Induction

Training Module
for ASHAs

Ministry of Health & Family Welfare

Nirman Bhavan, New Delhi
Induction Training Module
for ASHAs
(A consolidated version of Modules 1 to 5
for newly selected ASHAs)
Design and layout:
New Concept Information Systems Pvt. Ltd.
Contents
Section 1
Being an ASHA 7
Section 2
What is a Healthy Community? 19
Section 3
Understanding Rights and Right to Health 21
Section 4
Skills of an ASHA 29
Section 5
Knowing About Health, Hygiene and Illness 41
Section 6
Dealing with Common Health Problems 49
Section 7
Infectious Diseases - Tuberculosis,
Leprosy and Malaria 59
Section 8
Maternal Health 65
Section 9
Newborn Care 73
Section 10
Infant and Young Child Nutrition 79
Section 11
Adolescent Health 97
Section 12
Reproductive Tract Infections and
Sexually Transmitted Infections 105
Section 13
Preventing Unwanted Pregnancies 109
Section 14
Safe Abortion 113
Annexures 117
Acknowledgements
The Induction Training Module for New ASHAs is a consolidation of the
contents of the first five ASHA Modules. It represents the hard work of a large
number of individuals and institutions who were involved in developing
these modules. Acknowledgements are due to members of the National ASHA
Mentoring Group and State Nodal Officers for ASHA and Community Processes,
who provided valuable insights and feedback for developing this Module.
What is this Book about?
You have chosen to be an ASHA. You have been selected by your community
to serve as a resource because you understand their needs, their beliefs and
practices, the social factors, where the poor and needy live, and what people
want from health services. You already know a lot about the community
in which you live. However in order to be an effective resource, you need
additional knowledge and skills. You need to learn about health rights and
entitlements, the causes and treatment of common illnesses, and type of
treatment available at different facilities. You need to develop the skills to
communicate health related information to people in the community, to
counsel them on prevention of illness and to adopt healthy behaviours, to treat
minor ailments and the leadership ability to help people negotiate access to
rights and entitlements.

This book is the first in a series of books that will help you do this. As a new
entrant to the ASHA programme, this book provides you with a basic level of
knowledge and skills to enable you to start your work. After you have grasped
the contents of this book and have applied your new knowledge in your
community, additional rounds of trainings will follow, in which you will not only
learn many new things but also get more information on topics that you will
learn in this book. Your community is also an important source of knowledge.
Use the knowledge and skills that you get from your books, to build on your
learning from the community, so that you can offer help to the people. That
is why your training is conducted for a short duration and allows you time
to practice your new skills in the community. After this training, you will be
assessed and get a basic certification in communication and social mobilisation.
The next level of certification is after four rounds of training and this will enable
you to address issues in care of mothers, newborns and children. As your skill
level improves, additional certification will be available.
6 Induction Training Module for ASHAs
Section 1

Being an ASHA

What are the Main Roles of the ASHA?

An ASHA is “ a woman selected by her community, based in her community
and serves as a resource to her community”. Your role is three-fold: to be
a facilitator of health services and link people to health care facilities, to
be a provider of community level health care, and an activist, who builds
people’s understanding of health rights and enables them to access their
entitlements.

Didi, which day is the ANM

coming to our village?

This is the first day of diarrhoea. Do Didi, they are charging me at the
I have go to the far away town or is govt hospital and I don’t have the
there something you can suggest? money to pay – can you help me?

With continuous training and support, you mature in your role as an ASHA. You
gain the confidence of the people, make them aware of their health rights and
gradually start to involve and mobilise the community in local health planning.

Induction Training Module for ASHAs 7

 Activities of an ASHA

Home
Visits

Attending
Maintaining
the VHND
Record

Holding VHSNC Visits to the

Meetings Health Facility

Five key Activities of an ASHA

ASHA’s work consists mainly of five activities:

1. Home visits: For two to three hours every day, for at least four or five days
a week, you should visit the families living in your community. If it is a large
village, then you will have a certain number of allocated households. Home
visits are mainly for health promotion and preventive care. Over time,
families will come to you when there is a problem and you will not have to
go so often to their houses. However, where there is a child below two years
of age or any malnourished child or a pregnant woman, you should visit
the families at home for counselling them. Also, if there is a newborn in the
house, a series of seven visits or more becomes essential.

