest indrawing is normal in young infants because
their chest wall is soft.
■ Newborn infants are often sick from conditions related to labour and delivery in the first few
days of life, or they may have trouble in breathing due to immature lungs. These conditions
include birth asphyxia, birth trauma, preterm birth and early-onset infections such as sepsis
from premature ruptured membranes. Newborns who have any of these conditions need
immediate attention.
(5.3) WHAT OTHER SPECIAL CARE DO YOUNG INFANTS REQUIRE?

Infants are special cases and need special care.
DISCUSSION: what are important types of care for young infants? List important care practices on
SLIDE 30 and answer any questions. You will explain more about breastfeeding and signs of severe
disease later in the section.

(5.4) LET’S REVIEW THE IMCI PROCESS WITH THE SICK YOUNG INFANT
SLIDE 31, participants should refer to same flow chart in participants book PART 2, section 2
■ Remember that the IMCI process is the same for both age groups in its basic steps – (walk
through slide) GREET, ASSESS for very severe signs of illness and then for other symptoms and
problems, CLASSIFY, IDENTIFY TREATMENT, TREAT, COUNSEL, and FOLLOW-UP CARE.
■ Where do we see some differences with the sick child? (reference previous SLIDE 21 if
necessary) We assess for signs of severe disease and local infection, which are not the same
general danger signs in children, but same concept in assessing for serious signs that require
urgent referral. The signs we assess for identify the most common and serious conditions in
young infants. Emphasize feeding.
We see that ASSESSING the young infant follows the same steps as the child:
■ Assess for signs of serious illness that requires urgent referral. In children we call these
general danger signs, in young infants we are looking specifically for signs of bacterial
infection and jaundice.
■ Assess for common problems in young infants – we check feeding here because good
feeding is so critical in this young age.
Any questions about IMCI with the sick young infant?

(5.5) SIGNS OF POSSIBLE BACTERIAL INFECTION & JAUNDICE
Open to self-study Module 2. This entire module deals with the IMCI process for the sick young
infant – all of the steps we reviewed on the flow chart. You will complete this Module before our
next meeting.
We have learned that the first step is to check all sick young infants for signs of serious disease and
infection. We’ve learned that severe infections are the most common serious illness during first 2
months of life. This step is similar to assessing general danger signs first in sick children. These signs
require urgent referral. (Slide 32)
PLAY IMCI DVD “Demonstration – assessment of sick young infant” (disc 2, 14 minutes)
■ Instructions for participants: We will watch a video about how to assess an infant for these
severe signs. Open Chart Booklets to the first chart for the sick young infant on possible
bacterial infection. Follow along with the chart and your young infant recording form to see
how they guide you through the assessment. There is some content we do not know yet,
but you will learn this in Module 2
■ Facilitation: after the video concludes field questions.
Let’s look more closely at the classification table for serious disease and local infection
■ How would we classify a young infant with skin pustules, but nothing else? What is our
course of action? LOCAL BACTERIAL INFECTION; yellow classification, manage in clinic
■ What if the infant is breathing more than 60 breaths in one minute? POSSIBLE SEVERE
BACTERIAL INFECTION; red classification, pre-referral treatment and refer
■ What if the infant has a body temperature of 35.3 degrees C? Low body temperature sign of
POSSIBLE SEVERE BACTERIAL INFECTION; red, pre-referral treatment and refer
■ What if the infant shows no signs that we assessed for? NO BACTERIAL INFECTION; green
classification, advise on home care
■ What if the infant has yellow palms? JAUNDICE; yellow classification, refer for Hb test

After we assess the young infant for infection – and classify and treat – what do we do next? Flip
through young infant section with participants.
-We continue to assess and classify

■ Diarrhoea eg (Slide 33)
■ HIV infection—using either the
infant’s HIV status if known, or
mother’s status if known (Slide 34)
■ Feeding problem or low weight for
age – with 2 charts if breastfed and
those that are not (Slide 35)
-Then we check
■ Special risk factors for young infants
■ Immunization status
■ Other problems and the mother’s health
-Then we decide on treatment using the TREAT section, COUNSEL THE MOTHER, and give follow-up
care using instructions from the FOLLOW-UP section.

(5.5) THE IMPORTANCE OF BREASTFEEDING FOR THE YOUNG INFANT
The COUNSEL THE MOTHER section deals a great deal with feeding for the young infant, especially
breastfeeding.
The first point of important care for infants that we discussed ( SLIDE 24) is breastfeeding. Let’s look
more at this, because early and exclusive breastfeeding is so important for an infant’s healthy growth
and development.
1. Facilitate group discussion about personal experiences with breastfeeding

This discussion should personalise the issue of feeding, particularly breastfeeding. It is very useful for
women who have breastfed–both facilitators and participants–to share personal experiences.
It is important to discuss the difficult aspects of breastfeeding. This discussion can emphasize that
while many expect breastfeeding to be easy and natural, it actually requires a great deal of support.
■ How many of you have kids? How many of you breastfed, or have worked with a partner or
a family member during breastfeeding?
■ What were your experiences? Where did you seek help? Summarize conversation.
■ In your clinic what issues do mothers have with feeding (e.g. fear that they are not making
enough milk, nipple pain)?
Our personal experiences reinforce that as health workers, we have a critical role to play in
supporting breastfeeding.

2. Lead brief review of breastfeeding benefits (as you think necessary with your participants).
Remind participants that they will learn more about feeding, and counselling caretakers on feeding, in
Module 2.
■ Let’s review what we know about breastfeeding. What are some of the reasons
breastfeeding is so important for young infants? Record responses on FLIPCHART, add
from content below as necessary.
 Breastfeeding is one of most effective ways to ensure child health and survival
 Needed nutrients for healthy development and lifetime of good health
 Contains antibodies that help protect children from common childhood illnesses
 Benefits for family – breastmilk is readily available and affordable, health benefits for
mother
 Lack of exclusive breastfeeding contributes to over a million avoidable deaths each year
■ What are the important guidelines for breastfeeding?

 Exclusive until 6 months old, then add complementary foods.
 What do we mean by exclusive? Can I still give water? Exclusive means breastmilk and
nothing else.
 Early - breastfeeding should begin with an hour of birth.
 When we say breastfeeding should be “on demand,” what do we mean? As often as
child wants, day and night
 What about HIV positive mothers? Exclusive breastfeeding for first 6 months is an
important option.
■ Why is breastfeeding better than infant formula for young infants?

 Does not contain antibodies found in breast milk
 Potential for water-bourne diseases when mixing formula with unsafe water
 Infant feeding requires feeding bottles, and keeping them very clean
 Poor nutrition if dilute too much
 Many families cannot access or afford
 Breast milk supply changes when child isn’t frequently feeding (so if formula becomes
unavailable might not be able to return to breastfeeding)
■ What are feeding options for HIV-positive mothers?

 Exclusive breastfeeding (and safe transition to replacement at 4-6 months, expressing
and heat-treating breastmilk)
 Wet nursing from known HIV-negative woman
 Exclusive replacement feeding
■ Any questions on breastfeeding?

(5.6) USING IMCI TO SUPPORT INFANT FEEDING
Less than 40% of infants around the world breastfeed exclusively—so there is clearly a need for us as
health workers to encourage and support breastfeeding. When we shared our personal experiences,
it emphasized the important role health workers play in encouraging breastfeeding and supporting
mothers to feed properly. It is particularly important to help HIV-positive women find safe feeding
options.
IMCI for the sick young infant gives us guidance on how to assess feeding and counsel the mother.
You will learn more about breastfeeding and counseling on feeding in your self-study Module 2 on
the sick young infant.
PLAY IMCI DVD “Demonstration – breastfeeding assessment” (disc 2, 9 minutes)

■ Instructions for participants: Open to your charts on assessing breastfeeding. Follow your
chart booklets and recording forms to see how these tools guide you through the
assessment.
■ Facilitation: after video concludes, field questions
Any questions about the breastfeeding assessment?

■ IMCI for the sick young infant uses the same process as the sick child, but uses signs that are
most common and serious in young infants
■ Why do infants have special considerations? They can die quickly from infection, and show
signs of health problems differently than older infants or children.
■ Good feeding is a particularly important for young infants. IMCI gives guidance to the
health worker to assess feeding and counsel on problems.
■ Breastfeeding is critically important for infants’ growth and development. Breastfeeding
requires significant support from partners and family members, and correct positioning and
attachment. Health workers have an important role to play in counselling mothers on
correct feeding.

Assessing feeding and counselling mothers on feeding problems is an important focus in IMCI for the
young infant. We have learned how to assess for correct positioning and attachment during
breastfeeding.
We need good communication skills in order to counsel mothers on feeding, home treatment, and
providing other care. In the next section we will learn some of these important communications
skills.

SECTION 7 – GOOD COMMUNICATION & COUNSELLING SKILLS
TIME - 75 minutes, with a break for tea (the first part of the section should last 30 minutes, the
second with group role plays 30 minutes)
FACILITATOR SUMMARY
In this session, you will introduce good skills in communication and counselling. You will explain these
skills and then reinforce them with a video and/or facilitator role plays. When explaining skills, it is
important to provide concrete examples of using these skills within the clinic. Participants will have
an opportunity to practice with role plays.
OBJECTIVES
■ Emphasize how good communication skills facilitate integrated case management for the sick
child and young infant.
■ Introduce APAC process (ask, praise, advise, check understanding)
■ Introduce 3 teaching steps (give information, show example, let him/her practice)
■ Review checking questions for checking understanding
■ Relate skills to everyday clinical use through facilitator-led demonstrations and discussion and
participant role play scenarios.
MATERIALS
□ Props for role plays (1 cup, a rolled blanket to look like a baby)
□ Role play handouts (included in this section)
□ Recording form copies (1 sick child and 1 sick infant required for each role play group)
□ Flipchart
(6.1) INTRODUCE SESSION

We will be discussing useful communications skills for using IMCI in our clinics.
■ OPENING DISCUSSION – Why are good communication skills important to integrated case
management? Where will they help us provide better care with IMCI? e.g. creating a welcoming
environment, building trust and rapport, getting information about a child by asking the right
questions and listening to answers, advising and counseling families on care

(6.2) GOOD COMMUNICATION SKILLS - APAC PROCESS
Let’s review some simple communication skills used in the APAC process (SLIDE 36).
ASK and LISTEN – this helps us gather complete information about a child’s symptoms, signs, and
treatment for the condition
■ You have already learned that asking questions if critical for assessing the child’s problems.
■ Listen carefully to find out what the child’s problems are and what the caretaker is already doing
for the child. Then you will know what she is doing well, and what practices need to be changed.
PRAISE - this affirms good practices and builds a caretaker’s confidence in the things she is doing well
■ It is likely that the caretaker is doing something helpful for the child, for example, breastfeeding.
■ Praise the mother for something helpful she has done.
■ Be sure that the praise is genuine, and only praise actions that are indeed helpful to the child.
ADVISE - there are many good skills when advising caretakers, which we will discuss in a minute
■ Some advice is simple – for example, telling a caretaker to return with the child in 2 days
■ Other advice requires you to teach the caretaker how to do something. We will learn skills about
how to do this teaching in a minute.
CHECK understanding
■ After you advise a caretaker you want to be sure they understood you correctly, especially with
treatment at home.
■ You will ask questions to check their understanding and see if you need to explain anything more.

(6.3) GOOD SKILLS WHEN TEACHING A CARETAKER (SLIDE 37)
Sometimes you will need to teach a caretaker how to do something, like how to give medicine doses
at home, or change the way they breastfeed so that the infant attaches better.
Use three basic teaching steps.
■ GIVE INFORMATION by explaining how to do something, like apply eye ointment, prepare ORS,
or soothe a sore throat
 Use words she understands
 Focus on most important messages
■ SHOW AN EXAMPLE by doing the task yourself, like how to mix ORS, or hold the child still and
apply eye ointment
 If possible use real objects or pictures
 Use common teaching aids
■ ASK HER TO PRACTICE as you watch and give feedback. For example, ask her to mix ORS, apply
eye ointment, or describe how she would make a solution for a sore throat. This is the most
important step of teaching.
 A caretaker is more likely to remember something she has practiced
 As she practices you will be able to observe that she understands and what is difficult
 Answer all questions, and be calm and reassuring

(6.3) CHECKING THAT A CARETAKER UNDERSTANDS (SLIDE 38)
After you teach a mother how to treat her child, you want to be sure that she understands how to
give the treatment correctly. Ask questions to find out what the mother understands and what
needs further explanation.
If you get an unclear response, ask another checking question. Praise the mother for correct
understanding. Explain more if she does not understand.
■ USE CHECKING QUESTIONS

 These are open-ended, which means they cannot be answered YES or NOW
 Good questions begin with words like how, why, what, when, where
 Questions should not lead to the right answer, for example, you will remember to wash your
hands, won’t you?
■ Are these good checking questions?

 How will you prepare ORS? Yes, it is open ended and checks what she remembers
 Should you breastfeed your child? No, it can be answered “yes”
 How much extra fluid will you give after each loose stool? Yes, it is open ended and checks
what she remembers
 Will you remember to wash your hands? No, it can be answered “yes”
 Where on the eye will you put the ointment? Yes, it is open ended and checks what she
remembers
■ What do you do after you answer a question, any ideas? Record responses on FLIPCHART and
summarize discussion, emphasizing the following:
 Pause to give her time to answer - do not rush ahead or give her the answer, she might be
afraid to answer or is shy of authority, she might be afraid her answer is wrong, encourage
her to answer
 Is she answers incorrectly, do not make her feel uncomfortable, teach her again using
information, examples, and practice

(6.4) FACILITATOR ROLE PLAY OR VIDEO described in 6.5 (role plays are optional)
Two facilitators can role play counselling sessions between a health worker and a mother. Facilitators
should adapt the scenes as needed.

■ Present short, realistic clinical scenarios that demonstrate good communication skills.
■ Demonstrate communication skills discussed in this section, including the APAC process, 3
teaching steps, and checking questions.
■ Discuss ways the health worker could improve communication skills.
INSTRUCTIONS FOR FACILITATORS
Facilitators should present these scenarios at the front of the room, and stop after each role play
to discuss reactions. For consistency, the facilitator playing the health worker should play this
role in all of the scenarios. Each role play and discussion should only last a few minutes.
SCENARIO 1 – teaching a mother to treat skin pustules

In this scenario, the health worker does not use the 3 teaching steps or checking questions.
HW: You say your child has had these skin pustules. How have you been caring for this?
Mother: I am putting oil on the skin at night.
HW: The oil will not help this problem. I will tell you of a different way you must treat. You
need to wash the skin with soap and water. Wash away any pus. Then dry him off. Wash your
hands before and after. You should do all of this twice a day, for 5 days. Does that make sense?
Mother nods
DISCUSSION FOR SCENARIO 1

Ask the participants their reactions. Below are some points that the facilitators can emphasize.
What skills did the health worker use?
• The HW asked the mother how she had been treating the problem (ASK in APAC process).
This provided background information on the previous treatment.
How could the health worker improve his/her communication skills?
• The health worker did not use the 3 teaching steps when teaching the mother how to
treat skin pustules at home. The health worker only gave information, but did not
demonstrate or let the mother practice.
• The health worker did not check the mother’s understanding by using checking questions.
• The health worker said that treating with oil was not helpful, but did not explain why.
* * * * *
SCENARIO 2 – feeding from a cup
This scenario should demonstrate a health worker using the 3 teaching steps.

HW: I have showed you how to express breastmilk. You have some here in the cup (lifts cup). I
will show you how to give the milk in a cup.
Health worker takes “baby” (rolled blanket or other prop) from mother to demonstrate the
following steps. Explain the steps aloud.
HW says:
- First, put a cloth on his front to protect his clothes if some milk spills.
- Then, hold your baby upright in your lap.
- Measure the milk into the cup so you know how much you are giving.
- Hold the cup so it rests on the lower lip.
- Tip the cup so that the milk just reaches his lips. He should take the milk himself, you do not
pour the milk into his mouth.
- Now will you try?
Mother takes child and demonstrates steps, talking through them. The mother should have
trouble when she tries to sit the infant up. The health worker should remind her how to sit the
baby upright in her lap. Then the mother should continue through the steps.
HW: very good, we are done with this. You are very good to be giving breastmilk, even if you
have been having trouble with the attachment. Your breastmilk is so important for your baby
boy’s growth.
Mother: Thank you

What things did the health worker do well?

• She used the 3 teaching skills – explain, show example, and let the mother practice.
• When the mother needed help during practice, she explained more.
• The health worker affirmed the mother when her practice was done.
• The health worker praised the mother for giving expressed breastmilk even though she is
having trouble with attachment.
• The health worker used common items – a cup – to demonstrate the practice.
What else should the health worker do in this scenario – what skills were not used?
• The health worker did not check the mother’s understanding after they were finished –
for example, how often the feeding should occur, or why the milk should be measured.
* * * * *
SCENARIO 3 – increased fluid during illness

This scenario should demonstrate better use of checking questions.

HW: Your girl is sick, so it is important that she gets a lot of fluid. You should be giving her more
than usual. More nutrients and fluid will give her strength to fight the infection. You have been
really good to keep breastfeeding her, this is very important. What other foods or drink do you
give her?
Mother: She also takes rice and sometimes fruits. I boil water for her sometimes when the
water is dirty.
HW: Boiling water is very important, you are very good to do this, and should keep doing it. You
should keep giving her rice with water, soup, yogurt drinks, and more clean water.
Can you tell me how you will give her more fluids?
Mother pauses: I do not understand?
HW: can you give me some examples of what you will feed her?
Mother: I will keep giving breast milk. I will also give water and mix it with rice or yogurt.
HW: This is very good. This is exactly what you should do.

What things did the health worker do well?

• The health worker asked for more information about how the mother was feeding, and
praised the mother for breastfeeding and boiling water for complementary feeding.
• The health worker used a checking question to make sure the mother understood.
• When the mother did not understand the question, the health worker encouraged her.
What else should the health worker do in this scenario – what skills were not used?
• The health worker might use a teaching card or give the mother a picture to take home
with the recommended foods for increased fluids.
* * *

(6.5) PLAY VIDEO “Making Things Clear” (13 minutes)
This video shows two scenarios in a clinic. In the first scenario, the health worker does not use
most of the communication skills discussed in this section. The second scenario is improved.
The narrator provides analysis after each scenario.
■ Instructions for participants: this video will review many of the communication skills we
have just learned about. Take notes on the skills that you recognize. Take notes on areas
where the health worker does well, or where the health worker could improve.
■ Facilitation: after video concludes, ask for questions
(6.6) SUMMARIZE before tea break (use FLIPCHART to record key notes)
■ What is the APAC process? Ask (and listen), praise, advise, check understanding
■ What are 3 important steps when teaching a caretaker? Give information, show example, let her
practice
■ Can someone give me an example of a good checking question? Of a poor question?
■ What are some other useful tips when we are communicating with caretakers? Use words that
are easily to understand, use common teaching aids, be reassuring, affirm correct answers and
good practice, ask for questions and answer all, focus on important messages and don’t
overwhelm with information
BREAK FOR TEA

When we return we will do role plays to practice our communication skills with IMCI.

(6.6) PARTICIPANT ROLE PLAYS
We will now role play case scenarios in order to practice our communication skills and the IMCI
process that we have learned today.

■ Role plays give participants the opportunity to put the day’s assessment and communication skills
to practice. Rotating roles and having one observer per role play should provide constructive
feedback to the health worker.
■ Specific objectives for each role play are on following page. Each role play differs in order to
cover major content from Sections 4, 5, and 6.
1. Before we begin role plays, let’s quickly review the main steps in the IMCI process (SLIDE 39)
This short review should refresh key steps for
participants to follow during the role plays.
■ Greet the caretaker

■ Assess – first for signs of severe illness, and
then main symptoms and other common
health conditions
■ Classify all conditions and identify treatment
■ Treat the child or infant for all conditions
■ Counsel the caretaker
■ Provide follow-up care
2. Explain role play set-up to participants

■ Participants should divide into groups of
three, and bring their Chart Booklets and notepads. They will rotate between three roles.
■ Explain three roles:
• Caretaker – will background information on a handout. Only give the healthcare

provider the information if they ask for it – this is an exercise for them to ask you the
right questions, so do not give the information away too quickly. You want the best
for your child, but you are not offering the information unless asked.
• Health worker – will get a handout with information about what you observe during
the interaction. Your task is to use good communications skills and to greet the
caretaker and assess the child for problems using your Chart Booklet, including the
classification tables and the COUNSEL THE MOTHER section.

• Observer – take notes as you observe the interaction, focusing on how well the health
worker utilized the IMCI strategy, and how well they used important communications
skills like the APAC process, teaching steps, and checking questions.
*DISTRIBUTE 1 COPY OF HANDOUT A, B, and C TO EACH GROUP (TEAR IN HALF FOR CARETAKER
AND HEALTH WORKER). HANDOUTS LOCATED ON FOLLOWING PAGES.
* DISTRIBUTE 1 RECORDING FORM FOR THE CHILD (ROLE PLAY A) AND 1 FOR THE YOUNG INFANT
(ROLE PLAY B).
■ Timing: 10 minutes for each of the 3 role plays - 5 minutes for each role play scenario (most will
not take this long), followed by 5 minutes of discussion before rotating roles and using the next
handout. Facilitator should give 1 minute warning during group discussion, and then alert groups
when to switch roles and handouts.
■ DISCUSSIONS should concentrate on the questions on (SLIDE 38). Feedback is the most
important part of the activity, and all group members should provide constructive feedback on
what the health worker did well, and what he or she
Role play discussion questions
could improve next time. (Slide 40 also)
1. Did the health worker get all important information?
Groups should discuss amongst themselves, but 2. Did the health worker:
 Use the APAC process
facilitators might want to conclude the group discussions  Use the 3 teaching steps (explain, demonstrate, ask to practice)
 Use checking questions to check caretaker’s understanding
2 minutes early and gather thoughts from the entire 3. Caretaker: what did the health worker do well? What
group. Record group conclusions from the discussion could be improved?
Observer: what did the health worker do well? What
questions on FLIPCHART. 4.
could be improved?
5. Health worker: what would you do differently next
time?

ROLE PLAY A
Objective: assess and classify a child for general danger signs and cough, using Chart Booklet and
recording form. Review recording form (SLIDE 41)
• How was the health worker successful in

getting the necessary information from the
caretaker?
• How did you classify the child’s general
danger signs and cough?
• What does the colour-coded classification
tell about the course of action required?
ANSWERS: No general danger signs, very severe

pneumonia, red/urgent referral required
ROLE PLAY B
Objective: assess a sick young infant for signs of severe disease and bacterial infection, using Chart
Booklet and recording form. If health workers have time they may counsel on keeping the infant
warm on way to hospital. Review recording form (SLIDE 42).
• How was the health worker successful in

getting the necessary information from the
caretaker?
• How did you classify the infant – does she
have signs of severe disease or bacterial
infection?
• What does the colour-coded classification
tell about the course of action required?
What did you counsel the caretaker about?
ANSWERS: Very severe disease, red/urgent

referral required, counsel caretaker on keeping
the infant warm on the way to the hospital
ROLE PLAY C
Objective: counsel the caretaker on treating a local infection at home using the APAC process, 3
teaching steps, and checking the caretaker’s understanding
• How did the health worker use the APAC process? The 3 steps of the teaching method?
Checking questions?

(6.7) REINFORCE KEY PRINCIPLES (use FLIPCHART to record key notes, supplement comments with
notes below as necessary)
■ Why are communication skills important when using IMCI? Integrated case management relies
on us getting thorough information from the caretaker in order to properly assess and classify the
child. Communication skills help us effectively counsel the caretaker on important home
treatment, feeding, follow-up instructions, and other preventative care in the home. We can take
important steps to make a caretaker feel welcome and less anxious, which helps us build trust and
rapport, and helps them to remember the advice we give about care for the child. We remember
from our own experiences as caretakers, and we know from our time working in the clinic, that it
is very emotionally difficult when a child is sick.
■ What is the APAC process? Ask (and listen), praise, advise, check understanding
■ Can someone give me an example of praising a caretaker? Why is praise important? It affirms
good practices and builds rapport with a caretaker
■ What are 3 important steps when teaching a caretaker? Give information, show example, let
him/her practice
■ What are important skills to remember when we are teaching? Use clear language, use familiar
teaching objects, allow more practice if necessary, affirm good practice and give feedback,
emphasize take home messages and do not overwhelm with too much information
■ Can 3 people give me an example of a good checking question? Can 2 people give me a poor
checking question?

We have completed our content for today. In our last session will review the important details of
this course and plan our next steps. We will then do a course evaluation and close for today.

HANDOUT A
CARETAKER
Remember that this is an exercise for the health worker to ask the right questions to get
information about your child. Only give the information that is asked.
The health worker might ask for The information you have for response –
this information–
Child’s name? Jon (boy)
His age? 12 months
Your initial or follow-up visit? Initial visit
What is your child’s problem? My child has a cough that worries me.
He has had a cough for several days (3-4), and it is getting
worse.
Does your child have these
symptoms?
- unable to drink or breastfeed? - No, he can drink
- vomiting everything? - No, he is not vomiting
- had convulsions during this - No convulsions
illness?
HANDOUT A
HEALTH WORKER
Remember that this is an exercise in good communication skills as you use the IMCI process. Use
your Chart Booklet and a recording form as you assess the child for signs of severe illness and the
presenting symptom.
You measure:
 Temperature: 37 degrees Celsius
 Weight: 10 kg
Your observations about the child:

 Child is not lethargic or unconscious
 You count 48 breaths/minute
 Child has chest indrawing
Based on the signs you observe, how would you classify the child?

HANDOUT B
CARETAKER
Remember that this is an exercise for the health worker to ask the right questions to get
information about your infant. Only give the information that is asked.
The health worker might ask for The information you have for response –
this information–
Child’s name? Amira (girl)
His age? 4 weeks
Your initial or follow-up visit? Initial visit
What is your child’s problem? The baby seems feverish and is very unhappy
Is the child…
- having difficulty feeding? - No, she can breastfeed
- having convulsions during this - No convulsions

illness?
HANDOUT B
HEALTH WORKER
Remember that this is an exercise in good communication skills as you use the IMCI process. Use
your Chart Booklet and a recording form as you assess for signs of severe illness.
You measure:
 Temperature: 38 degrees Celsius
 Weight: 3 kg
Your observations about the child:

 You count 53 breaths/minute
 You observe chest indrawing
 The umbilicus is not red or draining pus.
 There are no skin pustules. Eyes are not draining pus.
 The child moves only when stimulated.
 No bulging fontanelle
 No nasal flaring or grunting
 No jaundice evident.
Based on the signs you observe, how would you classify? What is your course of action? How
could you counsel the caretaker?
HANDOUT C
CARETAKER
This exercise differs slightly from the previous role plays, and focuses on communication skills
with a caretaker. You should not disclose information or do anything that the health worker
does not ask of you – for example, do not volunteer to practice the home treatment unless they
ask you to do it. You do not need to immediately volunteer information to the healthworker, and
can ask for clarifications.
In this scenario, your infant has been classified with a LOCAL BACTERIAL INFECTION around the
umbilicus. The umbilicus is red. The health worker will counsel you about treating the local
infection at home.
HANDOUT C
HEALTH WORKER
This exercise differs slightly from the previous role plays, and focuses on communication skills
with a caretaker. You will be asked to use your Chart Booklet and counsel the caretaker on a
particular home treatment, which would happen after you have classified the child and
determined the appropriate treatment.
In this scenario, you have classified an infant with a LOCAL BACTERIAL INFECTION of the
umbilicus. The umbilicus is red. This classification is on the first chart for infants, for severe
disease and local infection. Use your COUNSEL THE MOTHER section in your Chart Booklet to
advise the mother how to treat the infection around the umbilicus.
You can take a minute to review the instructions for treating a local infection before you begin
to counsel the mother.

SECTION 8 – NEXT STEPS
TIME - 45 minutes
FACILITATOR SUMMARY
This section will review the course structure and calendar, and set plans for the next steps of the
course. Participants should be very clear about expectations for the first self-study phase, who they
are asked to involve in their study, and what materials they will be using. At the conclusion of this
section, you will administer an evaluation of the day.
OBJECTIVES
■ Reinforce course structure and expectations for the upcoming self-study phase—completion
of modules 1 and 2, practice in clinics and use of recording forms, identifying mentors and
communicating with in-charge officers
■ Ensure that all participants have necessary materials and know what to prepare for next
meeting
■ Administer meeting evaluation
COURSE CALENDAR – about 4 months total

MATERIALS Sessions Objectives Location Date
 Introduce IMCI process
□ PowerPoint slides Orientation

 Distribute learning materials &
introduce content to Modules 1 and 2
1st face-to-face ____________ _________
□ Evaluation form handout meeting
 Review distance learning course
structure & expectations
Meeting place (1 day)
 Read modules
(7.1) REVIEW CALENDAR (SLIDE 43 & 44), participants as you read

Self-study phase 1
should follow along in their books PART 2, SECTION 3 Modules 1 & 2
 Hold study group discussions
Home facilities
(3-4 weeks)
to fill in dates) facilitators

logbook
PHC child clients using IMCI – “sign local venue
1. Emphasize dates and location for second face-to- meeting 1
off” 2 seen patients
with patients
(1 day)
Review & practice

face meeting 1
2nd face-to-face
• Introduce content from upcoming
____________
Meeting place
_________
(1 day)
modules can be on-site
meeting
Provideprogress
• •Review clinical &
practice
issues in self-study
_________
2. Review what is expected during the following 3rd face-to-face
meeting
• Introduce content from upcoming
modules
Meeting place
can be on-site
(1 day)
several weeks of self-study:  Read modules

as you read
■ Complete modules 1 and 2 – read and do Self-study phase 3
written and DVD exercises  Hold study group discussions
(3-4 week)
facilitators
■ Practice content in clinics and use recording  Complete assessment exercises in
logbook
forms. Bring several recording forms to the Clinical Support
meeting 3
PHC child clients using IMCI – “sign off”
2 seen patients
local venue
with patients
_________
(1 day)
next meeting that demonstrate examples of • Review progress & issues in self-study
you: checking for general danger signs in a 4th face-to-face

meeting
 Individual action plans for continued
____________
Meeting place
Can be on site
_________
(1 day)
learning
child, and using the IMCI process with a sick  Course assessment (skills stations and
written exam)
young infant. Clinical Summative

weeks after 4th face to face to see PHC
Convenient
local venue
_________
■ Meeting with study group
with patients
assessment
■ Work with mentors

(7.2) INVOLVING OTHERS
1. Effective distance learning requires you to involve others in your studying. Who should you
reach out to? (SLIDE 45, participants can follow along in PART 1, section 2)
2. Planning your study groups (SLIDE 46 participants can follow along in PART 1, section 5).
We will organize and plan our study groups in a few minutes.
Why do you think we are arranging study groups for this group? What is the benefit of group
learning? Facilitate brief discussion around group studying, referring to your introductory materials
in this guide.

(7.3) LET’S DO A FINAL REVIEW OF YOUR MATERIALS
You will have distributed all materials at the beginning of the meeting, but review modules and
logbook with participants to tie the day’s content into the upcoming self-study phases.
1. Your logbook and materials (SLIDE 47)

Hold up materials to ensure that all participants have theirs collected.
Flip through the logbook with participants to show that it contains:

Logbook & materials
■ Written exercises for each module—
exercises are to be completed alone and Logbook includes:
will be assessed by facilitator. Written  Written exercises for each module—these will be handed in
for assessement
exercises include multiple-choice  IMCI recording forms
questions, true/false questions, and case  Signed by facilitator at clinical support meeting
 Individual recording forms
studies. These are valuable practice and  Pages to record questions and issues for discussing with
part of the course assessment. facilitators and study groups

*you will submit logbook for review at face-to-face meetings
■ Sections for writing notes on clinical As a reminder, the other materials you have are:
practice and personal experiences during  Self-study modules–includes overviews on course & IMCI
 Chart Booklet
study
■ Recording forms to record cases as you practice
o Some to be seem with facilitators at the clinical support meeting between face to face
meetings
o Some to be individually filled with patients seen at your own facility by yourself
*Emphasize that recording forms should be filled out and brought to the next meeting. The more
cases recorded, facilitators and peers can give better feedback*

2. Your self-study modules (SLIDE48)
Self-study modules
Remember that Modules 1 and 2 should be 1 General danger signs
SELF-STUDY MODULES
Identifying signs of severe illness in sick children

completed before our next meeting. Phase 1 2 Care of the sick young infant
Using the IMCI strategy with sick young infants
3 Cough or difficult breathing
Assess, classify, and treat cough or difficult breathing in sick child
These modules include: 4 Diarrhoea

Assess, classify, and treat diarrhoea and dehydration in sick child
 Reading material
5 Fever
Assess, classify, and treat fever in sick child
Phase 2 6
 Self-assessment exercises and answer keys

Ear problems
Assess, classify, and treat ear problems in sick child
7 Malnutrition and anaemia
 Review questions at the end of each Assess nutritional status and address malnutrition, anaemia, or
feeding problems
8 HIV/ART
module Phase 3
9
Assess classify and treat children with HIV infection
Cosider TB/ Assess Immunisation & Other
Assess and classify TB/ Immunisation and Other Problems
* Modules have recording forms to be used with cases in home facilities & with
facilitators, and must also be brought to face-to-face meetings
(7.4) PLANNING OUR STUDY (SLIDE49)

Review how participants should set a study agenda. Recommend timing and discuss questions.
Review how study groups should plan agendas together, with specific content to be covered.
Let's take 10-15 minutes to arrange our study groups. You will want to meet briefly after we finish
today to finalize your study calendar together and ensure that you all have each other's contact
information.
Facilitate participants arranging PLANNING: self-study phase 1

study groups by locality and INDIVIDUAL STUDY PLAN
facility--make sure everyone has a MODULE DATES STUDY GROUP RECORDING
MEETING FORM GOAL
study group. 1 week (9-16 Aug) 13 Aug 3
1
2 18 days (16 Aug-2 Sept) 20 & 27 Aug, 3 Sep 7
STUDY GROUP PLAN

DATE & TIME LOCATION MATERIAL LEADER
13 Aug, 5-6pm Bisho All Mod 1 -GDS L.M.
20 Aug, 5-6pm Bisho Mod 2, assess & classify upS.T.
to feeding (p.1
- 21)
27 Aug, 5-6pm Bisho Mod 2, assess feeding & M.T.
treat (p.21-48)
3 Sept, 5-6pm Bisho Mod 2 counsel & follow
-up L.J.
(48 -68), review all

(7.5) NEXT STEPS (SLIDE 50)
Review all take-home messages for the upcoming self-study period and preparations for the next
meeting.
What questions do we have about our next steps?
Next meeting: Review & Practice

DATE 12 Dec 2011 LOCATION East London Health resource centre
WHAT DO I BRING?
 Study modules (1 & 2 completed)
 Logbook (exercises for modules 1 & 2 completed)
 2 recording forms done with facilitator and signed
off
 2 Individually consulted recording forms (pref 1 sick
young infant and 1 sick child)
 Your questions—challenging cases, confusing
material
AT THE NEXT MEETING WE WILL–
 Review self-study progress
 Practice IMCI in clinic
 Introduce content from upcoming modules
(7.6) EVALUATION
Lead a discussion in the group to gather feedback on the day's content, presentation, and clarity. We
recommend that facilitators ask participants for feedback on specific topics before giving a printed
evaluation. Conversational evaluations can also provide useful information that is not included in a
written evaluation.
Distribute evaluation handout.
Provide time for participants to complete the evaluation and hand in. As participants finish the
evaluation, check in with them to make sure each is feeling comfortable about their self-study, and if
you can answer any individual questions.
(7.7) CLOSE MEETING
*DISTRIBUTE PARTICIPANT CONTANT INFORMATION SHEET*

Review how participants should best stay in touch with you, and your availability.
Affirm participants' engagement in the course and express your energy and anticipation for the
following three months.

ANNEX 1ST MEETING: ORIENTATION
CONTENTS
1. Course registration form
2. Sample participants list
3. Planning & managing study groups
4. Tables of clinical signs and classifications in logbook

1. SAMPLE COURSE REGISTRATION FORM
COURSE REGISTRATION FORM - IMCI DISTANCE LEARNING

Location, date
Please write clearly.
Full name
Preferred name (if

different than above)
Workplace (please
specify location)
Role
Mobile number
Other phone numbers
Email address
Post address
 Mobile call
How is it best to stay in  Mobile text
touch with you?  Other phone call
 Email
 Post
How did you learn of

this course?
What background do
you have with IMCI, if
any?
Have you done a
distance learning
course before?

2. SAMPLE PARTICIPANTS LIST
LIST OF PARTICIPANTS
IMCI DISTANCE LEARNING COURSE
SEPTEMBER - OCTOBER 2010

EAST LONDON PROVINCE, SOUTH AFRICA
NAME PREFERRED WORKPLACE ROLE MOBILE EMAIL POST HOW TO

CONTACT?
Example High clinic Professional 222222 Email Address Mobile
nurse 22 address

3. PLANNING & MANAGING STUDY GROUPS
Why is group learning important?

Working with others is very important for effective distance learning. Group study benefits your
study in 2 ways:
1. GROUP STUDY CAN IMPROVE THE QUALITY OF YOUR LEARNING

During group learning you learn from each other. You will be required to test your knowledge
because you have explain material to your peers. You need to understand it enough to teach
another person.
Discussing questions and problems with your group helps to improve your understanding of
concepts. Working in a group can also motivate you. You have a sense of responsibility to your
group and finishing your work so that you can contribute to the group study.
2. GROUP STUDY CAN HELP DEVELOP SKILLS

■ Teamwork skills—leadership skills, doing activities as a group, including group members
■ Analytical skills—critical thinking, problem solving, analyzing tasks and requirements,
evaluating the work of others, interpreting material
■ Collaborative skills—conflict management, negotiating and compromising, accepting
feedback
■ Organisational skills—time management, working efficiently (i.e. not leaving work until
the last minute, and giving yourself plenty of time to prepare for group meetings),
planning and managing a group study session
How do you manage study groups?

Group study has the above benefits if the group is well planned and managed. Steps for managing
study groups are below. Ideally, groups will meet regularly (e.g. once or twice a week) to review
modules and cases from the clinic. Groups might want to review the self-assessment exercises, or
decide its own ways to study together.
STEP 1: DETERMINE WHO WILL BE IN THE STUDY GROUP

Groups manage best with 3 to 5 members. Groups over 5 members are not recommended. They are
too big to work efficiently. The course facilitators will help participants organize into study groups.
Study group arrangements will depend on where participants live and work.
STEP 2: ESTABLISH GROUP MEMBERS’ ROLE(S) AND RESPONSIBILITIES

Efficient groups divide tasks so that each member has a certain role or responsibility. For example—
a group leader, a scheduler, or a note-taker.

STEP 3: DEFINE GROUP PROCEDURES
It is important to have clear guidelines or rules that all members should follow. Guidelines and
procedures for group work should be detailed. Group activities’ purpose and function must be clear.
STEP 4: SCHEDULE GROUP MEETINGS

When organizing meetings, groups must consider:
■ travel time and cost from multiple locations
■ part-time or full-time work commitments
■ family responsibilities
■ disabilities among members
These are not minor issues. Group study requires additional time and energy for attending and
contributing to group meetings. Planning must consider each member’s available time and work
schedule.
Below is a sample schedule for group study. When scheduling meetings, it is best to agree on the
specific date, time, location, timing of meeting, the material to be prepared before the meeting, and
the material that will be covered during the group study. This will make the group meeting time as
effective as possible for all group members.
MEETING DATE & TIME LOCATION CHAPTER & SECTION TIME

July 24, 2010 5:00 District Part 1: Course 1 hour
PM resource overview Part 2:
centre Introduction to IMCI
July 31, 2010 5:00 District Self-study module 1: 1 hour
Pm resource General danger signs
centre
August 7, 2010 5:00 District Self-study module: 1 hour
PM resource Young infant, section
centre 1 and 2
August 14, 2010 5:00 District Self-study module: 1 hour
PM resource Young infant, section
centre 3 and 4

4. TABLE OF CLINICAL SIGNS
RECORD OF CLINICAL SIGNS—SICK CHILD
CLINICAL SIGNS (SICK CHILD) DATE (OR RECORDING FORM #) OF WHEN SIGN SEEN
Not able to drink or breastfeed
Vomits everything
History of convulsions (with this
illness)
Lethargic or unconscious
Fast breathing
Chest indrawing
Stridor in calm child
Restless and irritable
Sunken eyes
Drinking poorly
Drinking eagerly, thirsty
Very slow skin pinch
Slow skin pinch
Stiff neck
Runny nose
Generalized rash of measles
Red eyes
Mouth ulcers
Deep and extensive mouth ulcers
Pus draining from eye
Clouding of the cornea
Pus draining from ear
Tender swelling behind the ear
Visible severe wasting
Severe palmar pallor
Some palmar pallor
Oedema of both feet

RECORD OF CLINICAL SIGNS—SICK YOUNG INFANT
CLINICAL SIGNS (SICK CHILD) DATE (OR RECORDING FORM #) OF WHEN SIGN WAS
SEEN
Difficulty feeding
History of convulsions (with this illness)
Fast breathing (over 60 breaths/min)
Severe chest indrawing
Umbilicus red or draining pus
Skin pustules
Reduced movements
Jaundice in skin or eyes
Jaundice in palms or soles
Restless or irritable
Sunken eyes
Very slow skin pinch
Slow skin pinch
Thrush
Ulcers

PART THREE
Review & Practice 1
2nd face-to-face meeting

Consolidating Modules 1 & 2.
Introducing Modules 3, 4, 5, 6 & 7
102
MEETING OBJECTIVES
The second face-to-face meeting aims to assess participants’ progress during the first self-study
phase, to address any challenges, and to introduce content from the remaining self-study modules.
The afternoon sessions are less structured in the event that facilitators need to work with
participants to address problem areas by giving more information or practice.
Where will this meeting take place?

The meeting is designed to take place on-site so that the facilitators and participants can practice
together in a clinical setting.
This could take place at the district hospital, at a centrally located facility, or during site visits with the
facilitator.
MODULE OBJECTIVES
By the end of this meeting, participants should be able to:
■ Demonstrate skills from Modules 1 and 2 in a clinical setting

■ Explain and demonstrate how to use IMCI chart instructions to assess, classify,
and treat main symptoms and conditions in a sick child (cough or difficult
breathing, diarrhoea, fever, malnutrition, and anaemia).
■ Plan self-study, group study, work with mentors, and clinical practice for modules
3-9.

9:00 REGISTRATION – use participants form provided PLANNING NOTES
9:00 – 9:15 SECTION 1 PLANNING NOTES

OVERVIEW (15 minutes)
Review course objectives and outline the day's objectives and
agenda.

REVIEWING SELF-STUDY PHASE 1(45 minutes)
Group discussion about self-study experiences, review recording
forms, and problem solving around difficult cases.
10:00 – 10:15 Tea break (15 minutes)

ASSESS & CLASSIFY THE SICK CHILD (PART 1)
(45 minutes)
Introduce main symptoms cough or difficult breathing and diarrhoea
using video demonstrations.

CLINICAL PRACTICE (90 minutes)
Clinical demonstrations and skills practice focusing on the sick young
infant, and general danger signs, cough or difficult breathing, and
diarrhoea in the sick child.
12:30 – 13:30 Lunch (1 hour)

ASSESS & CLASSIFY THE SICK CHILD (PART 2)
(75 minutes)
Introduce material on fever, malnutrition, anaemia, well child care,
and other modules in self-study phase 2.

INTEGRATION TREATMENT, COUNSELLING THE CARETAKER,
& FOLLOW-UP (30 minutes)
Review treatment for integrated case management, good
counselling skills, and instructions for follow-up. You will lead an
activity on dosaging.

Review expectations for study phase 2, and administer evaluation.

This is a checklist of suggested materials for the day. Each section of the day's meeting specifies
which of these materials is required during a particular section.
MATERIALS NUMBER  list
For facilitators
Registration form For check-in
Facilitator guide 1 for each facilitator
Module PowerPoint slides 1 file of slides
IMCI DVD 1 DVD (has 2 discs)
Tray and medicine tablets (see
For dosages activity in afternoon
Section 6 for specifics)
IMCI Photo Booklet At least 1 copy for visual aids
IMCI Wall Chart 1 displayed or other visual aid
IMCI facilitator guide for outpatient
clinical practice
IMCI guide for clinical practice in the
inpatient ward
Projector and/or computer screen For slides and video
Speakers for showing DVD As necessary, if showing on laptop or other
equipment with low sound
Flipchart or large paper 15 large sheets, for wall display
Flipchart markers
Clock or stopwatch for timekeeping -
best if visible to all participants
Masking tape As necessary for displaying
For everyone (all participants + all facilitators) *
Nametags or nameplates 1 for each
Copies of key slides for all if projector not
Printed PowerPoint slides
available
Copies as necessary for meetings and if
IMCI Recording Forms
extras needed for logbooks
Evaluation form 1 copy for each
Notebooks 1 for each
Pens and pencils 1-2 for each
Supplies for 2 tea breaks and lunch If provided
Other
* Materials should be ready and available for the facilitator to distribute at points during the day.
When the facilitator distributes a particular material, explain the content in full to the participants.
Participants should bring
Self-study modules distributed 1st meeting
IMCI Chart Booklets distributed 1st meeting
Recording forms - Modules 1 & 2 Completed in past 3-4 weeks in clinic
And any additional notes taken from clinical
Logbooks
practice or self-study

REGISTER
All participants should check-in to confirm their attendance. A registration form is provided. It also
requests important information about how the participants have studied and practiced on their own
in the past weeks.
MATERIALS FOR DISTRIBUTION AT REGISTRATION (or ready at place settings)

 Day’s agenda
MATERIALS PREPARED AND READY FOR DISTRIBUTION

 Copies of IMCI recording forms for video exercises and clinical practice– both for child and
young infant
 Printed PowerPoint slides (if you decide to distribute)
 Handouts for activities
 Individual learning contracts
EQUIPMENT PREPARATIONS
using 1 laptop for both, it is best to have the slides open, and the IMCI DVD disc 1 in your
computer and at the main menu. If both are open and prepped, it is more time efficient to
minimize one programme and open the other. Load IMCI DVD disc 2 at the lunch break.
 Audio—Test all audio equipment – projector screen shows properly, the DVD will run,
sound is adequate with speakers or sound system, etc.
NOTE: If this meeting is happening at facility level with a small group of health workers, you can use a
laptop to show the videos.

SECTION 1 – OVERVIEW
TIME - 15 minutes
FACILITATOR SUMMARY
You will facilitate re-introductions of the facilitators and course participants, and welcome the group
to the second face-to-face meeting. You will review the course objectives and structure, and provide
an outline for the day’s objectives and activities.
SECTION OBJECTIVES
■ Review course structure, emphasizing what components were accomplished in self-study
phase 1, and how the course will move forward in self-study phase 2
■ Introduce meeting objectives and brief agenda for the day
MATERIALS
□ Flipchart

Welcome participants to second face-to-face meeting, which is an opportunity to assess progress in
self-study, address any challenges we are having, and practice together as a group.
1. Re-introduce yourself and co-facilitators

 Name
 One thing that you have found particularly beneficial thus far in your self-study, group
learning, or clinical practice
3. SUMMARIZE participant comments about course benefits

(1.2) REVIEW COURSE DETAILS
Participants should follow along in books PART 2, section 2.
1. Review course objectives (SLIDE 2)
2. Review course structure (SLIDE 3)

Briefly review what components of the course have been completed, and what is upcoming.