2. Attending the Village Health and Nutrition Day (VHND): On one day
every month, when the Auxiliary Nurse Midwife (ANM) comes to provide
antenatal care, immunisation and other services in the village, you, as the
ASHA will promote attendance by those who need the Anganwadi or ANM
services and help with service delivery.

3. Visits to the health facility: This is usually accompanying a pregnant

woman or some other neighbour who requests her services for escort.

8 Induction Training Module for ASHAs

 The visit could also be to attend a training programme or review meeting. In
some months, there would be only one visit, in others, there would be more.

4. Holding village level meeting of women’s groups, and the Village

Health Sanitation and Nutrition Committee (VHSNC), for increasing health
awareness and to support village health planning.

5. Maintain records to help organise your work, and know what you need to
do each day.

Essential tasks for an ASHA

1. Maternal Care 2. Newborn Care when visiting

the newborn at home
a. Counselling of pregnant
women a. Counselling and problem
b. Ensuring complete solving on breastfeeding
antenatal care through b. Keeping the baby warm
home visits and enabling c. Identification and basic
care at VHND management of LBW (Low Birth
c. Making the birth plan and Weight) and pre-term baby
support for safe delivery d. Examinations needed for
d. Undertaking post-partum identification/first contract care
visits, Counselling for for sepsis and asphyxia
family planning.

3. Child Care

a. Providing home care for diarrhoea, Acute

Respiratory Infections (ARI), fever and
appropriate referral, when required
b. Counselling for feeding during illness
c. Temperature management
d. De-worming and treatment of iron deficiency
anaemia, with referral where required
e. Counselling to prevent recurrent illness
especially diarrhoea.

Induction Training Module for ASHAs 9

 4. Nutrition 5. Infections

a. Counselling and a. Identifying persons whose

support for exclusive symptoms are suggestive of
breastfeeding malaria, leprosy, tuberculosis, etc.
b. Counselling mothers during home visits, community
on complementary level care and referral
feeding b. Encouraging those who are put
c. Counselling on treatment to take their drugs
and referral of regularly
malnourished children. c. Encouraging the village
community to take collective
action to prevent spread of these
infections and individuals to
protect themselves from getting
infected.

6. Social Mobilisation

a. Conducting women’s group meetings

and VHSC meetings
b. Assisting in making village health plans
c. Enabling marginalised and vulnerable
communities to be able to access
health services.

These tasks need a set of specific skills like, Leadership, Communication, Decision-Making,
Negotiation, and Coordination which you will learn later in this training programme.

10 Induction Training Module for ASHAs

Values of an ASHA
Here are some important values which should guide you in your work:

Be kind: Have compassion for people and never be afraid to show that you
care. Be especially kind to those who are sick, it is more important than a
medicine. Try not to refuse your services to any individual who really needs
them.

Treat everybody equally: Treat each individual equally irrespective of her or

his class, caste, sex and religion. As a health worker your concern is well being of
all the individuals not just those you know well or who come to you or who are
the better off and powerful. Inequalities in our society deprive many sections
of community from health care services. These are the marginalised people and
include those who come from extremely poor families, live in inaccessible or
distant part of our villages, belong to scheduled caste/scheduled tribe families,
have only women in their households and are disabled or handicapped.
Treating everybody equally also means spending more time and effort on those
whose needs are more.

Be responsible: Be responsible to your designated duties and never misuse

your authority for your benefit or for the benefit of friends and relatives

Respect people’s traditions and ideas: People are slow to change their
attitudes and traditions and are true to what they feel is right. Rather than
insisting that they adopt your approach, you must try to build on their existing
knowledge with your ideas. For example-you can promote the use of modern
medicine together with the traditional methods and the combination may
serve better than either one alone. Thus, you can promote the use of ORS for
treating a child with diarrhoea but at the same time encourage mothers to use
traditional preparation like rice water, coconut water to overcome dehydration.

Keep learning: Use every chance you get to increase your own knowledge
either through reading books, or attending training programmes or asking
questions.

Be a role model: If you want people to take part in improving their village and
care for their health, you must be a role model and practise healthy habits and
behaviours. This way you will earn people’s trust and confidence.