Additional
Modules in future
new information
3-4 6-8 4 weeks

weeks weeks

Work with mentors


(1.3) TODAY’S OBJECTIVES & AGENDA
1. Review objectives of the second face-to-face meeting (SLIDE 4)
2. Briefly review the agenda for today – emphasizing that it is a busy day and will require discipline
to stay on task
■ This morning we will review our experiences in the past few weeks with self-study
■ Later in the morning we will practice IMCI in the clinic together – describe how group will
move and/or transition to clinical setting
■ In the afternoon we will review the IMCI process with common symptoms and conditions in
children, which is the focus of your upcoming modules

 Breaks in morning/afternoon, and lunch at midday. Note if provided.
 Facilities in this building - toilets, phone and computer access

■ Today is an opportunity to address any content or practice areas that you have found
particularly challenging – so do not be afraid to ask questions. Your upcoming self-study will
only become more difficult if you have confusions about IMCI or the material.
■ Today is also an opportunity to share our experiences practicing IMCI thus far, and to learn
from each other’s good practices.
■ We will prepare for the upcoming self-study phase by introducing material on assessing,
classifying, and treating common symptoms and conditions in children.

SECTION 2 – REVIEW SELF-STUDY PHASE 1
TIME - 45 minutes
We’ll begin our day reviewing experiences during the past few weeks of studying and practicing on
our own.
FACILITATOR SUMMARY
This section is a critical opportunity for facilitator to: (a) assess how well participants are using IMCI
material in their clinical practice, (b) assess how well participants comprehend integrated case
management strategies and content from Modules 1 and 2, and (c) assess and address any “big
picture” issues in the distance learning course arrangements, including self-study, study groups, and
mentorship. During the plenary discussion, facilitators not leading the discussion should collect and
review recording forms to identify common problems to discuss with group.
SECTION OBJECTIVES
■ Provide an opportunity to reflect on distance learning experience, and progress in
understanding and utilizing the IMCI strategy.
■ Assess how well participants are integrating material into their clinical practice, and address
problem areas and challenging cases.
■ Problem solve as group to address course or individual challenges. As a facilitator, note
where additional facilitation and support is required (i.e. for a particular participant struggling
with content or support at his/her clinic, or any course issues that require innovations in
course scale-up).
MATERIALS
□ Flipchart
(2.1) PLENARY DISCUSSION – OUR REFLECTIONS ON SELF-STUDY
1. Review objectives of this discussion:

■ This is an opportunity to share your experiences with the self-study modules, clinical practice,
working with mentors, and study groups.
■ We want to discuss any challenges you have encountered and address them as a group.
■ This is a valuable time to deal with problem areas now before we move into a longer self-
study phase with more content.
2. *COLLECT IMCI RECORDING FORMS AND LOGBOOK MCQ’s / CASES FROM PARTICIPANTS*
Facilitators not leading the plenary discussion should review recording forms to identify any problem
areas with using IMCI for the sick young infant or to check general danger signs. Rejoin the group to
discuss and address these problem areas.

3. PLENARY DISCUSSION: record key points of discussion on FLIPCHART
During this discussion, identify problem areas in content, self-study, and clinical practice. Brainstorm
solutions to problem solve group—encourage fellow participants to answer questions, share useful
experiences, or give advice—before you address any issues. Sample questions for this discussion are
below.
■ Module content: what were your experiences reading and doing exercises in Module 1?
Module 2? What components of the modules did you find particularly useful (i.e. written
exercises, content format, DVD exercises, review questions)? Who wants to share a practice
that they found particularly beneficial or effective in their studying (i.e. watching DVD
immediately after content, or later as a review, taking notes in logbook, etc)?
■ Checking understanding of modules: What about Module 1 was challenging? Module 2?

What questions can we discuss and explain as a group now?
■ Clinical practice: what were your experiences using IMCI in the clinic? How did you use your
Chart Booklets and recording forms? What is challenging about integrating the material from
Modules 1 and 2 in the clinic? Where are you facing problems?
■ Challenging cases: what particularly challenging cases did we see? Who wants to review a
case and their recording form so we can discuss your case?
■ Involving others in self-study: what were your experiences working with study groups? What
were you experiences in identifying an IMCI mentor—who are these mentors? How have you
reached out to them thus far? How will they be able to mentor you in your study? Who
wants to share how they discussed the course and the IMCI tools with their in-charge officer
and colleagues?
3. Facilitators reviewing recording forms should address problem areas.
(2.3) SUMMARIZE PLENARY

■ Problem areas identified and solutions reached as group, or areas still outstanding.
■ Affirm efforts to use IMCI in clinical practice
■ Emphasize good practices, particularly those that participants described as useful in their
self-study.

Now that we have shared our experiences with using IMCI, let us continue

SECTION 3 – ASSESS & CLASSIFY THE SICK CHILD (PART 1)
TIME – 45 minutes
FACILITATOR SUMMARY
You will be introducing the first two main symptoms in the sick child—cough or difficult breathing,
and diarrhoea. This will be a brief introduction so that these symptoms can be included in the clinical
practice session. Participants will learn more in Modules 3 and 4.
SECTION OBJECTIVES
■ Briefly review IMCI for the sick child—emphasize what steps have been covered (greet,
general danger signs) and what is forthcoming in the modules.
■ Introduce assessing and classifying cough or difficult breathing and diarrhoea with video
demonstrations and brief content discussions.
MATERIALS
□ IMCI DVD (disc 1)
(3.1) REFRESH: IMCI FOR THE SICK CHILD (SLIDE 5)

Briefly review IMCI for the sick child, emphasizing that this section will focus on the first two main
symptoms.
1. What important information do we want to

obtain when greeting the caretaker?
2. Without looking—what are the general danger

signs?
3. What actions do we take with a red

classification?
4. Walk me through the important steps starting

here (ASSESS box)—participant should walk group through assessing and classifying main symptoms
and other conditions, identifying treatment, treating in clinic or advising on home treatment,
counselling caretaker, and providing follow-up care)
In this section, we will look at the first two main symptoms—cough and difficult breathing, and
diarrhoea. You certainly see these symptoms frequently in your clinics.
What questions do we have before we begin?

(3.2) COUGH OR DIFFICULT BREATHING
Let us now look at assessing and classifying our first main symptom—cough or difficult breathing.
You will learn more in Module 3, but this will be an introduction.
1. ASSESSING cough and difficult breathing Classify cough or difficult breathing

Open Chart Booklets to chart on cough or difficult
breathing. Review instructions for assessing.
■ What do we ASK when assessing for cough or
difficult breathing? Does your child have cough or
difficult breathing? For how long?
■ What signs do we LOOK and LISTEN for? Fast
breathing, chest indrawing, and wheeze
■ What is fast breathing in a child? 2-12 months
40/minute, 12 months-5 years 50/minute
2. What are these signs?

This content will be explained in full in Module 3. Let’s briefly review these signs so that we know
what to look for when we practice this afternoon.
Let’s discuss what you already know before we watch a video on assessment. Present questions to
participants and follow-up to explain content as necessary. This discussion should familiarize
participants with signs before they see them in the video.
■ Fast breathing and chest indrawing are two signs of pneumonia.
■ What is fast breathing? The child is breathing faster than she normal should. Describe where
to look when you count for fast breathing.
■ What is chest indrawing in a child? Briefly describe chest indrawing.
■ What is stridor and wheezing? Briefly describe both symptoms and provide examples from
your clinical experience (i.e. to emphasize how harsh stridor sounds).
Identify treatment and follow up
PLAY IMCI DVD “Demonstration: cough and difficult
breathing” (disc 1, 12 minutes)
■ Instructions for participants: follow along with
Chart Booklet and recording form
■ Facilitation: stop video at stages of the
assessment to demonstrate how it is following
the Chart Booklet and recording form
■ After video: ask for questions and explain new
content
Any questions about cough or difficult breathing?
What do we do after we assess and classify cough or difficult breathing, and identify treatment?
We repeat the process for the next main symptom, diarrhoea.

(3.3) DIARRHOEA
Let’s continue to the next main symptom, diarrhoea. You will learn more about assessing and
classifying diarrhoea in Module 4, but we will introduce it today so that we can look for diarrhoea in
the clinic this afternoon.
1. ASSESSING diarrhoea
Open Chart Booklets to ASSESS chart for diarrhoea.
■ What do we ASK when assessing for diarrhoea? Does your child have diarrhoea? For how
long? Is there blood in the stool?
■ What signs do we LOOK for? Look for lethargy, unconsciousness, or if the child is restless or
irritable; look for sunken eyes; look to see how the child drinks fluid
■ What sign do we FEEL for? Skin pinch of abdomen
2. What are these signs?
Let’s briefly review any questions we have about these signs so that we know what to look for when
we practice this afternoon.
■ Why do we do a skin pinch? To test Classify and Treat- diarrhoea
dehydration; briefly explain how to do a
skin pinch
■ Do you have any questions about the
conditions we look for—lethargy,
unconsciousness, restlessness,
irritability? About how the child drinks?
■ How would you describe blood in the
stool if the caretaker is unsure?
Before we watch a video, what questions do you

Classify and Treat- diarrhoea
have?
PLAY IMCI DVD “Demonstration: assess and

classify diarrhoea” (disc 1, 9:30 minutes)
■ Instructions for participants: follow
along with Chart Booklet and recording
form
■ Facilitation: stop video at stages of the
assessment to demonstrate how it is
following the Chart Booklet and DVD Diarrhoea 1
recording form
■ After video: ask for questions and explain new content
Any questions about diarrhoea?

This section introduced us to the first two main symptoms we assess and classify in IMCI. Cough or
difficult breathing and diarrhoea are frequent presentations in our clinics.
We will break for tea.
Then we will move to a clinical setting to practice what we have learned thus far about using IMCI to
manage the sick young infant and sick child.
Reminders and review agenda:
■ BRING your chart booklets and IMCI recording forms (provide extra copies, or ask participants
to bring logbook)
■ REVIEW AGENDA—
o Transportation and transitions, need to keep time
o Describe where you will be seeing patients (i.e. outpatient, inpatient)
o Briefly describe how you will be seeing patients (i.e. demonstrations in small groups,
pairing participants with patients, etc.)
o Outline any expectations for participants
o Group will meet to return for lunch

SECTION 4 – CLINICAL PRACTICE
TIME – 90 minutes in clinic
FACILITATOR SUMMARY
This section is a critical opportunity to see patients with participants, reinforcing integrated case
management and mentoring participants as necessary.
Please refer to the IMCI facilitator guide for outpatient clinical practice and the IMCI guide for
clinical practice in the inpatient ward for guidance on how to facilitate this time in the clinic. These
arrangements will depend on the facility, case load, and prior agreements with the facility or patients.
You may choose to demonstrate key skills, or to assign participants individually or in groups, and then
observe and mentor.
SECTION OBJECTIVES
■ Participants see examples of signs of illness in real children, and gain experience and
confidence in using the skills as described on the case management charts.
■ Demonstrate good skills in managing sick children and young infants according to case
management charts
■ Practice assessing, classifying and treating sick children and young infants, and counselling
mothers about food, fluids, and when to return. This clinical session will particularly reinforce
course content on general danger signs, managing the sick young infant, and symptoms
introduced.
■ Observe and mentor participants’ practice, providing constructive feedback about how well
they have performed each skill and guidance about how to strengthen particular skills.
MATERIALS
(4.1) WHY CLINICAL PRACTICE?

Clinical practice is an essential part of any IMCI course.
Most of the clinical practice in this course will happen at distance, so this practice time with
participants is a critical time to mentor participants in their case management skills and ensure they
can perform them proficiently when they return to their own clinics.
The clinical practice skills should be presented in the order they are being learned in the modules.
Today’s session will concentrate on general danger signs, managing the sick young infant.
Participants will have been quickly introduced to assessing and classifying cough or difficult
breathing and diarrhoea in a sick child.

To make sure that participants receive as much guidance as possible in mastering the clinical skills,
the outpatient facilitator and/or inpatient instructor should give particular attention and feedback to
the skills practiced.
If any participant has difficulty with a particular skill, the facilitator or inpatient instructor continues
working with the participant on that skill in subsequent sessions until the participant can perform the
skill with confidence.
(4.2) OUTPATIENT SESSIONS
Outpatient sessions take place in outpatient clinics. The focus of the outpatient session is to provide
practice of the case management process with sick children and young infants.
Outpatient sessions should begin by demonstration of a case, and demonstrate all steps in the
IMCI process.
In outpatient sessions, participants will:

 see sick children and young infants who have been brought to the clinic by caretakers.
 practice assessing and classifying sick children and young infants according to the ASSESS &
CLASSIFY and YOUNG INFANT charts.
 practice identifying the child's treatment by using the "Treatment" column on the ASSESS &
CLASSIFY and YOUNG INFANT charts.
 practice treating sick children and young infants according to the TREAT and YOUNG INFANT
charts.
 practice counselling mothers about food, fluids, and when to return according to the
COUNSEL chart.
 practice counselling mothers of sick young infants according to the YOUNG INFANT chart.
 practice using good communications skills when assessing, treating and counselling mothers
of sick children and young infants.
2. PRACTICE - if possible, assign participants or small groups to a child. Observe while

participants assess and classify the children.
3. MONITOR - conduct rounds to review the children which participants assess and classify.
Have all participants practice assessing some signs, to give them more practice with severe
signs and signs which are difficult to assess.

(4.3) INPATIENT SESSIONS
Inpatient sessions should also begin by demonstration of a case, and demonstrate all steps in the
IMCI process.
Facilitators or inpatient instructors lead small groups in an inpatient ward. The focus of the inpatient
sessions is to practice assessing and classifying clinical signs, especially signs of severe illness.
During inpatient sessions, participants will:

 see as many examples as possible of signs of severe classifications from the ASSESS &
CLASSIFY and YOUNG INFANT charts, including signs not frequently seen.
 practice assessing and classifying sick children and young infants according to the ASSESS &
CLASSIFY and YOUNG INFANT charts, focusing especially on the assessment of general danger
signs, other signs of severe illness, and signs which are particularly difficult to assess (for
example, chest indrawing and skin pinch).
 practice treating dehydration according to Plans B and C as described on the TREAT chart.
 practice helping mothers to correct positioning and attachment for breastfeeding.
A designated inpatient instructor should lead all inpatient sessions with small groups of participants.
This instructor may be a facilitator, or another colleague requested to assist with the clinical practice
session.
This will change depending on the arrangements for this on-site meeting, and who will be able to do
necessary tasks in the ward before and during the clinical practice session.
Inpatient instructor tasks include:
Prior to practice session, if possible, selecting children with appropriate clinical signs to be assessed by
participants during the session. Also identify any additional children with infrequently seen signs to
show participants.
2. PRACTICE - assign each participant to a child, or small groups. Observe while participants
assess and classify the children.
3. MONITOR - conduct rounds to review the children which participants have assessed and
classified. Have all participants practice assessing some signs, to give them more practice
with severe signs and signs which are difficult to assess.

SECTION 5 – ASSESS & CLASSIFY THE SICK CHILD (PART 2)
TIME – 90 minutes, including a break for tea
FACILITATOR SUMMARY
In this section you will introduce content from forthcoming modules on fever, malnutrition and
anaemia, well child care, and others. While this introduction is brief, it is important that you reinforce
how these symptoms and conditions fit into integrated management of the sick child.
SECTION OBJECTIVES
■ Introduce how to assess, classify, and treat fever and ear problems
■ Introduce how to check malnutrition and anaemia
MATERIALS
□ IMCI DVD (disc 1 and 2)
The following sections 5.1-5.3 introduce content from upcoming modules:

 Fever
 Ear problems
 Malnutrition & anaemia
The content here is brief. However, this is an important opportunity to review the IMCI process
again with each symptom. You should fill in the content with your own observations, or by asking
questions. You should also answer all questions the participants have.
Each section should try to accomplish the following:

 INTRODUCE the symptom or problem: why should you care about this health issue? Why is it
included in IMCI?
 Review the ASSESS instructions
 Review what signs are used to CLASSIFY
 Examine the TREAT THE CHILD and COUNSEL THE MOTHER charts as you require. Share your
own clinical experiences.

 (5.1) ASSESSING FEVER
Fever is another common symptom we see in our clinics.
1. Introduction to fever
■ What can cause a fever in children?
Primary causes are malaria, measles, and Assessing a Child for Fever
other infections
■ How do we determine if a child has a
fever? History, feels hot, temperature 37.5
degrees Celsius or above
■ We decide if the area is high or low risk
for malaria. If more than 5% of fever cases
in child are due to malaria, the area is high
risk. If less than 5% of cases are due to
malaria, the area is low risk. Are we
considered a high or low risk area for
malaria?
2. What signs do we assess for fever?
Review ASSESS chart in chart booklets with participants.
■ What questions do we ASK? Does the child have a fever? For how long? If for longer
than 7 days, has fever been present every day? Has the child had measles within the past
3 months?
■ What do we LOOK and FEEL for? Stiff neck, runny noses, signs of measles (generalized
rash and either cough, runny nose, or red eyes)
■ If the child had measles within the last 3 months or has measles now, let’s look at the
measles chart. What do we LOOK for? Deep and extensive mouth ulcers, pus draining
from eye, clouding of cornea
Let’s see a video demonstration of assessing and classifying fever.
PLAY IMCI DVD “Assess and classify fever” (disc 1, 9:30 minutes)
■ Instructions for participants: follow along with Chart Booklet and recording form
■ Facilitation: ask for questions or needed clarifications after video
(5.2) EAR PROBLEMS

Ear problems are a common problem in children.
1. Introduction to fever
■ Why do we care about ear problems, aren’t they too common to worry about? Can
cause deafness, ear damage, and possible serious infection
■ What is mastoiditis? An infection of the mastoid bone behind the ear, explain this.
2. What signs do we assess for fever?
■ What questions do we ASK? Does the child have drainage from ears? For how long? Is
there ear pain?
■ What do we LOOK and FEEL for? Tender swelling behind ear, discharge/pus from ear
(5.3) CHECKING FOR MALNUTRITION & ANAEMIA
We learned in the first face-to-face meeting that undernutrition is an underlying cause of death in up
to 50% of all child deaths.
You should assess every child for malnutrition and anaemia. There are important signs of
undernutrition that we or the caretaker might not notice. Even children with mild and moderate
malnutrition have an increased risk of illness and death.
1. What is malnutrition?
■ Why are children malnourished? They are not receiving adequate essential vitamins and
minerals. When children are suffering from protein-energy malnutrition means they are
not getting enough energy or protein from their diet, which affects their growth and
development
■ What is anaemia? Anaemia is a deficiency of one of these essential nutrients, iron.
Children can also develop anaemia as a result of infections, malaria, or parasites that can
cause blood loss from the gut, like hookworm.
2. What signs do we assess for malnutrition?

■ What do we LOOK for? Visible severe wasting, oedema of both feet—both to be
described in video
■ We also need to determine weight for age. You learned this in the sick young infant
module, but there are separate charts for children. Find your weight-for-age charts in the
Annex. There is a chart for boys, and one for girls. Who can explain to the group how to
find weight-for-age?
■ Let’s practice charting weight-for-age.
 Girl, 14 months, 13 kg—healthy weight
 Boy, 8 months, 6.4 kg—low weight, close to very low weight
 Girl, 4 and a half years old, 12 kg – very low weight
2. What signs do we assess for anaemia?

■ What do we LOOK for? Pallor palmor—to be discussed in video
PLAY IMCI DVD “Assess for malnutrition, anaemia, and ear problems” (disc 2, 8:30 minutes)

■ Instructions for participants: follow along with Chart Booklet and recording form
■ Facilitation: ask for questions or needed clarifications after video
(5.4) Now let’s practice what we know up to now in IMCI for the sick child.
PLAY IMCI DVD “Case study: Jenny” (disc 2, 15:50 minutes)

■ Instructions for participants: follow along with your Chart Booklet and fill out a recording
form for the sick child
■ Facilitation: tell participants to disregard ear problems, or fast forward. Stop video before
classification begins at 9:50.
Ask participants to discuss classifications with a partner for 1 minute. Then bring group
together to discuss their classifications and any problem areas. Make sure you look for
confusion as you discuss classifications (i.e. who has something different? Where are we
confused?). Once group has discussed, play video classifications.

We have now been introduced to all of the main symptoms and conditions we assess and classify in
sick children.
We will now review what we do after assessing, classifying, and identifying treatment.
This section introduced us to the first two main symptoms we assess and classify in IMCI. Cough or
difficult breathing and diarrhoea are frequent presentations in our clinics.
We will now move to practice in a clinical setting what we have learned thus far about managing the
sick child and sick young infant with IMCI.
(5.6) BREAK FOR TEA – 15 MINUTES

We will now break for tea, then return to discuss the other modules we will cover in our self-study.

SECTION 6 – INTEGRATING TREATMENT, COUNSELLING THE CARETAKER, AND
FOLLOW-UP
TIME – 30 minutes
FACILITATOR SUMMARY
The day’s content has focused on assessing and classifying. This section should reinforce treatment
for integrated case management, counselling the caretaker, and providing follow-up care. This
discussion should ensure that participants are confident to utilize the IMCI algorithm in its entirety
during their clinical practice in home facilities.
SECTION OBJECTIVES
■ Reinforce instructions in the TREAT THE CHILD charts
■ Review key counselling skills, particularly the 3 steps when teaching a caretaker, and using
checking questions to ensure that they understand
■ Review how to manage a child during follow-up care
MATERIALS
□ Flipchart
□ Tray with medicines
□ Worksheet on dosages (included in this section)

(6.1) LET’S RETURN TO THE JENNY CASE STUDY
Take out your recording forms from the last video exercise we did with Jenny.
1. We assessed and classified Jenny for general danger signs, main symptoms, and other
conditions. What do we do next? Record steps on FLIPCHART.
■ Identify treatment based on each classification
■ Decide on appropriate treatment for Jenny, and where it should be given—referral, in
clinic, at home.
■ Where would Jenny be treated, according to our classifications?
■ Can someone give an example of one treatment she will require, and for what
condition?
■ Counsel the caretaker. What are two things we would counsel Jenny’s mother about?
■ Provide follow-up care. When should Jenny return for follow-up?
2. Final section of the day, we will review how to use IMCI to: (SLIDE 6)
■ TREAT THE CHILD
■ COUNSEL THE CARETAKER,
and
■ PROVIDE FOLLOW-UP CARE

(6.2) TREATING THE CHILD
Review TREAT THE CHILD charts with participants, and talk through examples as time allows.
1. Let’s consider one of Jenny’s classifications. Someone pick a classification and identify the
treatment for us.
Let’s turn to our TREAT THE CHILD section in the Chart Booklet and review this treatment.
2. Several classifications identify antibiotics for treatment. Let’s look more closely at antibiotics.
The TREAT THE CHILD chart indicates the schedule and dose for giving the antibiotic.
■ What is the schedule? The schedule tells you how many days and how many times each
day to give the antibiotic. Most antibiotics should be given for 5 days.
■ How do you determine an antibiotic dose with this chart? Look at the column that lists
the concentration of tablets or syrup available in your clinic. Choose the row for the child's
weight or age. The weight is better than the age when choosing the correct dose. The
correct dose is listed at the intersection of the column and row.
Some children have more than one illness that requires antibiotic treatment. What do you think we
should do in this situation?
Let’s review some treatment guidance:
■ When possible, select one antibiotic that can treat all of the child's illnesses.
For example, let’s consider a child with DYSENTERY and ACUTE EAR INFECTION.
Cotrimoxazole is a first-line antibiotic for an ACUTE EAR INFECTION and also a first- or
second-line antibiotic for DYSENTERY.
When treating a child with more than one illness requiring the same antibiotic, do not
double the size of each dose or give the antibiotic for a longer period of time.
■ However, sometimes more than one antibiotic must be given to treat the illness(es).
For example, the antibiotics used to treat PNEUMONIA may not be effective against
DYSENTERY in your country. In this situation, a child who needs treatment for DYSENTERY
and PNEUMONIA must be treated with two antibiotics.

Remember that the colour-coded classifications tell us where the child should be treated.
3. Some treatments are given specifically in the clinic—let’s review these treatments.
These treatments are often required when a child has a severe classification and must be referred
urgently.
■ Intramuscular antibiotic if the child cannot take an oral antibiotic

■ Diazepam to stop convulsions
■ Quinine for severe malaria
■ Breastmilk or sugar water to prevent low blood sugar
What should we do before giving these treatments—these instructions are on the TREAT chart?
Explain to caretaker why treatment is given, determine appropriate dose and measure accurately, use
sterile needle and syringe for injection
4. Other treatments can be given in the home. What types of treatments can be given at the
home? Oral drugs, treating local infection
These treatments require good counselling skills with the caretakers.

(6.3) ACTIVITY: practice preparing oral and intramuscular drug dosages
Participants will be asked to show you the proper dosages of drugs. They will use the
worksheet on the following page.
PREPARATIONS
■ Prepare a tray with an assortment of drugs.
■ Have copies of worksheet (on next page) ready for distribution
*DISTRIBUTE WORKSHEET*
INSTRUCTIONS TO PARTICIPANTS
Introduce activity: let us look at this worksheet together. You will see several scenarios of children
that need medications. You will their age and weight to calculate dosage.
You will use the drugs on this tray to prepare the dosage, and set it into the box of your worksheet.
■ First, take note of any tablets that look similar and could cause confusion when one or more
drugs are dispensed.
Do we see any drugs that are similar? What can we do to make sure this is not confusing
to us, or to caretakers?
■ Prepare the doses as indicated on the following page. You will have 10 minutes.
For intramuscular drugs, dilute the powder with sterile water and draw up the correct
amount in the appropriate syringe.
■ Place each dose in the space provided on the page.

Ask one of the facilitators when you are ready to have your dosages checked.

WORKSHEET - DOSAGES ACTIVITY (REVIEW & PRACTICE MEETING)
Name
Instructions: Use the TREAT THE CHILD section of your Chart Booklet. Place the actual dose in
each box.
a. Anele is 5 kg in weight and needs to
receive paracetamol for the
classification “Fever for other cause”.
Please define and demonstrate the
dosage to be taken and the frequency
of doses.
c. Sipiwo is 6kg in weight and needs to

receive the 1st dose of cotrimoxazole
for the classification “Severe
pneumonia”. Please define and
demonstrate the dosage to be taken and
the frequency of doses.
d. Nomonde is 3.5kg and has general

danger sign “Convulsing” for which
she should receive diazepam. Please
define and demonstrate the dosage to
be taken and the mode of
administration.
f. Sam is 18kg in weight and needs to

receive paracetamol and iron for the
classifications “Anaemia” and “Fever
other cause”. Please define and
demonstrate the dosage to be taken and
the frequency of doses.

(6.4) COUNSELLING THE CARETAKER
We discussed good communications and counselling skills in our first meeting, and you have read
more about this in your books.
Let’s quickly review how we counsel the caretaker.
1. What are some examples of what we counsel a caretaker for? Home treatment, feeding practices,
keeping an infant warm, making ORS, etc.
2. When we advise a caretaker, sometimes we have to teach them how to do a particular task.
What are the 3 basic teaching steps? Record steps as a flow chart on FLIPCHART.
■ GIVE INFORMATION
What are some important things to keep in mind when giving information?
Use words caretaker understands, do not overwhelm with too much information, affirm
■ SHOW EXAMPLE
What are some important things to keep in mind when showing an example?
Use visual aids that are common in the household
■ LET CARETAKER PRACTICE

What are some important things to keep in mind when he/she practices?
Affirm during practice, give feedback, give more practice if required
3. What should we do when checking that a caretaker understood us? Use checking questions
Give me 5 examples of good checking questions. Write key words (why, how, when, where) on
FLIPCHART to emphasize asking open-ended questions.

4. What happens when the case is complicated and you need to give the caretaker a lot of
information? (SLIDE 7)
One important thing we counsel the caretaker about is when to bring the child back to the clinic for
follow-up, or when to return to the clinic immediately.
Let’s review how we use IMCI during the follow-up visit.

(6.5) PROVIDING FOLLOW-UP CARE
Open to the charts on follow-up care in the TREAT THE CHILD section.
1. What are the steps when in follow-up care? What do we want to accomplish? (SLIDE 8)
2. Let’s look at one of Jenny’s conditions – how will we provide follow up care? What are the
steps?

We have completed reviewing IMCI for the sick child. Return to SLIDE 6.
We will now finish our day by reviewing what you will be doing in the upcoming self-study phase, and
when we will meet to conclude the course.

TIME - 30 minutes
FACILITATOR SUMMARY
This section will review the course calendar and expectations for the second self-study learning phase.
At the conclusion of this section, you will administer an evaluation of the day.
OBJECTIVES
■ Reinforce course structure and expectations for the upcoming self-study phase—completion
of remaining modules, practice in clinics and use of recording forms, identifying mentors and
communicating with in-charge officers
MATERIALS
□ Evaluation handout

(7.1) REVIEW UPCOMING SELF-STUDY PHASE 2
1. Review what is expected during the following several weeks of self-study:

■ Complete all modules – read and do written and DVD exercises (SLIDE 9)
Let's review a sample agenda for your self-study (SLIDE 10)
■ Practice content in clinics and use recording forms. Review instructions for using logbook and
recording forms.
■ Bring several recording forms to the next meeting that demonstrate examples of integrated
management for:
a. Sick young infant
b. Sick child—for each symptom, and also for full assessment of child
■ Work with mentors, colleagues, and in-charge officers
■ Meet with study groups

What questions or concerns do you have about these tasks? Are there any issues to discuss?

(7.2) DEVELOPING OUR STUDY PLAN (SLIDE 10)
Based on feedback from morning plenary, discuss how participants should develop a study plan to
pace their work.
Let's take 15 minutes and develop an agenda for our group learning.
Participants should divide into groups and discuss study agenda. Monitor groups and answer
questions.
(7.3) REVIEW PLANS FOR 3RD FACE-TO-FACE MEETING (SLIDE 12). Participants should take out the
calendars in their study modules to fill in dates.
NEXT MEETING:
Review and Practice 2
 DATE _____________________________
 LOCATION _____________________________
 TO BRING COMPLETED –
 All modules
 Logbook exercises for all modules
 Recording forms with examples from clinic
 AT THE NEXT MEETING WE WILL -

 Practice IMCI in clinical setting
 Review content from main symptoms and conditions
 Introduce the next modules (8 – HIV and ART/ TB /

Immunisation)
What questions do we have about our next steps or this meeting?

(7.4) EVALUATION
Lead a discussion in the group to gather feedback on the day's content, presentation, and clarity.
We recommend that facilitators ask participants for feedback on specific topics before giving a
printed evaluation. Conversational evaluations can also provide useful information that is not
included in a written evaluation.
*DISTRIBUTE EVALUATION FORM*
CLOSE MEETING
Affirm participants' engagement in the course and practice thus far.
Provide time for participants to complete the evaluation and hand in.
As participants finish the evaluation, check in with them to make sure each is feeling comfortable
about their self-study, and if you can answer any individual questions.

PART FOUR
Review & Practice 2
3rd face-to-face meeting
Consolidating Modules 3, 4, 5, 6 & 7

Introducing Module 8.

1.1 INTRODUCTION
Welcome to MODULE 8 of the distance-learning course for Integrated Management of Childhood
Illness (IMCI). This module focuses on HIV/AIDS care for children and young infants.1
HIV infection is very common in children in South Africa. It is estimated that HIV accounts for about
one third of deaths in children below five years of age. Preventing HIV infection in children is
therefore the best way to reduce child mortality rates in South Africa. This can be done through
prevention of primary infection (in adults) and through prevention of mother-to-child transmission of
HIV.
How can deaths be prevented in HIV infected children?

Important interventions to reduce the risk of children dying from HIV includes:
1. Early diagnosis of HIV
2. Initiation of Antiretroviral Therapy (ART) In South Africa,
3. Initiation of other prophylaxis and treatments
HIV accounts for
Children less than one year of age (also known as infants) are most at
an estimated 30%
risk of developing serious complications and dying from HIV infection –
therefore it is most important that these children are identified, and of all deaths in
placed on treatment as early as reasonably possible. children under five
years of age.
How has South Africa included HIV in IMCI?
South Africa was one of the first countries to include assessing and
classifying HIV infection in the IMCI case management process and chart booklet. The 2009 version
of IMCI required that consideration be given to the HIV status of every sick child who is seen at a
Primary Health Care (PHC) facility. IMCI provided instructions for follow-up of children who were
HIV-exposed and children who tested positive for HIV infection. However it did not include ART--
children who needed ART were referred to Comprehensive Care, Management, Treatment and
Support (CCMTS) sites
The 2011 version of IMCI, which is used in this course, has added ART. This is an important change
that happened because:
■ The eligibility criteria for starting ART were changed. Most importantly, all HIV-infected
infants (children less than one year of age) should be started on ART.
■ It is planned that ART should be provided at all health facilities in South Africa, including
PHC facilities. This means that professional nurses will need to play an important role in
initiation and follow-up of children (and adults) on ART.
■ Treatment regimens changed–stavudine is being phased out in initial care due to it’s side-
effects.
■ There have been important changes to the PMTCT guidelines. Most important for IMCI is
that all HIV-exposed infants will receive nevirapine after delivery for at least six weeks, which
has an impact on infant feeding.
1
This module has drawn its material from the IMCI Complementary Course on HIV/AIDS.
1.2 OBJECTIVES & STRUCTURE
What are the objectives of this module?

At the end of this module, participants should know how to:
■ Create some completion of the processes learnt up to the end of

modules 7.
■ Identify and respond to problems experienced by the learners.
■ Explain in basic terms how HIV affects the immune system, and how
children are infected with HIV
■ Assess and classify a child for HIV
■ Assess and classify a young infant for HIV
■ Counsel an HIV positive mother about feeding
■ Communicate effectively with the HIV positive mother, counsel the
mother of an HIV exposed child about her own health and taking her
child for an HIV test
■ Describe how to manage common acute illnesses in young infants and
children classified for HIV/AIDS
■ Prevent common illnesses in infants and young children classified for
HIV, through co-trimoxazole prophylaxis, nevirapine prophylaxis,
immunization, and Vitamin A supplementation
■ Describe the WHO paediatric clinical staging process
■ Explain the recommended ARV regimens for children, the possible side
effects of ARV drugs, and the management of possible side effects
■ Counsel the caregiver on ART adherence
■ To initiate an appropriate child on ART and provide good follow up if
this is in the scope of practice for that practitioner at that care site

How is this module structured?
As a facilitator you will convene two further face-to-face meetings—an module 8 orientation and a
synthesis (for the whole course including Modules 1-8) meeting about 4 weeks later. During this
period, participants are expected to study the module at home, practice in their home clinics, meet
with study groups, and seek mentors.
During the first face-to-face meeting, discuss the course calendar with your participants. Fill in the
meeting locations and dates in the calendar below.
MODULE CALENDAR (1 MONTH)
Sessions Objectives Location Date
REVIEW AND 1. Review & practice IMCI process
PRACTICE 2 2. Distribute ART recording forms __________
_________
3rd face-to- 3. Introduce HIV module content Meeting
4. Practice in clinic with group (1 day)
face meeting place
1. Read module
2. Complete self-assessment exercises as you
read
SELF-STUDY 3. Practice in clinic
PHASE 4. Record cases on IMCI recording forms and Home 3-4 weeks
Module 8 ART initiation/follow-up forms facilities total
5. Hold study group discussions
6. Maintain contact with mentors &
facilitators
7. Complete assessment exercises in logbook
1. Review cases from clinical practice during
FINAL
self-study
SYNTHESIS __________
2. Review HIV module content _________
4th face-to- Meeting
3. Practice in clinic with group (1 day)
face meeting place
4. Course assessment

What materials will you require to facilitate this course?
1. THIS FACILITATOR’S GUIDE

This facilitator guide provides key information for each meeting. There is more information
about this guide on the following page.
2. POWERPOINT PRESENTATION SLIDES FOR EACH FACE-TO-FACE MEETING

PowerPoint slides are designed as a training tool during your meetings with participants.
However, do not rely heavily on these slides. They are meant to provide visuals and key
points only. These may be used as slides, may be printed as participant materials, or both.
In settings where a projector or computer screen is not available, photocopies of key slides
should be provided to participants.
3. PARTICIPANT MATERIALS FOR DISTRIBUTION
A. SELF-STUDY MODULES—Participant self-study modules should be bound in a book.

The introduction to this book will include a review of the IMCI process and course
overview. This content will be covered during the Orientation meeting.
B. LOGBOOK—The logbook should accompany the study modules. The logbook includes
written exercises and recording forms that should be completed during the self-study
phases. The logbook will be submitted during the face-to-face meetings for the
facilitators to review.
C. IMCI CHART BOOKLETS
D. ART CHARTS (CHART BOOKLET SUPPLEMENTATION)
E. IMCI RECORDING FORMS
F. ART INITIATION FORMS
G. ART FOLLOW-UP FORMS

MEETING OBJECTIVES
BY THE END OF THE FIRST FACE-TO-FACE MEETING, PARTICIPANTS WILL:
√ Explain and demonstrate IMCI clinical process with sick children and
young infants
√ Demonstrate good use of IMCI charts and recording forms in clinical
practice
√ AND
√ Explain how HIV affects the immune system
√ Explain how children are infected with HIV
√ Assess and classify a child for HIV
√ Assess and classify a young infant for HIV
√ Understand the key feeding options and recommendations for HIV-
positive mothers
√ Counsel an HIV positive mother about feeding
√ Describe measures to prevent common infections in children with HIV
√ Explain what ART does
√ Explain when children should be initiated on ART
The third face-to-face meeting will bring together several months of working with these course
participants and introduces the 8th module (HIV and ART in Children)
The facilitator seeks problems / challengest that have arisen, received and assesses the logbook taks,
briefs them on the objectives / structure of module 8, reviews HIV/AIDS, and introduces the use of
IMCI in managing HIV.

8:30—9:00 REGISTRATION PLANNING NOTES

INTRODUCTION & REVIEW OF IMCI (15 minutes)
Review module objectives and structure. Facilitate brief
review of IMCI process and integrated management.
9:15 – 9:35 SECTION 2a PLANNING NOTES
REVIEWING SELF-STUDY PHASE 2 (20minutes)
Plenary discussion about self-study experiences, and
problem solving around difficult cases from clinical practice.
09:35 – SECTION 2b PLANNING NOTES
09:50 INTRODUCING HIV/AIDS (15 minutes)
Review of HIV/AIDS epidemiology and transmission.
ASSESSING & CLASSIFYING HIV STATUS (50 minutes)
Explain testing methods and interpretation. Reinforce use
of chart booklet for assessing and classifying HIV. Include
video case study for assessing and classifying.
10:40 –10:55 Tea break (15 minutes)
11:00 – SECTION 4 PLANNING NOTES
12:30 CLINICAL DEMONSTRATION & PRACTICE (90 minutes)
Demonstrate assessing and classifying HIV status, and
facilitate small group practice. And also any IMCI
Classification that arise
12:30 - 13:15 Lunch (45 minutes)
INFANT FEEDING (60 minutes)
Reinforce feeding options and practice with roleplays.
14:15 – SECTION 6 PLANNING NOTES
14:45 TREATMENT & PREVENTATIVE PROPHYLAXIS (30 minutes)
Review preventative measures and treatment for children
identified as HIV-exposed or infected. Exercises on
treatment.
INTRODUCING ART (60 minutes)
Introduce ART and use of chart booklet and recording forms
for initiating ART and follow-up.

This is a checklist of suggested materials for the day. In this guide, each section of the meeting
details which of the materials below are required for that particular section.
MATERIAL NUMBER  LIST
FOR FACILITATION
Facilitator guide 1 per facilitator
PPT slides 1 electronic file
IMCI DVD 1 DVD (2 discs)
IMCI Guide for Clinical Practice in Inpatient Ward 1 per facilitator
IMCI Guide for Clinical Practice in Outpatient Ward 1 per facilitator
Projector and/or computer screen (for viewing) 1
Laptop 1
Clock or stopwatch (timekeeping, best if visible to all) 1 per facilitator
Flipchart or large paper 5-10 sheets
Flipchart markers As required
Tape (for hanging papers or displays) As required
IMCI wall chart (optional wall display) As required
Roleplay props, models, or other display materials As required
FOR DISTRIBUTION*
Registration forms (sample in ANNEX) 1 per participant
Name tags or displays 1 per participant/facilitator
Contact information sheet (compiled from 1 per participant/facilitator
registration)
Self-study modules (printed and bound) 1 per participant/facilitator
Logbook (printed and bound) 1 per participant/facilitator
IMCI Chart Booklet (preferably national adaptation) 1 per participant/facilitator
IMCI DVD (for take-home study) 1 per participant/facilitator
IMCI Recording Forms – Sick Young Child, Sick Child, Copies as necessary
ART initiation – the 6 steps, ART follow up – the 7
steps.
Meeting handouts (for all activities) 1 per participant/facilitator
Meeting evaluation form 1 per participant
Notebook 1 per participant/facilitator
Pens or pencils 1 per participant/facilitator

Tea (morning and afternoon) and lunch supplies As necessary
* Materials should be ready and available for distribution at points during the day. When the
facilitator distributes a particular material, s/he must explain the content in full to the participants.
Logbooks And any additional notes taken
Recording forms - all modules At least 5 completed at home clinic

REGISTRATION
All participants should check-in to confirm their attendance. Distribute the registration form to
collect valuable information on the participant’s experiences during self-study.
MATERIALS FOR DISTRIBUTION AT REGISTRATION (or ready at place settings)

 Notebook or paper for notes
 Day’s agenda
 Registration form

 Modules
 Logbooks
 ART charts
 Copies of recording forms—IMCI form, ART initiation, ART follow-up
 Printed PPT slides, if distributing
 Meeting activity handouts
 List of participants with contact information (prepared during day and distributed by
closing)
EQUIPMENT PREPARATIONS
using 1 laptop for both, it is best to have both programmes are open and prepped. It is
more time efficient to minimize one programme and open the other.

SECTION 1 – WELCOME & REVIEW OF IMCI AND INTRODUCTION HIV/ART
Module
TIME - 15 minutes
FACILITATOR SUMMARY
You will facilitate re-introductions of the facilitators and course participants, and welcome the group
to the 3rd face to face meeting. You will review the course objectives and outline the day’s objectives
and activities particularly the introduction of the HIV/ART Module
SECTION OBJECTIVES
■ Review course objectives
■ Introduce HIV module within context of distance learning course
■ Explain module structure
■ Introduce meeting objectives and brief agenda for the day, especially the assessments
MATERIALS
□ Flipchart

Welcome participants to final face-to-face meeting, which is an opportunity to summarize the
distance learning experience, and assess and practice IMCI skills.
1. Introduce yourself and co-facilitators, describing:

 Your clinical background
 Your experience with IMCI and HIV/AIDS care for children
 Your relevant experience as a trainer and mentor
 How you will serve this role as a course facilitator

 Name
 One way this course has changed the way you are practicing in your clinic
 One challenge, or a question, from practicing IMCI in your clinic

Participants should follow along in books PART 2, section 2
ASK of participants:
 How do you feel about where you're at with these objectives?
 What areas are you feeling weak?

Briefly review what components of the course have been completed.

Additional
Modules in future
new information
3-4 6-8 4 weeks

weeks weeks

Work with mentors


1. Review objectives of the third face-to-face meeting (SLIDE 4)
to stay on task
■ This morning we will review our experiences in the past few weeks with self-study. You will
also meet individually with a facilitator to review your logbook and discuss your clinical
practice. Your logbook exercises and recording forms will be assessed.
■ In the afternoon you will be assessed on your IMCI skills. You will be assessed in skills
stations and a written examination.
■ We will finish the day with a celebration as we award your certificates of completion.
 Meeting runs until 4:30pm.

particularly challenging– so do not be afraid to ask questions.
■ Today is our last opportunity together to review important points in integrated treatment and
case management. Please share your clinic experiences.

■ In the afternoon you will be assessed on your skills in IMCI through skills stations and a
written examination. You will also be assessed based on your logbook exercises and the
recording forms you brought from clinical cases.

We’ll begin by reviewing our self-study and practice like we did last meeting. This is an important
time to address any issues or challenges.

(1.2) REVIEWING THE IMCI PROCESS
3. WHAT IS IMCI?
IMCI is a strategy for integrated case management for the most common symptoms and
conditions that cause illness and death in children under 5 years of age.
4. Briefly re-orient participants to the IMCI process (SLIDE 2)

(1.4) MODULE OVERVIEW
Direct participants to follow along in PART 2 Course Overview of their books.
5. Review objectives of this module (SLIDE 3)
6. Review module structure and provide dates for calendar - (SLIDE 4)

_________
3rd face-to-face • Introduce content from upcoming Meeting place
(1 day)
 Read modules
as you read
Self-study phase 3
 Hold study group discussions (3-4 week)
facilitators
logbook
meeting 3 (1 day)
____________
4th face-to-face  Provide clinical practice _________
Meeting place
meeting  Individual action plans for continued (1 day)
Can be on site
learning
 Course assessment (skills stations and
written exam)
Convenient
Clinical Summative weeks after 4th face to face to see PHC _________
local venue
with patients
assessment

7. Reiterate objectives for today’s Orientation meeting (SLIDE 5)
(1.5) WHAT IS REQUIRED FOR EFFECTIVE DISTANCE LEARNING?

√ Significant motivation, time, and energy
√ Practice in your home clinic, using IMCI tools like the chart booklets and recording forms
√ Involving others in their study. Participants should reach out to mentors, study group
members, colleagues, and in-charge officers. Much learning happens through feedback and
problem solving together.

 Review facilities in this building - toilets, phone and computer access

We’ll begin our day by quickly discussing what HIV is and how children are infected. We will also
discuss why HIV is included in IMCI.

SECTION 2a – REVIEWING THE SELF STUDY PHASE 2 (20min)
2.1) INTRODUCTION – OUR REFLECTIONS ON SELF-STUDY

■ This is an opportunity to share your experiences with the self-study modules, clinical practice,
■ Facilitators not leading the discussion will call participants out for individual discussions about
their self-study experience and their recording forms.
Record key points of discussion on FLIPCHART

below.
■ Module content: what were your experiences reading and doing exercises in these modules?
What components of the modules did you find particularly useful (e.g. written exercises,
content format, DVD exercises, review questions)?
Chart Booklets and recording forms? What is challenging about integrating the material in the
clinic? Where are you facing problems?
(2.4) ADDRESS PROBLEM AREAS

■ What problem areas identified and solutions reached as group, or areas still outstanding.
self-study.

SECTION 2b – INTRODUCING HIV/AIDS
TIME - 15 minutes
FACILITATOR SUMMARY
In this section, facilitators will introduce review HIV in simple terms. so that participants can, by the
end of this brief session, be able to explain in simple terms how HIV affects the body, and how
children are infected.
OBJECTIVES
■ Explain how HIV damages the body, in a way that participants can use to explain to caretakers
and children
■ Explain how children infected with HIV
MATERIALS
□ Powerpoint slides
□ Flipchart
(2.1) WHAT IS HIV?