Induction Training Module for ASHAs 11

 ASHA Support and Supervision
For you to be effective and to continuously improve your skills, you
need support and mentoring while you work in the community and
also refresher trainings.

ASHA Support
mainly comes from

Anganwadi Worker and Village

Health Sanitation and Nutrition
Committee Members

ASHA Facilitators

Auxillary Nurse Midwife

You all are expected to work together as a village health team

12 Induction Training Module for ASHAs

Anganwadi worker

The Anganwadi worker, like you is also a local resident. She is in charge of the
Anganwadi Centre, which provides these services:

l Supplementary nutrition: For children below six years, and for pregnant
and lactating Mothers. This could be a cooked meal, or in the form of take-
home rations. Malnourished children are given additional food supplements.
Adolescent girls (10 years to 19 years) are also given Weekly Iron and Folic
Acid Supplement and tablets for de-worming.

l Growth monitoring: Involves weighing of all children below 5 years of age,

but especially those who are under 3 years of age, growth monitoring through
growth charts, tracking malnourished children and referral for children who are
severely malnourished.

l Pre-school non-formal education: Includes activities for playful learning

and providing a stimulating environment, with inputs for growth and
development especially for children between three to six years of age.

Village Health and Sanitation and Nutrition Committee (VHSNC)

The Village Health and Sanitation and Nutrition Committee (VHSNC) is an
institution constituted at the level of a revenue village to promote collective
action around health, sanitation and nutrition. The VHSNC is the platform
for taking ‘local level community action’ for monitoring health status, and to
undertake local level health planning. The VHSNC includes the Panchayat
Representatives, the AWW, the ANM, and other community members, particularly
women, and the marginalised. In most states you are the Convenor or Member
Secretary of this Committee. The VHSNC is meant to serve as a support to you
in social mobilisation and in enabling the community to access their rights and
entitlements. With the support of the VHSNC you can also take action on water
and sanitation issues, and on social issues like early marriage, sending girls to
school, violence against women or any other problems that are specific to
your village.

The VHSNC receives a sum of Rs. 10,000/- per year as an untied fund. This is to be
used in order to undertake activities for village level improvements in sanitation
and health status. It is your responsibility to help the PRI member and AWW to
call the meeting, record the minutes, and take follow up action.

Future training module will extensively cover your role and the functions of
the VHSNC.

Induction Training Module for ASHAs 13

 Roles and responsibilities of VHSNC –The VHSNC convenes a monthly meeting
with representation of the members from the villages and attached hamlets. It
undertakes following functions-

l P
rovide information on health
Generate Awareness in programmes and related entitlements
the community about,
l M
 otivate people to avail the public
sanitation and nutrition
health care services

l M
 onitor availability, quality, outreach,
Monitor Health Services and reach to the marginalised sections
being provided l O
versee/support work of public
service functionaries

l Total population, number of households,

families falling under BPL category, with
information their religion, caste, language.
Report and Maintain
l Births
information/data of village
l Infants, maternal and other deaths
l Outbreaks

l B
ased on the needs assessment of the village
situation of health, sanitation and nutrition,
Make Village health plan and health service delivery, identify which
and take follow up action sections of the community have not received
services, reasons thereof, determine what
action is needed, where it is needed and act
accordingly

Through
l D
isinfection/chlorination of water sources,
Improve drinking safe disposal of waste, cleanliness around
water facilities and households and hand pumps
cleanliness of village l C
onstruction of household toilets (under
Total Sanitation Campaign)
l P
reventing breeding of mosquitoes which
cause diseases like malaria

l Through collective community action

Improve other social on literacy, early age of marriage, low sex
determinants of health ratio, poverty, nutrition (mid-day meals,
food safety), substance abuse
14 Induction Training Module for ASHAs
ASHA Facilitator
The first level of support for you is the
ASHA facilitator. In most states there is
full time woman employee for this role.
In a few states the ANM plays the role of
an ASHA facilitator. There is one facilitator
for every 10 to 20 ASHAs. She will meet
with you at least twice a month. One of
these interactions will be in the form of
a “mentoring” visit to the households
where you provide services. You will
also meet your facilitator in the monthly
review meeting or a cluster meeting
(with other ASHAs from neighbouring
villages).