√ Define HIV
√ National and regional prevalence/impact
√ Other
(2.2) WHAT DOES HIV DO ONCE IT IS IN THE BODY? (SLIDE 6)

(2.3) HOW DOES HIV ATTACK THE BODY AND DAMAGE THE IMMUNE SYSTEM? (SLIDE 7)
(2.4) GROUP EXERCISE: HOW DO WE DEFINE THESE IMPORTANT TERMS? (Record on FLIPCHART)
√ CD4 cell
Answer: A CD4 cell is a special type of white blood cell in the body that helps to fight against
infection. The CD4 cell has a special receptor on its surface called the CD4 receptor. The HIV
virus attaches to this receptor to enter the white blood cell.
√ Immune system
The immune system is the body’s defence system to fight infection. White blood cells form
part of the human immune system.
√ Opportunistic infection
An opportunistic infection is an infection that causes disease only in people whose immune
system is not functioning well. Thus an opportunistic infection will not cause illness and
disease in healthy people. Oral thrush and tuberculosis are examples of opportunistic
infections.
What questions do we have before moving on?

(2.5) GROUP QUESTION: HOW DO CHILDREN BECOME INFECTED WITH HIV?
1. Record participant answers on FLIPCHART

2. For each response, ask: what do you think is the risk of this transmission? Do all children
born to HIV-positive mothers get infected with HIV? Do all children breastfed by HIV-
positive mothers get infected with HIV?
3. Review the actual risks (SLIDE 8)
What questions do we have about transmission to children? Ensure that participants understand
the concept of risk.
■ HIV in the body: CD4 cells protect the body. HIV invades the body by entering CD4 cells and
making new copies of itself. It uses the CD4 as a factory for more HIV. Once CD4 cells are
damaged, the body is less able to defend itself. It becomes vulnerable to common illnesses
like cough, diarrhoea, and others.
■ Transmission to children: most common way is from mother-to-child
■ MTCT: can occur during pregnancy, labour, delivery, and breastfeeding.
■ PMTCT: there are important interventions to reduce the risk of MTCT. If 20 mothers deliver
babies, and they do not have any interventions, about 7 babies will be infected with HIV.
Now we will learn about using IMCI for HIV. We will learn how to assess and classify HIV status in
children and young infants using the same IMCI process.

SECTION 3 – ASSESS & CLASSIFY HIV STATUS
TIME – 60 minutes
FACILITATOR SUMMARY
You will explain how HIV fits into the IMCI process, and why HIV is important to be included in IMCI.
You will review testing methods, signs to assess for, and classifications. You will facilitate
opportunities to practice with written case studies.
OBJECTIVES
■ Emphasize the age specificity of testing methods
■ Clarify when a child can be confirmed positive in South Africa
■ Review how these tests are used in ASSESS a sick child or infant
■ Explain the signs used to ASSESS a sick child or infant
■ Explain classifications
■ Provide opportunities to practice in written exercises and cases
MATERIALS
□ Copies of IMCI recording forms (child and sick young infant) – distribute before you begin
□ Roleplay handouts (if necessary – enclosed in this section)
□ Flipchart

(3.1) WHY HIV IN IMCI?
In the last section we learned about how HIV affects the body. We have all seen the widespread
results of HIV in South Africa.
Why is HIV included in IMCI? (SLIDE 9)
What if I already see adults who have HIV. What makes HIV/AIDS care for children different?
(SLIDE 10)

(3.2) WHERE DOES HIV FIT INTO IMCI for the sick child?
1. FOR THE SICK CHILD: You’re learned the IMCI process for the following signs and symptoms. Here
is where HIV fits. Walk through IMCI process. (SLIDE 11)
Open your chart booklets. Show participants where the HIV charts begin.
2. REVIEW IMCI RECORDING FORM. Show where HIV is recorded (SLIDE 12)
*COMPLETE THE SAME DISCUSSION FOR THE SICK YOUNG INFANT – SLIDE 13 and SLIDE 14

(3.2) HIV TESTING
1. When you begin your assessment, the first thing you will ask is if the child or infant has already
been tested for HIV (SLIDE 15)
2. What are the types of tests? (SLIDE 16)

As you review, emphasize the specificity to age and breastfeeding.
3. When can you confirm a child’s status? (SLIDE 17)

As you review, emphasize the specificity to age and breastfeeding. Explain very clearly the national
testing procedures.

4. TESTING EXERCISE (SLIDE 18)
Give participants a few minutes to answer the questions on their own. Discuss results as group.
ANSWERS:
1. YES – Viral particles have been detected in this
baby’s blood.
2. NO – the antibodies may have come from the
mother. The antibody test will have to be
repeated after 18 months and at least 6 weeks
after breastfeeding stops. If it is still positive at
this stage, then the baby is positive. A virological
test can be done at least 6 weeks after
breastfeeding stops and at any age. If this
virological test (done at least 6 weeks after
breastfeeding stops) is positive then the baby is confirmed HIV positive.
3. YES – maternal antibodies should have disappeared by the age of 18 months; hence the antibody
test at age 18 months is measuring antibodies developed by the child and this means that he is
HIV infected.
4. YES – the virological tests did not measure any viral particles in the blood of the baby and the
baby was not exposed to virus during the previous 3 months; hence there is no chance that he is
still developing an infection.
5. NO – although the antibody test did not detect antibodies to HIV the child was last exposed to HIV
infection one week ago and may still have acquired an infection during that time. The antibody
test will have to be repeated in 5 weeks time (i.e. 6 weeks after breastfeeding stops) to determine
whether the child is truly HIV uninfected.

(3.3) ASSESS & CLASSIFY THE SICK CHILD FOR HIV
Review the ASSESS and CLASSIFY charts in full. Provide clinical experience, stories, or examples to
illustrate clinical signs used to ASSESS.
1. Open your ASSESS charts for the sick child to HIV. What do you observe? (SLIDE 19)
2. If the child has a test result: review the charts. Ask probing questions of participants.
3. If the child does not have a test result: review the charts. Ask probing questions of participants.

4. CASE STUDY EXERCISES: Walk through the case studies below. Give participants time to read
each section and discuss responses. Then show the results. (SLIDE 21 and SLIDE 22)
The slides’ text appears in 3 segments. The first ASSESS-CLASSIFY will show on the slide.
When you want to show results, click once and the second segment will appear. After the
second visit has been discussed, click once more and the final classification will appear.
CASE STUDY: THABO
Thabo is a 14 week old boy who comes to the clinic for his routine immunizations.
His mother was part of the PMTCT programme, but Thabo has not been tested
for HIV infection. Thabo is well, and has no features of HIV infection.
How will you classify Thabo?
You classify him as HIV EXPOSED. You counsels his mother regarding an HIV
test for Thabo, and his mother agrees that he should be tested. A PCR test is
sent, and you request his mother to return in two weeks to get the result. You
start Thabo on cotrimoxazole prophylaxis.
Thabo’s mother returns after two weeks. The PCR test is negative. The health
worker asks about feeding, and Thabo’s mother says that she breastfed him
until he was four weeks old and then stopped. He has not had any breastmilk
since then.
How will you now re-classify Thabo?
Because Thabo had stopped breastfeeding more than six weeks before the
test was done, you classify as HIV NEGATIVE. You will stop the cotrimoxazole
prophylaxis. (But remember Thabo’s mother still needs care herself)
CASE STUDY: NANDI

Nandi is 9 months old. Her mother is HIV positive, but Nandi has never been tested
for HIV. Her mother brings her to the clinic with a history of cough and fever. You
assess her as having PNEUMONIA, CHRONIC EAR INFECTION, NOT GROWING
WELL and NO ANEAMIA. She has no thrush or parotid enlargement, but has some
lymph nodes in her groin, neck and axillae.
How will you classify Nandi?
Because she has at least four features of HIV infection (PNEUMONIA now, ear
discharge, unsatisfactory weight gain and enlarged lymph nodes) she is classified as
having SUSPECTED SYMPTOMATIC HIV INFECTION. She needs to be started on
cotrimoxazole prophylaxis.
After counselling her mother agrees to have Nandi tested for HIV infection. You send
a PCR test. Nandi comes back after a week—her PCR test is positive.
How will you now re-classify Nandi?
You now classify as HIV INFECTION. She should be initiated on ART using
the six steps.
(3.3) ASSESS & CLASSIFY THE SICK YOUNG INFANT FOR HIV
Review the ASSESS and CLASSIFY charts in full. Provide clinical experience, stories, or examples to
illustrate clinical signs used to ASSESS.
1. Why is assessing a young infant different than a sick child? (SLIDE 24)

2. Open your ASSESS charts for the sick young infant to HIV. What do you observe? (SLIDE 25)
3. If the infant has test result: review the charts. Ask probing questions of participants. (SLIDE 26)
4. If the infant does not have has a test result: review the charts. Ask probing questions of
participants. (SLIDE 27)
(3.4) ROLEPLAY (SLIDE 28 OR HANDOUT ON NEXT PAGE)

DISCUSSION
After the roleplay facilitate a group discussion about the issues of informing a mother that her child
may be HIV-infected.
√ Does the group feel that they will be able to do this at their own clinic?
√ Why is it important that it should be done?
√ Discuss strategies that could be used to make it easier for health workers to discuss the topic
of HIV infection with their clients.

HANDOUT A
CLASSIFICATION ROLEPLAY (SECTION 3)
CASE STUDY
Sandile is an 18 month old boy with cough and fever. He is classified as PNEUMONIA and NOT
GROWING WELL. The health worker considers his HIV status and symptoms. Neither the mother
nor the child has had an HIV test.
Sandile is low weight for age, and has unsatisfactory weight gain. On examination the health
worker finds that Sandile has oral thrush and enlarged glands in the neck and groin.
As there are 5 features present the health worker classifies Sandile as SUSPECTED
SYMPTOMATIC HIV.
ROLES: what should I be doing?
HEALTH WORKER: Counsel the mother that there are signs that Sandile may have HIV infection
and that he needs a test. Tell her that you are not sure that he is suffering from HIV infection
but that you think it is important he has a test, so that he gets the treatment he needs.
MOTHER: Try to behave as a real mother might behave. She may be confused or distressed or
she may not understand.
OBSERVERS: Watch the role play and note anything that may be important in the discussion.
DISCUSSION
After the roleplay you will have a group discussion about the issues of informing a mother that
her child may be HIV-infected.
√ Does the group feel that they will be able to do this at their own clinic?
√ Why is it important that it should be done?
√ Discuss strategies that could be used to make it easier for health workers to discuss the
topic of HIV infection with their clients.

(3.5) REVIEW ASSESS & CLASSIFY
Ask participants to review the cases individually or in groups. (SLIDE 29)
Answers:
1. SUSPECTED SYMPTOMATIC HIV INFECTION
2. HIV INFECTION
3. POSSIBLE HIV INFECTION
4. HIV INFECTION
5. HIV UNKNOWN
What questions do you have about ASSESSING and CLASSIFYING?
(3.6) REINFORCE KEY PRINCIPLES (Return to SLIDES as required)

√ Importance of early identification
√ Importance of test results by age and breastfeeding status
√ National testing procedures
√ ASSESS sick children without a test result using clinical signs common to HIV
√ ASSESS sick young infants without a test result using the mother’s status
(3.7) TRANSITION TO NEXT SECTION – BREAK FOR TEA (15 MINUTES) AND CLINICAL PRACTICE
Explain how the group will move into tea and then to the clinic. Brief the participants on the
clinical experience as required.

SECTION 4 – CLINICAL DEMONSTRATION & PRACTICE
TIME – 90 minutes
FACILITATOR SUMMARY
This section is a critical opportunity to demonstrate using IMCI with the sick child or sick young infant.
arrangements will depend on the facility, case load, and prior agreements with the facility or patients.
SECTION OBJECTIVES
■ Participants practice using the IMCI approach to ASSESS and CLASSIFY HIV
■ Participants see examples for clinical signs used to ASSESS and CLASSIFY for HIV
MATERIALS
(4.1) HIV IN THE CLINIC
There should be two components to this session:
1. Facilitators show participants examples of the signs that they will look for when assessing and
classifying for HIV
2. Participants have the opportunity to practice (individually or small group) using the IMCI
process, including HIV, with sick young infants and children. Facilitators should demonstrate
first, then observe and provide ongoing feedback.

SECTION 5 – INFANT FEEDING
TIME - 60 minutes
FACILITATOR SUMMARY
This section will continue with the IMCI approach, but focus on IMCI for the sick young infant.
It is important that participants leave the Orientation meeting with a strong understanding of the
IMCI process for both children and infants before they begin self-study.
This section will not cover all Module 2, which participants will complete before the next meeting.
OBJECTIVES
■ Explain the new South African Dept of Health decision that breast milk substitute will no
longer be supplied on the basis of mothers HIV status.
■ Explain that Nevirapine prophylaxis is not supplied for 6 weeks to all babies of HIV positive
mothers, and then until 1 week after breast feeding ceases (Except after 6 weekds of age in
babies whose mothers are controlled on ART, or where the baby is PCR positive at 6 weeks of
age).
■ Explain the benefits of exclusive breastfeeding
■ Explain why breastfeeding is still important for children who are exposed to HIV
■ Reinforce AFASS criteria
■ Introduce feeding recommendations for HIV-positive mothers
■ Discuss special feeding considerations for HIV-positive children
■ Facilitate a counselling roleplay on infant feeding
MATERIALS
□ Handouts for roleplay (if using)
□ Roleplay props (as necessary)
□ Flipchart
(5.1) WELCOME TO AFTERNOON SESSION

■ Are there any questions that came up during lunch that I can answer?
■ Tell me what you think so far about using IMCI for HIV in the clinic.
(5.2) INTRODUCTORY DISCUSSION ON FEEDING INFANTS & HIV: What are important things we
need to consider when thinking about feeding options for families? Record answers on FLIPCHART
to initiate discussion
Points to cover include:
√ Exclusive breastfeeding versus mixed feeding
√ Risk of transmission during breastfeeding with NVP as provided in the new South African
PMTCT
√ Breastfeeding even when the mother is HIV-positive—benefit to child survival

√ Interventions have made it safer for women to breastfeed (e.g. Nevirapine and cotrimoxazole
prophylaxis, ART for the mother)
√ Replacement feeding is not always an option for families and must be thoroughly considered
√ Feeding options require counselling and continued support
√ Good feeding is vital to optimal growth and development, disease prevention, and fighting
infection, especially in HIV affected children

(5.3) CONSIDERING FEEDING OPTIONS: REVIEW THE AFASS CRITERIA (SLIDE 30)
Facilitate a discussion about the AFASS criteria. Engage participants by asking them to explain a
certain criteria (e.g. Can someone explain what they think ‘Sustainable’ means? What questions
might you ask a mother when you are talking about this criteria point?)
Acceptable—Will the mother have difficulty in her home or community if she chooses this option,
due to stigma, social pressure, cultural reasons, or fear of discrimination? Does she have adequate
support to deal with family, community, and social pressures? For example, ‘Will a mother who
doesn’t breastfeed be accepted in her community?’
Feasible—Will the mother and family have enough time, skills, knowledge, and other resources to
prepare food and feed the infant? For example, ‘Can the mother prepare fresh formula every three
hours, around the clock?’
Affordable—Will the mother and family be able to pay the costs for purchasing/producing,
preparing, and using this feeding option—including all equipment, fuel, clean water, and ingredients?
For example, ‘Can the mother afford this much Rand worth of formula in the first month, and even
more in the second month onwards?’ and ‘Will these costs affect the health and nutrition of other
family members?’
Sustainable—Is the supply of food dependable, and continuous? Are the mother and family capable
of giving the food as frequently as required? For example, ‘Can the family buy milk and equipment
for 6 months or more?’ or ‘Can the mother accept to never breastfeed the baby and only give
replacement formula, even under family pressure?’
Safe—Can replacement foods be hygienically stored and correctly prepared in adequate quantities
for the child’s nutritional needs? For example, ‘Does the mother have easy access to clean water?’ or
‘Does the family have clean utensils for preparation and giving food?’ or ‘Does the mother have
access to a refrigeration, and electricity?’

(5.3) FEEDING RECOMMENDATIONS FOR THE HIV-POSITIVE MOTHER
1. Open your chart booklets to the feeding recommendations. We will discuss feeding options
for two scenarios – there are separate charts.
a. The child is exposed but status is not confirmed (PAGE 21)
b. The child is confirmed positive or is symptomatic (PAGE 20)
2. Review recommendations for EXPOSED
a. Review main points (SLIDE 31)
b. Ask participants to follow along in CB page 21. Discuss more specific feeding
recommendations using the CB (e.g. complementary foods)
3. Review recommendations for CONFIRMED/SYMPTOMATIC

a. Review main points (SLIDE 32)
b. Ask participants to follow along in CB page 20. Discuss more specific feeding
recommendations using the CB (e.g. complementary foods, special issues with +)

(5.4) ROLEPLAY
Facilitate roleplay to practice counselling a mother on feeding options. Note that this case
study is for a woman who has not yet delivered. You can show the roleplay using SLIDE 33 or
alternatively the handout on the next page.
DISCUSSION
After the roleplay facilitate a group discussion about the issues around counselling on infant feeding
practices.
√ What did the health worker do that was particularly helpful in this counselling session?
√ What would you have done differently if you encountered this situation in your clinic?
√ What are good strategies for counselling mothers on feeding options?
√ Let’s pretend that Lungile came to you after she already had the baby. The baby is one
week old. How would you counsel her?
What questions do we have before moving on to the next section?
(5.4) REINFORCE KEY PRINCIPLES OF INFANT FEEDING (refer to 5.3 discussion on FLIPCHART)

We have discussed infant feeding recommendations in this section, which are an incredibly
important part of good HIV/AIDS care. Now we will learn more about preventing and treating
illnesses in children exposed or infected with HIV.

HANDOUT B
FEEDING ROLEPLAY (SECTION 5)
CASE STUDY
Lungile Dludlu is 26 years old. She is 37 weeks pregnant. She has just found out that she is HIV
positive. Lungile lives in a tin shack in the centre of the city. She gets water from the tap in the
street 200 metres from her home. She lives alone. Her partner works in another city and comes
home at weekends. Her mother lives on the farm. Lungile visits her mother during Christmas.
Lungile is working – she has temporary jobs.
After the baby is born she does not know whether she will go back to work. Maybe she will go
back to the farm for a while before she returns to work. When she returns to the city her
mother will look after her baby. Neither her mother nor her partner knows that she is HIV
infected. She wants to tell her partner but she is scared as maybe he will get angry with her and
he will not give her any money for this baby.
ROLES: what should I be doing?
HEALTH WORKER: Counsel Lungile on how she might feed her baby once he or she is born
LUNGILE: Try to behave as Lungile would in a real situation.
OBSERVERS: Watch the role play and note anything that may be important in the group
discussion that will follow the roleplay.
DISCUSSION
After the roleplay you should have a group discussion about the issues around counselling on
infant feeding practices.
√ What did the health worker do that was particularly helpful in this counselling session?
√ What would you have done differently if you encountered this situation in your clinic?
√ What are good strategies for counselling mothers on feeding options?
√ Let’s pretend that Lungile came to you after she already had the baby. The baby is one
week old. How would you counsel her?

SECTION 6 – TREATMENT & PREVENTATIVE PROPHYLAXIS
TIME - 30 minutes
FACILITATOR SUMMARY
In this session, you will introduce important measures for preventing and treatment illness in HIV
exposed and infected children and young infants. These are important measures of follow-up care.
OBJECTIVES
■ Review opportunistic infections and why prophylaxis is important
■ Introduce nevirapine prophylaxis—when used, and dosing
■ Introduce cotrimoxazole prophylaxis—when used, and dosing
■ Reinforce immunizations and continued follow-up care
MATERIALS
□ Flipchart
(6.1) INTRODUCE PROPHYLAXIS

Review the concept of opportunistic infections, and why prevention and quick management of illness
is required. Record responses and discussion points on FLIPCHART.
OPENING DISCUSSION – Can someone remind us what opportunistic infections are? Why are HIV
exposed or infected children more vulnerable to infection? Why is it critical to prevent and manage
illness?
(6.2) INTRODUCE NEVIRAPINE Review content & refer to chart booklet (SLIDE 34)
Who should receive nevirapine

prophylaxis?
 All HIV-exposed from birth until 6 weeks of age

 Children receiving ANY breast milk, until 1
week after breastfeeding stops, unless mother is
on lifelong ART/ or the child is shown to have
HIV infection.

(6.3) INTRODUCE COTRIMOXAZOLE Review content & refer to chart booklet (SLIDE 35 & 36)
(6.4) PRACTICE EXERCISE (SLIDE 37)

Ask the participants to complete the exercise individually or in a group. DISCUSS answers and
clarifying any questions.

ANSWERS
1. Yes, 1 mL daily till 6 weeks old 2. Yes, 2 mL daily 3. Yes, 2 mL daily 4. Yes, 2.5 mL daily
5. Yes, 5 mL daily 6. No
(6.5) CASE STUDIES (SLIDE 38)

Provide time for participants to review case and complete form.
DISCUSSION: What steps will you take? What preventative prophylaxis is required today? How will
you manage this?

√ The need for prophylaxis and important kinds
√ Integrated management
(6.7) TRANSITION & BREAK FOR TEA (15 MINUTES)

We’ll break for tea and then return to discuss more treatment, especially ARV drugs.

SECTION 7 – INTRODUCE ANTIRETROVIRAL TREATMENT
TIME - 60 minutes
FACILITATOR SUMMARY
This section will introduce ART and review the 6 steps of initiation. The session should emphasize
when children should begin ART, and what makes children eligible. This session will not focus on
adherence or follow-up, which will be emphasized in the next meeting.
OBJECTIVES
■ Introduce the concept of ART and emphasize main points about treatment
■ Introduce 6 steps of initiating ART
■ Emphasize when children should initiate ART, including a review of clinical staging and
necessary tests
MATERIALS
□ ART charts for distribution
□ ART initiation forms – 2 copies each
□ Recording forms
(7.1) INTRODUCING ART
1. Review ART with participants, particularly taking questions (SLIDE 39)
Mechanisms of ARV Action

Nucleoside reverse
transcriptase inhibitors (NRTI)
Non-Nucleoside
reverse transcriptase
inhibitors (NNRTI)
Protease Inhibitors (PI)

2. ARV DRUGS: review national drug protocols
(7.2) INITIATING ART IN CHILDREN
1. Distribute the ART charts and the ART initiation form

2. Review the 6 steps of initiation (SLIDE 41), and follow along with recording form (SLIDE 42)

(7.3) SUMMARY: WHEN IS A CHILD ELIGIBLE FOR ART? (SLIDE 43)
How do we define these important terms? (use FLIPCHART)

√ CD4 count and percentage
√ Viral load
√ Clinical staging
(7.4) EXERCISES TO REVIEW

1. What are these children’s clinical stages? (SLIDE 44)
Give participants time to do exercise individually or in small groups.
ANSWERS: 1, 4, 3, 3, 4
What questions do we have about clinical staging before we move to the next activity?
2. Are these children eligible for ART? (SLIDE 45)

Give participants time to do exercise individually or in small groups.
ANSWERS: NO, YES, YES, YES, YES
What questions do we have about eligibility for ART?

(7.5) CASE STUDY REVIEW (SLIDE 46)
1. Distribute IMCI RECORDING FORM FOR THE SICK CHILD and an ART INITIATION FORM.
2. Give participants time to complete the case study and complete forms.
3. Lead a discussion after the case study.
CASE STUDY: CEDI

Cedi is three months old and weighs 6 kg. Her temperature was recorded as
36.50C. This is an initial visit. Her mother tells you she has had diarrhoea for
10 days. Her skin pinch goes back slowly, you do not see sunken eyes, she
drinks normally and is alert. She does not have a cough or ear problem. She
is not pale and is growing normally. She has no TB contact nor fatigue.
Her mother was found to be HIV-infected during pregnancy.
Cedi had blood tests at six weeks and had a positive HIV PCR. Further blood
tests were taken for which she returns today and are VL 12,000 copies/mm3,
CD4 count was 800 cells/ mm3 (30%) and Hb is 11g/dL.
She is breastfeeding and is generally well. Her length is 60 cm and her head
circumference is 41 cm. She lifts her head, responds to sounds and follows
objects with both eyes.
Her mother has not disclosed her own or Cedi’s HIV status to anyone at home,
but is a regular member of the clinic support group. She has been counselled
regarding adherence, and is available and committed to ensuring that Cedi
receives her ARVs twice a day.
How will you classify Cedi today? What actions need to be taken today.
What treatment should she received and what advice concerning this
treatment.

(7.6) SUMMARIZE TODAY: GOALS OF HIV/AIDS CARE FOR CHILDREN (SLIDE 47)
√ Where do the topics we discussed today fit into this continuum of care?
√ Who can summarize why HIV/AIDS is included within IMCI?
(7.7) REINFORCE KEY PRINCIPLES OF ART

√ Why give ART? What are the benefits, what does it do? Slows HIV replication in
body, minimizing damage to immune system
√ There are 6 steps for initiating ART
√ All children under 12 months who are confirmed positive should initiate ART
√ Use clinical staging and test results (viral load, CD4) to determine how much HIV is
active in the body, and how suppressed the immune system is
√ First line drugs: ABC, EFV, LRV/r
√ Adherence is critical to ART effectiveness
Any questions about ART?

We have completed our content for today. We will now review what is expected during the
upcoming self-study phase. We will do an evaluation of today’s meeting, and close.

TIME – 15-30 minutes
FACILITATOR SUMMARY
This section will review the module structure and calendar, and set plans for the next steps.
Participants should be very clear about expectations for self-study phase, including clinical practice,
use of logbook, and study groups. At the conclusion of this section, you will administer an evaluation
of the day.
OBJECTIVES
■ Reinforce module structure and expectations for the upcoming self-study phase
■ Review logbook structure
■ Ensure that all participants have necessary materials and know what to prepare for next
meeting
MATERIALS
□ Evaluation form handout
(8.1) REVIEW CALENDAR (Refer to SLIDE 4, participants should follow along in their module books
OVERVIEW to fill in dates)
1. Emphasize dates and location for second face-to-face meeting
2. Review what is expected during the following several weeks of self-study:

■ Read module and complete self-assessment exercises (answers in annex)
■ Complete logbook exercises
■ Complete logbook recording forms
■ Meet with study group
■ Work with mentors

(8.2) REVIEW LOGBOOK 8
Flip through logbook with participants as you explain sections.
There are two instructions for the logbook:
3. Complete the exercises after you read the module. 30 questions. Do not use your study
materials, but you can use your chart booklet.
4. Complete recording forms as you practice in your clinic

√ At least 2 IMCI recording forms, including assessment for HIV.
√ At least 1 ART initiation form or ART follow-up form,
√
*Emphasize that recording forms should be filled out and brought to the next meeting. The more
cases recorded, facilitators and peers can give better feedback*
(7.3) NEXT STEPS (SLIDE 48)

Review all take-home messages for the upcoming self-study period and preparations for the next
meeting.
What questions do we have about our next steps?

(7.5) CLOSE MEETING
*DISTRIBUTE PARTICIPANT CONTANT INFORMATION SHEET*

Review how participants should best stay in touch with you, and your availability.
Affirm participants' engagement in the course and express your energy and anticipation for the self-
study phase. Congratulate participants, or close with an activity to revive energy.

PART FIVE
Synthesis & Assessment
th
4 face-to-face meeting
Consolidating Modules 1 – 8
Summative Assessment

MEETING OBJECTIVES
During this meeting, the facilitator with synthesize the HIV material from the self-study period. This
is a critical opportunity for the facilitator to address any issues, challenges, and confusions in using
IMCI for HIV/AIDS care.
During this meeting, the facilitator will also provide an opportunity to practice in the clinic.
Participants will also complete a written examination on IMCI material including HIV/ART module
material.

PROPOSED AGENDA
08:00 - 08:30 REGISTRATION

WELCOME & OVERVIEW (15 minutes)
Welcome participants, review course objectives and agenda.
REVIEWING SELF-STUDY (60 minutes)
Plenary discussion about self-study experiences, review of
recording forms, and addressing difficult cases or problems.
REVIEWING IMCI FOR HIV (30 minutes)
A written case study to practice using IMCI for HIV.
10:30 - 10:45 Tea break & depart for clinical practice (15 minutes)

CLINICAL DEMONSTRATION & PRACTICE (90 minutes)
Demonstrate assessing and classifying HIV status, and facilitate
small group practice.
12:30 - 13:15 Lunch (45 minutes)

ASSESSMENT BY SKILLS STATIONS (75 minutes)
Skills stations will assess skills with video demonstrations,
written case studies, and photo exercises.
ASSESSMENT BY MULTIPLE-CHOICE EXAMINATION (45
minutes)
Multiple choice and open-answer exam.

NEXT STEPS & FORMAL CLOSING (45 minutes)
Participants create and discuss their individual action plans,
administer course evaluation. Facilitators award certificates of
completion.

This is a checklist of suggested materials for the day. In this guide, each section of the meeting
details which of the materials below are required for that particular section.
MATERIAL NUMBER  LIST
FOR FACILITATION
Facilitator guide 1 per facilitator
PPT slides 1 electronic file
IMCI DVD 1 DVD (2 discs)
IMCI Guide for Clinical Practice in Inpatient Ward 1 per facilitator
IMCI Guide for Clinical Practice in Outpatient Ward 1 per facilitator
Projector and/or computer screen (for viewing) 1
Laptop 1
Clock or stopwatch (timekeeping, best if visible to all) 1 per facilitator
Flipchart or large paper 5-10 sheets
Flipchart markers As required
Tape (for hanging papers or displays) As required
IMCI wall chart (optional wall display) As required
Roleplay props, models, or other display materials As required
FOR DISTRIBUTION*
Registration forms (sample in ANNEX) 1 per participant
Name tags or displays 1 per participant/facilitator
Contact information sheet (compiled from 1 per participant/facilitator
registration)
IMCI Recording Forms 1 child and 1 young infant,
plus extras
Multiple-choice examination I copy for each
Multiple-choice examination answer sheet I copy for each
Skills station answer sheet I copy for each
Individual action plan form I copy for each
Meeting handouts (for all activities) 1 per participant/facilitator
Meeting evaluation form 1 per participant
Notebook 1 per participant/facilitator
Certificates (attendance or completion)
Pens or pencils 1 per participant/facilitator
Tea (morning and afternoon) and lunch supplies As necessary

* Materials should be ready and available for distribution at points during the day. When the
facilitator distributes a particular material, s/he must explain the content in full to the participants.
Logbooks And any additional notes taken
Recording forms - all modules At least 5 completed at home clinic

6. REGISTRATION
All participants should complete a registration form (a sample form is in the Annex).
7. MATERIALS FOR DISTRIBUTION AT REGISTRATION (or ready at place settings)

 Day’s agenda
 Registration form

 Copies of recording forms—IMCI form, ART initiation, ART follow-up
 Printed PPT slides, if distributing
 Meeting activity handouts
 Copies of written assessment and answer sheet
 Copies of skills station answer sheet
 Copies of photo booklet, if planned to use during skills station
 Individual action plan forms
 Course evaluation forms
9. EQUIPMENT PREPARATIONS
using 1 laptop for both, it is best to have both programmes are open and prepped. It is
more time efficient to minimize one programme and open the other. You will begin the
day with DVD disc 2.
 Skills stations—ensure that you have adequate space and tables/chairs for the afternoon’s
assessments:
o 4 spaces for skills stations (2 have audio and should be in separate spaces), if
participants will move between stations
o In the main room, ensure adequate space for privacy when participants take their
written examination

OVERALL ASSESSMENT-GRADING PARTICIPANTS FOR PASS/FAIL
Three aspects of the participant’s performance will be considered. Each of these could be given
equal weighing (i.e. about 1/3 of the total mark):
1) Assessment of progress using performance on the log book
2) Clinical assessment using the OSCE approach
3) Written, theoretical examination using multiple-choice questions
1. LOGBOOK ASSESSMENT
Assessing the logbook is intended to assess the participant’s ongoing progress during the course. The
logbook assessment has two parts: (a) theoretical questions – both multiple-choice and true-false,
and (b) recording of clinical cases as requested during IMCI practice in their home facilities. These
two parts will each count for 50% of the total “logbook assessment” mark, which again is 1/3 of the
total course mark.
2. CLINICAL SKILLS ASSESSMENT

The clinical assessment may be carried out using real patients where there is an adequate number
and variety of patients for the participants. However, where an adequate number of patients will not
be available (this is the most likely scenario in many settings), facilitators are advised to use skills
stations. Participants will rotate between stations that assess them on different skills using video,
photos, or clinical case scenarios. The clinical assessment could count for 30-40% of the total mark.
3. MULTIPLE CHOICE EXAM ASSESSMENT

The multiple-choice written examination will make up 30% of the total mark.
To summarize the course assessment structure:

ASSESSMENT SPECIFIC ASPECTS MARK OUT
COMPONENTS OF 100%
1. Logbook a. Assessment exercises for all 9 modules 15
(progressive b. Recording forms completed well during each of the two 15
assessment) self-study periods – min 10 altogether
2. Clinical skills a. Video spot diagnosis of IMCI signs 18
assessment b. Photos of IMCI signs and BF technique 15
(OSCE) c. Case scenario of a sick child: classify, treat, counsel, and 7
follow up
3. Multiple- 50 multiple-choice questions on written exam 30
choice exam
TOTAL POSSIBLE 100

*PASS MARK* *50*
PLUS
Clinical Summative assessment at in about 6 weeks to confirm competence to
practice

ASSESSMENT—GRADING PARTICIPANTS FOR PASS/FAIL
The course assessment should consider three components of the participant’s performance. Each
of these can be given equal marking—that is, about 1/3 of the total mark.
1) Logbook performance
2) Written examination
3) Clinical assessment, using the OSCE (objective structure clinical examination) approach
4. LOGBOOK ASSESSMENT
The logbook is intended to assess the participant’s ongoing progress during the course. The
logbook assessment has two parts, each of which will count for 50% of the total “logbook
assessment” mark:
(a) Theoretical questions (multiple choice and true/false) on each module, and
(b) Recording forms for each module from clinical cases in home facilities.
5. WRITTEN EXAMINATION
The written examination is a theoretical examination testing participants with multiple-choice
and true/false questions.
6. CLINICAL SKILLS ASSESSMENT

The clinical assessment may be carried out using real patients where there is an adequate
number and variety of patients for the participants. However, where this setting is not be
available—the most likely scenario in many settings—facilitators are advised to use skills stations.
Participants will rotate between stations that assess them on different skills using video, photos,
or clinical case scenarios. This section is not applicable in the current HIV module used in East
Cape.
IN ADDITION A CLINICAL SUMMATIVE ASSESSMENT IS CARRIED OUT AT 6 WEEKS AFTER THE FINAL
SYNTHESIS MEETING - only if this is positive will a CERTIFICATE OF COMPETENCE be issued. Other
wise for those passing the marking system but not the 6 week clinical assessment a CERTIFICATE OF
COMPLETION can be issued.
See also part 7 on SUMMATIVE CLINICAL ASSESSMENT

SECTION 1 - INTRODUCTION & REVIEW OF IMCI
TIME - 15 minutes
FACILITATOR SUMMARY
In this section you will facilitate group re-introductions, review the day’s agenda, and make all
necessary announcements.
SECTION OBJECTIVES
■ Review module structure
■ Review day’s agenda and make all announcements
MATERIALS
□ Flipchart

Welcome participants to final face-to-face meeting, which is an opportunity to summarize the
distance learning experience, and assess and practice IMCI skills.
3. Re-introduce yourself and co-facilitators

 Name
 One way this course has changed the way you are practicing in your clinic
 One challenge, or a question, from practicing IMCI in your clinic
5. SUMMARIZE participant comments about course benefits
6. SUMMARIZE participant comments about challenges during the self-study practice period—these
will be discussed in length in the next section

Briefly review what components of the course have been completed.
Additional
1st face-to-face 2nd face-to-face 3rd face-to-face 4th face-to-face Modules in future
new information
3-4 6-8 4 weeks

weeks weeks

Work with mentors



to stay on task
■ This morning we will review our experiences in the past weeks with self-study. You will also
meet individually with a facilitator to review your logbook and discuss your clinical practice.
Your logbook exercises and recording forms will be assessed.
■ In the afternoon you will be assessed on your IMCI skills. You will be assessed in skills
stations and a written examination.


We’ll begin by reviewing our self-study and practice like we did last meeting. This is an important
time to address any issues or challenges.

Participants should follow along in books.
1. Review module objectives (SLIDE 2)

2. Briefly review the agenda for today
■ This morning we will review our experiences in the past few weeks with self-study. You will
also meet individually with a facilitator to review your logbook and discuss your clinical
practice. Your logbook exercises and recording forms will be assessed.
■ In the afternoon you will be assessed on your IMCI HIV skills. You will be assessed with a
written examination.



We’ll begin by reviewing our self-study and practice like we did in the previous SYNTHESIS meeting.
This is an important time to address any issues or challenges.

SECTION 2 – REVIEW SELF-STUDY
TIME – 60 minutes
FACILITATOR SUMMARY
This section is a critical opportunity for facilitator to: (a) assess how well participants are using the
IMCI process and integrating material into their clinical practice, and (b) assess how well participants
comprehend integrated case management strategies and content from the HIV module.
During the plenary discussion, facilitators not leading the discussion should collect and review
recording forms to identify common problems to discuss with group. They should request participants
to join them for a brief individual discussion about self-study, practicing IMCI, and the logbook. The
logbook answer key is located in the ANNEX. Review marking information on page 8.
Issues common in the recording forms and individual discussions should be addressed at the end of
this section with clarification or extra practice. Section 3 is also a 30 minute section to address any
issues identified in the recording forms, one-on-one meetings, or plenary.
SECTION OBJECTIVES
■ Provide an opportunity to reflect on distance learning experience, and progress in
understanding and utilizing the IMCI strategy for HIV.
■ Assess how well participants are integrating material into their clinical practice.
■ Address problem areas and challenging cases. Problem solve as group to address course or
individual challenges. As a facilitator, note where additional facilitation and support is
required post-course, or in future course implementation.
MATERIALS
□ Flipchart
□ Logbook answer key (in ANNEX)
(2.1) INTRODUCTION – OUR REFLECTIONS ON SELF-STUDY

■ This is an opportunity to share your experiences with the self-study module, clinical practice,
■ Facilitators not leading the discussion will call participants out for individual discussions about
their self-study experience and their recording forms.
(2.2) INDIVIDUAL DISCUSSIONS & RECORDING FORM REVIEW (simultaneous with 2.3)

Facilitators not leading the plenary discussion should call participants for individual discussions and
review their recording forms to identify any problem areas with using IMCI. When finished, rejoin the
group to discuss and address these problem areas.
(2.3) PLENARY DISCUSSION (simultaneous with 2.2): record key points of discussion on FLIPCHART
below.
■ Module content: what were your experiences reading and doing exercises in these modules?
What components of the modules did you find particularly useful (e.g. written exercises,
content format, DVD exercises, review questions)?
■ Check understanding of module: What questions from the modules can we discuss and
explain as a group now?
Chart Booklets and recording forms? What is challenging about integrating the material in the
clinic? Where are you facing problems?
■ Involving others in self-study: what were your experiences working with study groups? How
did your mentors help you with this content? How will you continue to work with these
mentors?
(2.4) ADDRESS PROBLEM AREAS

After the facilitators that are reviewing recording forms finish with all participants, they should join
the group to address key or common problem areas. If extra time needed, review videos or explain
content in Section 3.

■ What problem areas identified and solutions reached as group, or areas still outstanding.
self-study.

Now that we have shared our experiences with using IMCI for HIV/AIDS care, let us continue review
IMCI and address any problems we have.

SECTION 3 – REVIEWING IMCI FOR HIV
TIME – 30 minutes
FACILITATOR SUMMARY
This section is an opportunity to address any problem areas identified in the plenary discussion. This
section includes a written case study. Section 6 includes a roleplay on infant feeding, and this can be
used during this time period if most applicable to the issues highlighted in the discussion.
SECTION OBJECTIVES
■ Review integrated treatment using a written case study, highlighting any problem areas
MATERIALS
□ Flipchart
□ 1 copy SICK CHILD recording form
(3.1) CASE STUDY REVIEW (SLIDE 4)

Walk through the case below. The slides’ text appears in 3 segments. The first ASSESS-CLASSIFY will
show on the slide. When you want to show results, click once and the second segment will appear.
After the second visit has been discussed, click once more and the final classification will appear. Give
participants time to read each section and discuss responses. Then show the results.
CASE STUDY: MODUPE Modupe Continued
Modupe is a 34-month old boy. His grandmother cares for him, and has brought him into the
clinic today for a first visit. The complaint was cough and fever for 3 days. His temperature is
38.2oC, and he weighs 10.5 kg. His grandmother cares for him, and has brought him today.
You check for general danger signs, and he has none. Modupe has a cough and you count 44  Modupe comes back after 2 weeks and has gained 200g in weight and is
breaths per minute, but does not have chest indrawing. He does not have any diarrhoea. He looking well though still slightly pale. His Hb is 9 g/dl. His length is 90cm.
has pus draining from his ear, and his grandmother says it has been present for about 3
weeks (There is no swelling behind the ear). His Hb test is 8 g/dl. His mother died shortly  He has no general danger signs, has no cough or difficult breathing and is
after his birth, and the grandmother does not know if she ever tested for HIV. breathing at 24 breaths per minute.
How will you classify Modupe?
 His temperature is now normal.
You classify Modupe as PNEUMONIA, FEVER – OTHER CAUSE, CHRONIC EAR INFECTION,
ANAEMIA, NOT GROWING WELL, POSSIBLE TB and SUSPECTED SYMPTOMATIC HIV INFECTION.  His ear has stopped draining.
You classify as SUSPECTED SYMPTOMATIC HIV INFECTION because he has three features of HIV
infection.  His tuberculin skin test was negative after 2 days.
You counsel his grandmother on HIV testing, and because she is his primary caregiver, she can  He is otherwise well with no oral thrush, organomegaly or
consent. She agrees to testing. You conduct a rapid test, and it is positive.
lymphadenopathy.
How will you now re-classify Modupe? What treatment will you provide  He is able to talk in short sentences, run around and can see even small
today? items and pick them up between his thumb and first finger
You re-classify Modupe as HIV Positive. His grandmother is shocked  His viral load is 150,000 and his CD4% is 10%.
What will you do now?  What steps now?
IF you feel it appropriate it may be useful to use the following cases as well – time permitting

Mpho Further information
 Mpho is a 2 yr old boy who has come to see you today because he  GDS – alert but miserable and not playful, no convulsions, feeding OK, Not
has loss of appetite, a distended abdomen, vomiting and swollen vomiting everything
feet.  Cough and Difficult Breathing - No
 His weight is 9kg, but is still gaining weight slowly. Length 80cm  Diarrhoea - No
 His temperature is 37.0oC  Fever - No
 Ear Problem - No
 He has been admitted 3 times previously for pneumonia
 Nutrition – 12kg, No visible severe wasting, oedema both feet,
 His mother is on HAART
 HIV Classification – Elisa +ve , Mother Elisa +ve on treatment, enlarge
 He lives in a corrugated iron informal single room house with his cervical glands, no oral thrush, parotid enlargement.
mother, father and 3 siblings – the siblings and father have not had  TB Classification – no additional information
an HIV test.
 Immunisation – is complete except for measles 2
 Mpho’s Elisa was positive and his CD4% is 18.2%.
•What is Mpho’s Classification?
What further information would you like to ask or look for in
order to classify Mpho? •How will you now manage Mpho?

We will break for tea. Then we will move to a clinical setting to practice IMCI for the sick young
infant and sick child. Remind participants to bring chart booklets and recording forms. Review
agenda or other announcements as required.

SECTION 4 – CLINICAL DEMONSTRATION & PRACTICE
TIME – 90 minutes
FACILITATOR SUMMARY
This section is a critical opportunity to demonstrate using IMCI with the sick child or sick young infant.
arrangements will depend on the facility, caseload, and prior agreements with the facility or patients.
SECTION OBJECTIVES
■ Participants practice using the IMCI approach to ASSESS and CLASSIFY HIV
■ Participants see examples for clinical signs used to ASSESS and CLASSIFY for HIV
MATERIALS
(4.1) HIV IN THE CLINIC
There should be two components to this session:
3. Facilitators show participants examples of the signs that they will look for when assessing and
classifying for HIV
4. Participants have the opportunity to practice (individually or small group) using the IMCI
process, including HIV, with sick young infants and children. Facilitators should demonstrate
first, then observe and provide ongoing feedback.

SECTION 5 – ASSESSMENT BY SKILLS STATIONS
TIME – 75 minutes
FACILITATOR SUMMARY
This is the first part of a two-part assessment. There will be 4 skills stations. Two stations are written
case studies where participants will fill in a recording form, one is a video case study, and one has
short photo and video exercises. You will divide the group into 4, and they will have 15 minutes at
each station. If space or logistics are a problem for running skills stations, run each of the skills
stations as an entire group.
This assessment is intended to demonstrate the range of skills required for integrated case
management. You are expected to facilitate the timing of the assessment (e.g. movement between
skills stations), and to maintain order and a quiet assessment environment. You can answer clarifying
questions as necessary.
See page 141 for more information about marking. The answer key for the skills stations handout is
in the ANNEX.
SECTION OBJECTIVES
■ Assess participant skills in integrated case management to ensure that they have met course
learning objectives
MATERIALS (handouts are in ANNEX)

□ 1-2 laptops or screens for showing DVDs
□ IMCI DVD 1 and 2
□ Powerpoint slides
□ Copies of skills station answer sheet
□ 1 copy each of IMCI recording forms for sick child and young infant
□ Multiple copies of IMCI photo booklet or soft copies shown on a laptop
□ Visible clock or stopwatch to display time remaining
PREPARATIONS FOR SKILLS STATIONS

□ 4 areas of room(s) designated as skills stations. Stations will require 1 table and a cluster of
chairs for groups of participants to sit in during the station.
□ If possible, arrange separate rooms/spaces for the Stations 1 and 2, which both have video, so
that the noise from the DVD does not disrupt the other stations.
□ IF STATIONS WILL HAPPEN TOGETHER AT ONCE: Powerpoint slides will introduce each
station and provide content (e.g. photos, written case studies). Facilitators can display these
slides and the videos from the same projector screen, and facilitate the timing between
stations.

(5.1) INTRODUCE SKILLS STATIONS
1. 4 stations will assess you on different IMCI skills using case studies, video, and photos.
2. We will do each station together today. I will show you material using video and powerpint
slides.
3. You will record your answers on an answer sheet.
4. You can use your chart booklets and a recording form to decide your answers.
**DISTRIBUTE THE FOLLOWING TO EACH PARTICIPANT FOR THE SKILLS STATIONS**

 SKILLS STATION ANSWER SHEET
 1 SICK INFANT RECORDING FORM
 2 SICK CHILD RECORDING FORM
 1 ART INITIATION FORM
 1 ART FOLLOW UP FORM
STATION 1—IDENTIFYING SIGNS – PHOTO EXERCISE

OVERVIEW: Participants will view photos to identify signs. They will record their answers on the skills
station answer sheet.
MATERIALS
□ Laptop
□ SLIDES 10-18 with photographs (have ready to
show on laptop) OR IMCI photo bookletS
TIMING
There are 15 photographs on 8 slides. This station can
take 60-90 seconds per slide.
INSTRUCTIONS FOR PARTICIPANTS

1. We will review several slides with photos of clinical signs.
2. Record your observations on the answer sheet. If the picture if of breastfeeding, make your
observations on the attachment.

1. Explain instructions to participants and ensure they have skills station handout.
2. Show photos on the PPT slides (8 slides – 30-45 seconds per slide).

STATION 2—IDENTIFYING SIGNS – VIDEO EXERCISES
OVERVIEW: Participants will review three videos and identify signs. They will record their answers on
the skills station answer sheet.
MATERIALS
□ Laptop
□ DVD disc 2 (Have “Review exercise: chest
indrawing” ready to play)
□ SLIDE 19
TIMING
The three videos in total take ~15 minutes.

1. You will view three videos and decide if the children you see have a particular sign.
2. Record your answers on the answer sheet.

1. Explain instructions and ensure participants have their worksheets for recording answers.
2. PLAY IMCI DVD “Review exercise: chest indrawing” (disc 2). Stop the video at 6:00 before
the answers begin to play.
3. PLAY IMCI DVD “Sunken eyes exercise G” (disc 2). Stop the video before it gives answers.
4. PLAY IMCI DVD “Skin pinch exercise G” (disc 2). Stop the video before it gives answers

STATION 3—ASSESS, CLASSIFY, & TREAT THE SICK CHILD (WRITTEN CASE STUDY)
OVERVIEW: Participants will read a case study (on slide and also typed on their answer sheet), record
classifications, and will answer a question about treatment.
MATERIALS
□ IMCI recording form for the sick child (if participants
don’t already have)
□ SLIDES 20-21

1. Read the SICK CHILD case study on this slide.
2. Use your recording form and chart booklet to assess
and classify.
3. Answer the two questions about the case on your answer sheet.

1. Explain instructions to participants.
2. Advise participants when there are 3 minutes left at this station.
THE CASE STUDY (SLIDE 21):

STATION 4—ASSESS, CLASSIFY, & TREAT THE SICK YOUNG INFANT (WRITTEN CASE STUDY)
MATERIALS
□ IMCI recording forms for the sick young infant (if
participants don’t already have)
□ SLIDES 22-23

1. Read the SICK YOUNG INFANT case study on this
slide.
2. Use your recording form and chart booklet to
assess and classify.


STATION 5—ASSESS, CLASSIFY, & TREAT THE SICK CHILD (ART) (WRITTEN CASE STUDY)
MATERIALS
□ IMCI recording form for the sick child (if participants
don’t already have)
□ SLIDES 20-21

4. Read the SICK CHILD case study on this slide.
5. Use your recording form and chart booklet to assess
and classify.

Case to be created and put in power point collection
(5.2) WHEN STATIONS ARE COMPLETED:

 Collect answer sheets and begin marking (see marking information on page 141)
 Participants should assist in moving chairs and tables as appropriate for the written
examination.

SECTION 6 – MULTIPLE-CHOICE EXAMINATION
TIME – 45 minutes
FACILITATOR SUMMARY
You will facilitate a 60-minute written examination that includes multiple-choice and open-ended
questions. You must ensure a good testing environment, including silence and adequate space
between participants. This section is scheduled for 65 minutes, but the exam should last 60
minutes—you will need to use your judgment about giving participants more than the 60 minutes
time if the entire group is having trouble finishing in that amount of time.
Participants will write all of their answers on a single answer sheet. This is intended to make marking
easier and quicker for facilitators.
See Section 7 for more information about marking. An answer key is included in the ANNEX.
SECTION OBJECTIVES
■ Assess participant skills in integrated case management to ensure that they have met course
learning objectives
MATERIALS (in ANNEX)

□ Copies of exam
□ Copies of written exam answer sheet
□ Visible clock or stopwatch to display time remaining
INSTRUCTIONS FOR PARTICIPANTS:

1. Participants have 40 minutes to complete
2. Show end time on a stopwatch or clock that is visible to all participants
3. Participants must respect silence during the assessment
4. Any questions before we begin?
*DISTRIBUTE COURSE EXAM S - Both IMCI and HIV assessment papers – 25 questions each*
INSTRUCTIONS FOR FACILITATORS:

1. If participants ask clarification questions about a question, but be sure to not lead participants
to the answers.
2. Announce a 5 minute warning
3. Once participants turn in their answer sheets, facilitators should begin marking them using
the answer key in the annex. See Section 7 for more details on marking.
4. When all participants complete the exam, they can break for tea.
TEA BREAK (15 MINUTES)

SECTION 7 – NEXT STEPS & FORMAL CLOSING
TIME – 45 minutes
FACILITATOR SUMMARY
You will review the course goals and facilitate a discussion about next steps for participants.
Participants will complete individual action plans for continued learning, practice, and work with
others. You will administer the course evaluation.
If participants are given a certificate of completion,
During this section, facilitators not leading the session should be marking skills stations worksheets,
recording forms, and the written assessment. Answer keys are in the ANNEX.
SECTION OBJECTIVES
■ Re-examine course objectives and discuss how they have been met
■ Discuss and plan how participants can continue to work on the learning objectives by using
IMCI in their clinic, continued learning, and mentorship.
■ Administer course evaluation
■ Discuss how facilitators will follow-up with participants after the course
MATERIALS
□ Individual action plan forms (in Annex)
□ Flipchart
□ Certificates of completion, if being provided
□ Course evaluation (in Annex)
(6.1) RETURN TO COURSE OBJECTIVES

(SLIDE 19)
How have we met these objectives?
How will we continue to move forward

with these objectives?

(6.2) INDIVIDUAL ACTION PLANS
**DISTRIBUTE ACTION PLAN FORM*
Ask participants to write down goals or an action plan for the following topics (use FLIPCHART if
participants using their own notebooks and not the action plan form):
■ continued learning (refreshing skills and developing new skills),
■ using IMCI in clinics
■ continued work with mentors, and
■ dissemination of information and collaboration with colleagues and in-charge officers
Give participants 10-15 minutes to think through plans. Lead as discussion on topics to brainstorm as
a group. Record thoughts on FLIPCHART. For example:
■ Who wants to share their ideas for using IMCI everyday in their clinics, with every sick child
and young infant they see?
■ Who wants to share their ideas for learning more about IMCI and health topics in your
clinic? What continued training will you pursue?
■ Who wants to share their ideas for working with mentors if you have questions about IMCI?
■ Who wants to share their ideas for showing colleagues and in-charge officers how you are
using IMCI in your practice?
(6.3) AWARD CERTIFICATES

These will only be awarded after the 6 week summative clinical assessment at district level.
(6.4) GROUP REFLECTIONS

Facilitation group reflections about the course. For example, you might ask: what thoughts do each
of you have for the group before we close the course?
(6.5) ADMINISTER COURSE EVALUATION

Explain the importance of honest and detailed responses on the course evaluation: this evaluation
will be reviewed by facilitators and IMCI administrators. Participant feedback is the only way to
improve the course and make important changes.
**DISTRIBUTE COURSE EVALUATION (included in the ANNEX)** Allow participants adequate time
(~15 minutes) to complete the evaluation.
(6.6) FORMAL COURSE CLOSING

Offer your closing thoughts, thank participants for their time and energy, and close the meeting.

PART SIX
Local Clinical Supportive
Meetings
st nd rd
1 2 and 3 Local Clinical Supportive
Meeting
214
SECTION 1 – MEETING OBJECTIVE
Two objectives exist for these meetings:

1. To provide clinical facilitated learning of recognition of findings, and application of the IMCI
process correctly by means of clinical case management in supervised small groups.
In this process the communication between local IMCI facilitators and the participants is
anticipated to be strengthened both for the duration of the course and for subsequent support
relationship after the completion of the formal course.
2. To ensure that genuine clinical practice is carried out by the participants, this is ensured by
insisting on the submission of 2 signed off case records for each clinical support session.
SECTION 2 – CARRYING OUT THE MEETINGS
Participants in suitable sized groups (probably between 4 and 8 per group) should meet ½ way
between the face to face with a local IMCI facilitator to practice supervised clinical IMCI
consultations.
Ideally they should meet at a convenient local venue that has adequate patient numbers, (eg District
Hospital / CHC / Large clinic) and see patients with the participants.
Each participant should see 2 patients will be recorded on the normal recording form and must be
“signed off” by the IMIC Facilitators. These forms are found the participant’s logbook and will be
submitted as part of the participants course evaluation.
In seeing patients – while it would be ideal for each participant to see 2 patients individually, it might
be necessary to have small groups seeing patients together if only a small number of patients is
available.
It is important to use the time constructively to see the patients, but also to allow queries to be aired
and modelling to occur so that participants can see

PART SEVEN
Final Local Clinical
Summative Meeting
Final Clinical Summative Meeting
216
SECTION 1 – MEETING OBJECTIVE
The aim of this meeting is to assess the ability of a participant to safely and effectively carry out and
IMCI consultation from assessment to counsel and follow up for all the modules (ie the full IMCI
process including child NIMART)
This assessment in addition to the module submissions from the log book process, plus the final
synthesis multiple choice assessment will be used to certify competency of the participant to function
as an independent IMCI practioner.
It can be see that this assessment is important in the overall ensureing of competency in our IMCI
practitioners.
If a participant is not found to be safe and effective during this assessment that should be told that they
have not fulfilled the clinical skills and remedial practice should be offered with reassessment 2 weeks
later.
The course director must be supplied with the outcomes of the 6 week summative assessment
including the opinion of the facilitator and the marks achieved – irrespective if they outcome is
positive or negative.
SECTION 2 – ASSESSMENT PROCESS AND FORMS FOR CLINICAL ASSESSMENT
In the clinical summative assessment the participant, 6 weeks after the 4th face to face, must meet with
the local facilitator at a site convenient to them, where sufficient clinically relevant primary care child
patients are available to carry out a clinical assessment of the participants skills.
A number of participants might be asked to attend on the same day at the same place but will be
assessed individually.
Each participant is to carry out two IMCI consultation in the presence of the local IMCI facilitator who
will assess them for competence in carrying out this consultation, assessing, classifying, treating,
counselling and arranging follow up. The cases may be either sick child, or sick young infant but only
a total of two cases. If undecided a 3rd case may be added.
Two assessment tools are on the following page – one for the sick child, one for the sick young infant.
These should be used to assess the participant and are derived from the SA IMCI Health Facility
Survey Tools. Only 2 children/infant consultations need to be assessed but the option of additional
cases is provide allow flexibility..
Ticks are made when the facilitator finds an intervention or item, and similarly for when the
participant does so. The total number of ticks for facilitators is counted and that for the participant
counted – they are used to calculate the percentage achieved for the 2 assessment consultations.
Total number of ticks by particpant both cases × 100
Percentage combined cases =
Total number of ticks by facilitator both cases
It is expected that a participant should score over 60% but the assessment is finally an opinion of the
facilitator.

Assessment : Sick Child (age 2 months up to 5 years)
Facilitator: Complete this assesment for 2 sick child - additional column if needed
Date: Participants Name: Course:
Case Management Task
Child Child Extra Marking
1 2 Comment / notes
First, tick () decisions by Supervisor No of No
Then, tick () if Health Worker agreed with Facili- Partici-
tator pant
Participant
Participant
Participant
supervisors decision.
Facilitator
Facilitator
Facilitator
BUT
Mark  if Health worker did not agree with ’s ’s
supervisors decision
Draw a line through both boxes if not
relevant to case
Assessment
1 Correctly assessed dangers signs 1. 1.
2 Assessed for presence of all main
symptoms (cough, diarrhoea, fever, ear 2. 2.
problem)
3 Assessed for presence of 3 symptoms
3. 3.
(cough, diarrhoea, fever)
4 Correctly checked weight 4. 4.
5 Correctly checked immunization 5. 5.
6 Assessed for malnutrition and anaemia 6. 6.
7 Assessed for HIV infection 7. 7.
8 Assessed for TB 8. 8.
Treatment
Severe cases
9 Severe cases referred 9. 9.
10 First dose ceftriaxone or amoxil given
10. 10.
if indicated
Non severe treatment cases
11 Antibiotic given for pneumonia 11. 11.
12 Antibiotic given for dysentery 12. 12.
13 Antibiotic given for acute ear infection 13. 13.
14 ORS given for some dehydration 14. 14.
15 Zinc given with diarrhoea 15. 15.
General and counsel
16 Immunization given according to
16. 16.
schedule
17 Assessed for feeding, and mother
17. 17.
counselled on feeding incl breast feeding
18 Mother counselled when to return 18. 18.
19 Advise on home care giving extra fluid
19. 19.
at home
20 Assessed other problems 20. 20.
Time (Write minutes taken to manage Total ticks for each
case, not including skills reinforcement column

Assessment :Sick Young Infant (SYI) (age birth up to 2 months)
Facilitator: Complete this assesment for 2 sick young infants- additional column if needed
Date: Participants Name: Course:
Infant Infant Extra Marking
CASE MANAGEMENT TASK
1 2 Comment / notes
First, tick () decisions by Supervisor No of No
Then, tick () if Health Worker agreed with Facili-- Partici-
tator pant
Participant
Participant
Participant
supervisors decision.
Facilitator
Facilitator
Facilitator
BUT
Mark  if Health worker did not agree with ’s ’s
supervisors decision
Draw a line through both boxes if not relevant to
case
Assessment
1 Correctly assessed for signs of serious
1. 1.
bacterial infection
2 Assessed for presence of diarrhoea. 2. 2.
3 Correctly assessed for presence of severe
3. 3.
or some dehydration.
4 Assessed for HIV infection 4. 4.
5 Correctly checked weight 5. 5.
6 Assessed for feeding and growth - breast
6. 6.
fed child
7 Assessed for feeding and growth - non-
7. 7.
breast fed child
8 Correctly checked special risk factors 8. 8.
9 Correctly checked immunization 9. 9.
Treatment
Severe Bacterial Infection
10 Severe cases referred 10. 10.
11 First dose ceftriaxone given 11. 11.
12 Test for low blood sugar carried out 12. 12.
13 Advised how to keep Infant warm on way
13. 13.
to hospital
Non severe treatment cases
14 Erythromycin given if local bacterial
14. 14.
infection
15 Referral if yellow palms or soles 15. 15.
16 ORS given for some dehydration 16. 16.
General and counsel
17 Immunization given according to schedule 17. 17.
18 Mother counselled on feeding incl breast
18. 18.
feeding
19 Mother counselled when to return 19. 19.
20 Assessed for other problems 20. 20.
Time (Write minutes taken to manage Total ticks for each

case, not including skills reinforcement column
Facil Parti
Ticks from sick child cases
Ticks from sick young infant cases
Total Ticks from both cases added together
Final Percentage both cases (100 x participants total ticks / facilitator total ticks) %

Reporting tool for outcomes of Summative Clinical Assessment
needs further
support and
assessment
Competent
Percentage
Participant Name Comment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

ANNEX
HANDOUTS FOR MEETING

1. Registration form
2. Written examination
3. Written examination answer sheet
4. Course evaluation
5. Template letter to District Manager requesting support in attendance,
transport, venue and catering support for the course.
ANSWER KEYS FOR FACILITATOR USE

a) Logbook MCQs
b) Written examination

REGISTRATION FORM—FINAL SYNTHESIS MEETING
Full name
Mobile phone
About how long did it take you to read and study the module?
What is your opinion of the amount of time given for self-

learning? Should the self-study period have been shorter or
longer (recommend # of weeks if different)?
How did you find the language in the module? Was it too
complicated to understand, or easily understood?
How did you find the layout of the module? Were there
enough pictures and graphics to make confusing things easier
to understand?
How did you find the opening case story in the module? Was it
useful, or what would you improve?
How did you organize time to practice IMCI in the clinic?
How did you find the recording forms and chart booklets as job
aids?
Did you feel prepared to practice the modules’ material in your

clinic?
Have you completed the exercises in the logbook? These YES NOT COMPLETELY
include multiple-choice, true/false, and case studies. NO (If no, explain)
Have you completed 5 or more recording forms while you YES NO (If no, explain)
practiced IMCI in your clinic?
Did you complete any ART initiation forms before referring the YES NO
child?
Did you carry out study groups? YES NO
If yes,
o How was it managed in each group?
o Was the timetable provided useful? How can it be
improved?
o What were the advantages of group study?
o What were the challenges of group study?

Did you do clinical practice alone or as a group? ALONE IN GROUP
If yes, BOTH ALONE & IN GROUP
o Did you see cases from each module?
o If there were difficulties on clinical practice, list them:
1.
2.
3.
4.
Have you received support from your mentors (tutor,
facilitator, group leader)?
If yes,
o Who are these mentors?
o How many times did you speak or meet? MOBILE PHONE TEXT/SMS
o How did you communicate with them? IN PERSON OTHER:
o How often is s/he available? Were they available when you
needed them?
o How did the mentor help? Describe in detail please.
What were the main challenges to learn and practice IMCI? CHALLENGES:
List down the main challenges and how they were resolved. HOW THEY WERE RESOLVED
Please describe in detail. (OR STILL NEED TO BE
RESOLVED):

ASSESSMENT TOOLS
MULTIPLE-CHOICE QUESTIONS MODULES 1-7
NAME MEETING SITE DATE
Instructions: Circle the correct answer(s). Remember that for some questions there may be more
than one correct answer. You may use your IMCI Chart Booklet and case recording forms as you
answer questions. You will have 30 minutes to complete the exam.
Mark for each if the answer is true(correct) or false(incorrect) True False
Correct Incorrect
1 Where should the IMCI guidelines be used?

in the inpatient ward of a hospital
in the outpatient ward of a hospital
in clinics and CHC’s
in specialized hospitals
2 The IMCI clinical guidelines describe how to manage a child:

with a chronic problem
with an acute illness
with injuries
during a follow-up visit
with trauma
3 The IMCI clinical guidelines are designed for use with which of the
following age group(s)?
Birth up to 5 years
2 months up to 2 years
1 month up to 5 years
4 When a child is brought to a health facility you should always check

for general danger signs. The general danger signs are:
child is restless or nervous
child is lethargic or unconscious
child cries loudly or too long
child is not able to drink or breastfeed
child vomits frequently
child has convulsions
child vomits everything
5 What is the cut-off rate for fast breathing in a child who is 10

months old:
60 breaths per minute or more

6 To classify the dehydration status of a child with diarrhoea you

should LOOK and FEEL for the following:
Sunken eyes
Blood in stool
If the child’s condition is restless or irritable
If the child is able to drink, or is thirsty
Skin turgor by skin pinch
Distended abdomen
7 In addition to assessing dehydration status, the mothers of ALL

children with diarrhoea should be asked:
For how long has the child had diarrhoea?
How many times did the child have watery stool?
What did the child eat before the diarrhoea started?
Is there blood in the stool?
Do other family members have diarrhoea?
8 A child should be assessed for the main symptom of FEVER if the

child:
has a history of fever
does not feel well
feels hot
has temperature 37º
has temperature 37.5º or above
has generalised rash
9 Which children should be checked for malnutrition and anaemia?

all children with feeding problem(s)
all children who are less than 12 months of age
all children brought to the clinic
all children who are not breastfeed
10 Read the case. For each classification indicate if it is correct or not.

Pemba is 18 months old. He weighs 9 kg, and his temperature is
37ºC. His mother says he has had a cough for 3 days. Pemba's
mother said that he is able to drink and has not vomited anything.
He has not had convulsions. Pemba was not lethargic or
unconscious. You counted 42 breaths per minute. The mother lifted
the child's shirt and you did not see chest indrawing. You did not
hear stridor when you listened to the child's breathing.

GENERAL DANGER SIGN
PNEUMONIA
COLD OR COUGH
SEVERE PNEUMONIA

Heera is 3 years old. She weighs 10 kg. Her temperature is 37ºC.
Her mother came today because Heera has diarrhoea. She does not
have any general danger signs. She does not have cough or difficult
breathing. When you asked how long Heera has had diarrhoea, the
mother said, "For more than 2 weeks." There is blood in the stool.
Heera is irritable during the visit, but her eyes are not sunken. She is
able to drink, but she is not thirsty. A skin pinch goes back slowly.
SEVERE DYSENTERY
SEVERE DEHYDRATION
SEVERE PERSISTENT DIARRHOEA
SOME DEHYDRATION
PERSISTENT DIARRHOEA

Anders is 3 years old. He weighs 10.2 kg. His temperature is
37,5ºC. His mother says he feels hot. He also has a cough, she says.
Anders was able to drink, had not vomited, did not have
convulsions, and was not lethargic or unconscious. The mother said
Anders had been coughing for 3 days. You counted 51 breaths a
minute. You did not see chest indrawing. There was no stridor
when Anders was calm. Anders does not have diarrhoea. Because
Anders’ temperature was 37.5ºC you assessed the child further for
signs of fever. The risk of malaria is high. The child has felt hot for
5 days, the mother said. The child did not have a stiff neck, but
there was runny nose, and generalized rash. There is no clouding of
cornea, pus draining from the eye, or mouth ulcers.
GENERAL DANGER SIGNS
FEVER OTHER CAUSE
COUGH OR COLD
PNEUMONIA
SUSPECTED MENINGITIS
MEASLES
SUSPECTED MALARIA

Dana is 18 months old. She weighs 9 kg. Her temperature is 37ºC.
Her mother said that Dana had discharge coming from her ear for
the last 3 days. Dana does not have any general danger signs. She
does not have cough or difficult breathing. She does not have
diarrhoea and she does not have fever. You asked about Dana's ear
problem. The mother said that Dana does not have ear pain, but
the discharge has been coming from the ear for 3 or 4 days. You can
see pus draining from the child's right ear. You do not feel any
tender swelling behind either ear.
MASTOIDITIS
CHRONIC EAR INFECTION
ACUTE EAR INFECTION
FEVER OTHER CAUSE
Kalisa is 11 months old. He weighs 8 kg. His temperature is 37ºC.

His mother says he has had a dry cough for the last 3 weeks. Kalisa
does not have any general danger signs. You assessed his cough. It
has been present for 21 days. You counted 45 breaths per minute.
You do not see chest indrawing. There is no stridor when the child is
calm.
Kalisa does not have diarrhoea. He has not had a fever during this
illness. He does not have an ear problem. You checked Kalisa for
malnutrition and anaemia. Kalisa does not have visible severe
wasting. His palms are very pale and appear almost white. There
is no oedema of both feet. Look at the weight for age chart in your
chart booklet and determine Kalisa's weight for age.
SEVERE PNEUMONIA
PNEUMONIA
COUGH OR COLD
SEVERE MALNUTRITION
NOT GROWING WELL
GROWING WELL
SEVERE ANAEMIA
ANAEMIA
SEVERE MALNUTRITION
GROWING WELL

15 Read the following case: Ahmed has been brought for a follow-up
visit for pneumonia. He is three years old and weighs 12.5 kg. His
axillary temperature is 37ºC. He has been taking amoxicillin. His
mother says he is still sick and has vomited twice today.
What signs will you look for when you reassess Ahmed today?
General danger signs
Fast breathing
Dry cough
Chest indrawing
Stridor or wheeze
If the child is restless or irritable
16 What questions will you ask Ahmed’s mother to re-assess his cough
or difficult breathing?
Is the child breathing slower?
Is there less fever?
Is the child eating better?
Is there diarrhoea?
17 Read the rest of the case: When you reassess Ahmed, you find that
he is able to drink and does not always vomit after drinking. He has
not had convulsions. He is not lethargic or unconscious. He is still
coughing, so he has been coughing now for about 2 weeks. He is
breathing 55 breaths per minute. He has chest indrawing. He does
not have stridor. His mother says that sometimes he feels hot. She
is very worried because he is not better although she tells you how
she has given the medicine as you instructed. He has hardly eaten
for two days.
Is Ahmed getting worse, the same, or better? How will you treat
him?
Ahmed is better. He requires home treatment for cough. You
will counsel on feeding recommendations to encourage Ahmed
to eat better.
Ahmed is the same. He requires cotrimoxazole, the second line
drug for PNEUMONIA, because the first line amoxicillin did not
clear up the cough.
Ahmed is worse. He requires a first dose of ceftriaxone IM and
urgent referral.
18 Oko is 2 years old. He is classified with SUSPECTED MENINGITIS,

CHRONIC EAR INFECTION, and ANAEMIA. He needs referral for
SUSPECTED MENINGITIS. Of his identified treatments listed below,
which are the urgent, pre-referral treatments that he requires?

Advise mother when to return for follow-up
Prevent or treat low blood sugar
Give first dose of paracetamol in clinic for high fever (38.5ºC or
above).
Dry the ear by wicking
Give first dose of ceftriaxone IM
Give iron oral
Give mebendazole
19 A 6-month-old (7.4 kg) child has PNEUMONIA and MASTOIDITIS.

What treatments and dosages will you provide at the clinic right
now?
Ceftriaxone IM, 500 mg (dilute in 2 ml sterile water)
Amoxicillin syrup, 10ml (125mg/5ml)
Paracetamol syrup, 2.5 ml (120mg/5ml)
Cotrimoxazole syrup, 5ml (40/200mg)
Ceftriaxone IM, 250 mg (dilute in 1 ml sterile water)
20 What topics are included in the IMCI guidelines for counselling a

mother of a sick child?
Feeding recommendations
Home treatment, like a soothing remedy for sore throat
When to return for follow-up
When to return immediately
Giving oral antibiotics
21 Which of the following are not in the 3 rules of home treatment of

diarrhoea?
Give zinc supplements
Give extra fluid
Give iron
Continue feeding
When to return
Reduce feeding
22 A child has the following classifications: no general danger signs,

diarrhoea with NO DEHYDRATION, PERSISTENT DIARRHOEA, NO
ANAEMIA, and GROWING WELL. What signs will you teach the
mother to watch for, to return immediately?
The child becomes sicker
Not able to drink or breastfeed
Convulsions
Vomits everything
Develops a fever

Blood in stool
Drinking poorly
23 Rena is 5 months old and weighs 4 kilograms. She is classified

SEVERE MALNUTRITION. When you assess Rena's feeding, her
mother tells you that she breastfeeds 4 times in 24 hours and also
gives Rena cow's milk by feeding bottle 2 times per day. The mother
explains that she gives no other foods to Rena and her feeding did
not change during this illness.
What are Rena's feeding problems?
She is not being breastfed enough—she should breastfeed at
least 8 times in 24 hours.
She should not receive other foods besides breast milk.
Rena has no feeding problems.
24 It is important to ask good checking questions to ensure that a

mother understood well your treatment instructions. How could
you ask: “Do you remember how to give the syrup?” as a checking
question?
Do you know what syrup to give?

How will you give the syrup?
Remember to give the syrup twice a day.
25 The following sick children need urgent referral—true or false?

Read their classifications and decide.
Sara is 11 months and has no general danger signs. She is
classified: PNEUMONIA, ACUTE EAR INFECTION, NO ANAEMIA,
GROWING WELL.
David is 7 months old. He has no general danger signs. He is
classified: MASTOIDITIS, FEVER OTHER CAUSE , NO ANAEMIA,
GROWING WELL.
Isoke is 2 years old. She has no general danger signs. She is
classified: diarrhoea with NO VISIBLE DEHYDRATION, and
SEVERE MALNUTRITION.

MULTIPLE-CHOICE QUESTIONS MODULE 8
NAME MEETING SITE DATE
Instructions: Circle the correct answer(s). Remember that for some questions there may be more
than one correct answer. You may use your IMCI Chart Booklet and case recording forms as you
answer questions. You will have 30 minutes to complete the exam.
Mark for each if the answer is true(correct) or false(incorrect) True False

Correct Incorrect
1 What is an opportunistic infection?

An infection that takes advantage of the weakness of the
immune system to cause disease
An infection that takes advantage of an open lesion in a
person’s body to cause disease
A disease for which home care is the only treatment
2 A child can be infected with HIV from his mother:

During pregnancy if maternal PMTCT ART is not given
During delivery if maternal PMTCT ART is not given
During breastfeeding if infant NVP or maternal full ART is not
given
3 If nothing is done to prevent transmission from mother-to-child,

the chance of transmission is:
About 50%
About 35%
About 80%
4 What is the difference between assessing a child and young infant

for HIV?
A young infant often has clear presentation of clinical features
of HIV
There is not difference.
A child often has clear presentation of clinical features of HIV
5 Which of the following is true about testing a young infant for HIV?
All children of HIV positive mothers should be tested at 6 weeks
old using PCR; if the infant shows signs of HIV infection earlier,
they should be tested at that time.
Young infants should be tested with an rapid antibody test if
HIV is suspected or exposed.
If the child is breastfeeding the HIV test must be repeated 1
week after breastfeeding has stopped

6 Zahir is 23 months old, and his rapid test is positive. What are your
next steps?
Classify as HIV INFECTION
Repeat a second antibody test
Collect blood specimen for a PCR test
Enlarged lymph glands (in two or more sites), oral thrush, or

parotid enlargement
Diarrhoea, fever, and cough more than 14 days.
Skin rashes, red eyes and enlarged lymph glands.
8 Masha is 21 months old. She tested positive with a rapid antibody

tested, but her second confirmatory test is negative. Does she have
confirmed HIV infection, and what is your next step?
No, the second test is the most accurate due to age, no further
test.
Possibly, you must take a third rapid test
Possibly, send an ELISA test to the laboratory
9 Thabo is 9 months old, and has tested negative with a PCR test. He
is still breastfeeding. How will you classify?
HIV NEGATIVE
HIV EXPOSED
POSSIBLE HIV INFECTION
10 Matello is 7 weeks old. Her mother’s HIV status is not known. How
will you classify?
HIV EXPOSED
HIV UNKNOWN
HIV UNLIKELY
11 Raul is 5 months old with PERSISTENT DIARRHOEA, SEVERE

MALNUTRITION, and oral thrush. He has not been tested for HIV,
and neither has his mother. How will you classify?
SUSPECTED SYMPTOMATIC HIV INFECTION
HIV EXPOSED
12 Rahima is 7 months old with PNEUMONIA, ear discharge, and

parotid swelling. She tested HIV positive with a PCR test. How will
you classify?
SUSPECTED SYMPTOMATIC HIV INFECTION

HIV INFECTION
13 An 8 week old boy is brought to your clinic. He was abandoned at

birth. He had a PCR test done at 6 weeks, and it was negative. How
will you classify?
HIV INFECTION
HIV NEGATIVE
14 Juanelo is 21 months old with PNEUMONIA and a positive

confirmed HIV antibody test. How will you classify?
HIV INFECTION
HIV NEGATIVE
15 What does a CD4 count or percentage tell you?

The amount of HIV in the body
The severity of damage to the body’s immune system that HIV
has caused
How much HIV virus has been destroyed by ART
16 Mark is 2 months old. You have used a PCR test, and the test is
positive. His mother reports that he has had persistent diarrhoea,
and you measure that he is low weight for age. He is breastfeeding.
Which of the following steps will you take?
Initiate ART today and provide feeding recommendations
Start co-trimoxazole prophylaxis, do CD4 count and staging.
Manage the diarrhoea appropriately to the IMCI process and
begin the preparation for ART.
17 In advising about HIV care, you should tell the caretaker and/or the
child:
ART drugs can be taken anytime during the day.
ART drugs must be taken every day for life at the exact same
time.
Drug doses can be doubled if he/she forgets to take it one day.
18 Liam is 7 months old, and tested negative (PCR) at 6 months of age.

He stopped breastfeeding at 3 months. He weighs 8kg today.
Should he begin cotrimoxazole?
Yes, 2.5 mL daily
No

Yes, 5 mL daily
19 Which of the following children are eligible for ART according to the
criteria?
Kira is 14 months old, HIV positive and clinical stage 1. Her CD4
% is 23%
Zinsi is 18 months, HIV positive and clinical stage 3. Her CD4 %
is unknown.
Imrana is 4 years old, HIV positive, and clinical stage 2. Her CD4
% of 40%.
20 What does a viral load test tell you?

How much of the body’s CD4 lymphocytes have been damaged
How much active HIV virus is in the blood; the higher the viral
load, the more HIV present
How much HIV virus has been destroyed by ART
21 How could you ask: “Do you remember how to give the
cotrimoxazole syrup?” as a checking question?
How will you give the cotrimoxazole syrup?
Do you know what syrup to give?
Remember to give the cotrimoxazole syrup twice a day.
22 What are the feeding recommendations for HIV positive women in

South Africa?
Breastfeed with complementary food even in the 1st 6 months
to increase nutritional content as nevirapine is now given, may
be continue to do so even after 6 months.
Preferably provide replacement milk from birth if AFASS criteria
are met.
Breastfeed exclusively for 6 months, then also give
complementary food until about 12 months. Start nevirapine
from birth and continue for the duration of breast feeding.
23 Jo began first-line ART 6 weeks ago, and his mother brought him to
the clinic today because his eye have become yellow in the last 3
days. What actions will you take?
Stop the medications and refer urgently
Change the dosing of Abacavir
Give paracetamol
For Each of the following indicate true or false

24 ART is a lifelong therapy.
25 Working with a caretaker on drug adherence is a critical step in HIV
care for the child. You may have to delay ART initiation if you feel
the caretaker is not ready.

IMCI DISTANCE LEARNING COURSE - SKILLS STATIONS ANSWER SHEET
NAME ______________________ MEETING SITE DATE_________
STATION 1 - IDENTIFYING SIGNS – PHOTO EXERCISE

Review the photographs and background information provided. Identify the clinical sign or
condition. If a photo is of breastfeeding technique, assess the infant’s attachment.
PHOTO WHAT CLINICAL SIGNS or CONDITIONS DO YOU IDENTIFY?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
STATION 2 – IDENTIFYING SIGNS – VIDEO EXERCISES

VIDEO EXERCISE 1 - Do the seven children in the video have chest indrawing?
CHILD CHEST INDRAWING? CHILD CHEST INDRAWING?

1  YES  NO 5  YES  NO
4  YES  NO
VIDEO EXERCISE 2 - Do the six children in the video have sunken eyes?
CHILD SUNKEN EYES? CHILD SUNKEN EYES?

VIDEO EXERCISE 2 – Does the skin pinch in each child return: immediately, slowly, or very slowly?
CHILD SKIN PINCH
1  IMMEDIATELY  SLOWLY  VERY SLOWLY
STATION 3 - CASE STUDIES

Read the case studies. You can use your chart booklet and recording form to assess and classify.
Then answer the two questions below each case.
Zinet is 2 years old. Her mother brought her for an initial visit for cough and bloody diarrhoea. She
has had the diarrhoea for 2 days. Her weight is 9.0 kg. She has a temperature of 38.6o Celsius.
On assessment you find that Zinet breathes 54 breaths per minute. You do not observe chest
indrawing, wheeze, stridor or general danger signs. She has sunken eyes, and she is restless and
irritable. She has palmar pallor, but no visible wasting. She never received any immunizations. She
is still breastfeeding, but eats other foods as well. She has had ear discharge for the last 3 weeks.
Classify Zinet's illnesses:
List the priority treatments you will give at this initial visit for Zinet:
--------
Mitu was born 3 days ago after prolonged labour. Her mother says she has not been sucking the
breast at all in the past 24 hours. Mitu breathes with difficulty. You measure her breathing twice.
She breathes 86 and 90 breaths per minute in the two counts. She has chest indrawing. She does
not move at all. Her palms are very yellow.
How would you classify Mitu’s illness?
What actions will you take immediately?

INDIVIDUAL ACTION PLAN
YOUR IMCI ACTION PLAN

This is an opportunity for you to think about goals and next steps after this course.
Using IMCI in your clinic

■ How will you continue using IMCI in your clinic?
■ How will you improve the ways you use IMCI in your clinic?
Continued learning & refreshers

■ How will you continue to learn new skills in integrated case management and caring for sick
children and young infants?
■ How will you plan to refresh your skills in IMCI?
Working with others

■ How will you continue to work with mentors? What mentors are available to you, especially if
you have questions or problems with a case using IMCI?
■ How will you share IMCI with your colleagues and in-charge officer? How will you show others
how you are using the chart booklet and recording forms on the job?

COURSE EVALUATION
MEETING SITE:
NAME (OPTIONAL):
1. As you finish this course, do you feel prepared to use integrated case management with children
in your clinic?
2. What areas or skills do you still have concerns about?
3. What are two things that you found the most useful during your self-study?
a.
b.
4. What are two things you would improve about the self-study process?
a.
b.
5. What did you find most useful during the face-to-face meetings?
6. How can the facilitators improve the face-to-face meetings?
7. Would you recommend this course to colleagues? Why or why not?

PROFORMA LETTER — SUPPORT REQUEST FOR COURSE
Your Heading
Date
The District Manager/ LSA Manager

Health
District / LSA __________________
Dear Sir/Madam,
Re: distance IMCI Course for PHC nursing staff in your district/sub district
As you will know from your training or MCWH manager ____ PHC nurses from your district / sub
district have been enrolled to undergo training in IMCI case management (which include child
NIMART) over the next period from ___d ___m ____y to ___d ___m ____y . Their names are on the
attached page.
While the format of the course has been amended to minimise their time away from their posts and
avoids overnight stays, it is still critical for the success of their learning that they received support for
the specified learning processes and we wish to ask for your specific support in the following
respects.
1) Their attendance at each of the 4 face to face meetings needs to be from 08h30 to 16h30 and to
this end we ask that you facilitate the following:
a) That they are permitted to leave their work sites for each of these days.
b)That transport is provided for them to go to and return from the meeting sites.
c) That an IMCI course director and 1 or 2 IMCI facilitators are released for each of these days (the
same facilitators should ideally be release for each day in the course for continuity).
d)That you assist with booking a venue suitable for 25 people who will need seating (ideally with
tables/ desks to work on), suitable for data projection and close to a clinical setting which has
significant numbers of children for clinical practice (often a district hospital is best) for each
meeting.
e) That you assist with the provision of morning tea / coffee (with biscuits) and a light lunch (eg
sandwiches) with juice for each meeting.
f) The dates and sites of these meetings are:

Date Site
1 __________________ _________________________________
2 __________________ _________________________________
3 __________________ _________________________________
4 __________________ _________________________________
2) Their attendance at each of 3 clinical support meetings between face to face meetings and 1
summative clinical assessment 6 weeks after the last face to face meeting needs to be between
08h30 and 13h00 and to this end we request.
a) That they and the facilitators are permitted to leave their work sites for each of these ½ days
b) That transport be provided for them to reach the agreed clinical meeting sites.
c) That morning tea/coffee with biscuits be provided on these days.
The actual sites, dates and numbers attending on each day will be coordinated by the course
facilitators but will usually be about 4-10 people for each of 3-6 morning meetings ½ way
between each face to face meeting, plus 6weeks after the last face to face meeting, at a site
convenient for each group with adequate clinical patients for clinical practice.
We wish to thank you in anticipation of your support for the training of your staff in these critical
skills with which we believe some advances will be made towards improving the health and survival
of our provincial children. The training is totally consistent in content with the national IMCI/Child
NIMART competencies and designed to run on adult learning lines in a less disruptive and less
expensive format.
Yours Sincerely
_________________
IMCI Course Director
_________________ District / LSA

ANSWER KEYS
Module Answers

MODULE 1 - GENERAL DANGER SIGNS
ASSESSMENT QUESTIONS
Below are questions about the module. Mark the answers correct (true) or incorrect (false).
You are allowed to use your Chart Booklet, but not your study modules, as you answer the questions.
More than one answer may be correct (true) for each question.
Module answer keys still to be inserted

IMCI DISTANCE LEARNING COURSE - SKILLS STATIONS ANSWER SHEET
NAME ______________________ MEETING SITE DATE_________
STATION 1 - IDENTIFYING SIGNS – PHOTO EXERCISE

Review the photographs and background information provided. Identify the clinical sign or
condition. If a photo is of breastfeeding technique, assess the infant’s attachment.
PHOTO WHAT CLINICAL SIGNS or CONDITIONS DO YOU IDENTIFY?

1 Sunken eyes - dehydration
2 Very slow skin pinch - dehydration
3 Red eyes and rash - measles
4 Clouded cornea – measles w/ eye compli.
5 Severe wasting – severe malnutrition
6 Oral thrush
7 Palmar pallor - anaemia
8 Umbilicus pustules - infection
9 Bipedal oedema – severe malnutrition
10 Poor attachment
11 Poor attachment
12 Umbilicus local infection (redness)
13 Good attachment
14 Poor attachment
15 Good attachment
STATION 2 – IDENTIFYING SIGNS – VIDEO EXERCISES

VIDEO EXERCISE 1 - Do the seven children in the video have chest indrawing?
CHILD CHEST INDRAWING? CHILD CHEST INDRAWING?

1  YES  NO 5  YES  NO
2  YES  NO 6  YES  NO
4  YES  NO
VIDEO EXERCISE 2 - Do the six children in the video have sunken eyes?
CHILD SUNKEN EYES? CHILD SUNKEN EYES?
2  YES  NO 5  YES  NO

VIDEO EXERCISE 2 – Does the skin pinch in each child return: immediately, slowly, or very slowly?
CHILD SKIN PINCH
1  IMMEDIATELY  SLOWLY  VERY SLOWLY
2  IMMEDIATELY  SLOWLY  VERY SLOWLY
3  IMMEDIATELY  SLOWLY  VERY SLOWLY
4  IMMEDIATELY  SLOWLY  VERY SLOWLY
5  IMMEDIATELY  SLOWLY  VERY SLOWLY
STATION 3 - CASE STUDIES

Read the case studies. You can use your chart booklet and recording form to assess and classify.
Then answer the two questions below each case.
Zinet is 2 years old. Her mother brought her for an initial visit for cough and bloody diarrhoea. She
has had the diarrhoea for 2 days. Her weight is 9.0 kg. She has a temperature of 38.6o Celsius.
On assessment you find that Zinet breathes 54 breaths per minute. You do not observe chest
indrawing, wheeze, stridor or general danger signs. She has sunken eyes, and she is restless and
irritable. She has palmar pallor, but no visible wasting. She never received any immunizations. She
is still breastfeeding, but eats other foods as well. She has had ear discharge for the last 3 weeks.
Classify Zinet's illnesses:
 PNEUMONIA  CHRONIC EAR INFECTION
 SOME DEHYDRATION  ANAEMIA
 DYSENTERY  NOT IMMUNIZED
List the priority treatments you will give at this initial visit for Zinet:
 Antibiotic for pneumonia and ear infection -  Advice when to return immediately
amoxicillin for 5 days  Follow up in 2 days - at that stage, if child has
 Plan B to manage some dehydration improved continue same treatment, and begin
 Zinc for 2 weeks treatment for anaemia and chronic ear
 Antibiotic for dysentery - ciprofloxacin x 3 days infection
--------
Mitu was born 3 days ago after prolonged labour. Her mother says she has not been sucking the
breast at all in the past 24 hours. Mitu breathes with difficulty. You measure her breathing twice.
She breathes 86 and 90 breaths per minute in the two counts. She has chest indrawing. She does
not move at all. Her palms are very yellow.
How would you classify Mitu’s illness?

 POSSIBLE SERIOUS BACTERIAL INFECTION  JAUNDICE
What actions will you take immediately?

 Give oxygen
 Give first dose ceftriaxone IM
 Test for low blood sugar and treat
 Refer urgently
 Keep infant warm on the way

246
9. Final assessment answer keys still to be inserted

POST-COURSE MONITORING
AFTER THE 6 WEEK SUMMATIVE ASSESSMENT THE PARTICIPANT WILL BE CERTIFIED COMPETENT AND FURTHER MONITORING AND
SUPPORT WILL BE FROM THE USUAL VISITS BY MCWH MANAGER AND NIMART MENTORS OF THE LOCAL LSA.


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Zaf CH 20 01 Operational Guidance 2012 Eng South Africa DL Imci Facilitator Manual Colour

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DISTANCE LEARNING COURSE

World Health Organization

WHAT IS IN THIS GUIDE?

PART ONE ......................................................................................................................................... 4

FACILITATOR GUIDE – Distance learning course on IMCI 3

WHY DISTANCE LEARNING?

HOW IS THIS COURSE STRUCTURED?

FACILITATOR GUIDE – Distance learning course on IMCI 5

■ IMCI includes instructions to do the following:

FACILITATOR GUIDE – Distance learning course on IMCI 6

HOW WAS THIS COURSE ADAPTED IN-COUNTRY?

Distance learning course structure

3-4 6-8 4 weeks

Self-study phase 1 Self-study phase 2 Self-study phase 3

Review with study groups

Work with mentors

Clinical Formative Clinical Formative Clinical Formative Clinical

about 4 months 6 weeks

FACILITATOR GUIDE – Distance learning course on IMCI 9

FACILITATOR GUIDE – Distance learning course on IMCI 10

FACE-TO-FACE / CLINICAL MEETINGS

FACILITATOR GUIDE – Distance learning course on IMCI 11

MEETING LEARNING OBJECTIVES

1st Clinical Support Meeting

FACILITATOR GUIDE – Distance learning course on IMCI 12

MEETING LEARNING OBJECTIVES

2nd Clinical Support Meeting

3rd meeting—review and practice 2

MEETING LEARNING OBJECTIVES

FACILITATOR GUIDE – Distance learning course on IMCI 13

4th meeting—final synthesis

MEETING LEARNING OBJECTIVES

If not, certificates of attendance or completion may be issued as appropriate at the course

FACILITATOR GUIDE – Distance learning course on IMCI 14

FACILITATOR GUIDE – Distance learning course on IMCI 15

What is the logbook?

FACILITATOR GUIDE – Distance learning course on IMCI 16

This course has several components:

• COURSE FACILITATORS: Facilitators should be clear with participants about corresponding

FACILITATOR GUIDE – Distance learning course on IMCI 17

Activity Objectives of assessment Submission date

FACILITATOR GUIDE – Distance learning course on IMCI 18

WHAT DO PARTICIPANTS RECEIVE WHEN COMPLETING THE COURSE?

FACILITATOR GUIDE – Distance learning course on IMCI 19

AFTER THE COURSE

FACILITATOR GUIDE – Distance learning course on IMCI 20

Who should facilitate this course?

How many facilitators are required?

Who are your participants?

FACILITATOR GUIDE – Distance learning course on IMCI 21

What does a facilitator do?

FACILITATOR GUIDE – Distance learning course on IMCI 22

FACILITATOR GUIDE – Distance learning course on IMCI 23

 Be attentive to participant needs and questions. Be available to participants and encourage

 Encourage participants to ask questions or seek clarification with open-ended questions

 Be respectful, and promote a respectful learning environment. Do not allow anyone to

FACILITATOR GUIDE – Distance learning course on IMCI 24

1. This facilitator guide, which includes a chapter for each meeting

2. PowerPoint presentation slides for each face-to-face meeting

3. IMCI training DVD

4. Participant self-study modules and logbook for distribution

5. IMCI chart booklets for distribution to all