Tasks of the ASHA Facilitators

1. Support to ASHA to promote healthy behaviours and improve service
access among families who find it difficult to change behaviours,
through household visits.
2. Provides on the job training to the ASHA by observing and helping her
during counselling or care.
3. Helps ASHAs plan her work.
4. Builds up mutual solidarity and motivation among ASHA in a cluster.
5. Collects health related information on the ASHA’s work.
6. Troubleshoots problems, especially as regards payments and addressing
grievances.
7. Refills ASHA drug kit

Auxiliary Nurse Midwife

The ANM provides services at the first level of the health system, which is the
sub centre. But her main interaction with you is through the Village Health and
Nutrition Day. You will learn about the sub centre later in this module.

Induction Training Module for ASHAs 15

 Village Health and Nutrition Day
(VHND)
It is a common platform for people to access
services of the ANM, Male health worker and
of the Anganwadi Worker (AWW). It is held
at the Anganwadi Centre (AWC) once every
month. The ANM gives immunisation to the
children, provides antenatal care to pregnant
women and provides counselling and
contraceptive services to eligible couples.
In addition, the ANM provides a basic
level of curative care for minor illness with referral where needed. The VHND
is an occasion for health communication on a number of key health issues. It
should be attended by the members of PRI, particularly the women members,
pregnant women, women with children under two, adolescent girls and general
community members.

It is important for you to know that VHND is a major mobilisation event for your
community and a good opportunity to reinforce health messages. As you gain
experience and learn from different training programmes, you should use this
forum to provide information on the topics in Annexure (1). These topics can
be taken up one by one and completed over a period of one year.

What should you do for a successful VHND?

After finishing this round of training, you can go back and make a list of the
following and ensure their presence during the upcoming VHND
l Pregnant women for their antenatal care and mothers needing
postnatal care.
l Infants who need their next dose of immunisation.
l Malnourished children.
l TB patients who are on anti-TB drugs.
l Those with fever who have not been able to see a doctor.
l Eligible couples who need contraceptive services or counselling.
l Any others who want to meet the ANM.

Remember: As you prepare the list of people requiring services at VHND,

make special effort to include individuals from families of new migrants, those
living in distant hamlets, vulnerable persons because of poverty or otherwise
marginalised. Coordinate with the AWW and the ANM to know in advance
which day the VHND is scheduled so as to inform those who need these
services and the community, especially the VHSNC members.

16 Induction Training Module for ASHAs

Clarifying roles and responsibilities: Given that you, the AWW, and the ANM
work as a team, it is important that you understand not just your role, but their
as well. The chart given in section 4 will help you understand your work with
respect to ANM and AWW.

Working arrangements
As a volunteer you have a flexible work schedule. Your workload is limited
to putting in about three to five hours per day on about four days per week,
except during some mobilisation events and training programmes. Your tasks
are to be so tailored that it does not interfere with your normal livelihood, and
fits into the ‘five activities’ described on page: 8.

You will receive monetary incentive for some of the tasks you perform but there
are many tasks which are essential for the good of the community that you
would need to undertake voluntarily. For tasks where you have to be away for
most of the day, you would be compensated. For example - training days and
for participating in monthly meetings.

(An illustrative list of activities for which you are paid incentives is given in
Annexure 2. The package of services for which ASHAs are given incentive is
state specific and varies from state to state. Thus the list provided in annexure 2
should be replaced with state specific details.)

Learning to organise your work

It is not possible to memorise the details of all

individuals needing services. Keeping a systematic a. Village Health
record of your work would help you in being Register
organised and plan better. The following tools
would proove useful in organising your work.

Village Health Register

In this you can record details of pregnant women,

0-5 year old children, eligible couples and others in
need of services. Your village visits will help you in
b. ASHA Diary
updating this register

An ASHA diary

It is a record of your work and also useful for

tracking performance based payments due
to you.

Induction Training Module for ASHAs 17

 ASHA Drug Kit

At the end of the training programme you will be

given a drug kit. This is provided so that you are able
to treat minor ailments/problems. The content of
c. Drug Kit
the drug kit has been provided in Annexure 3 along
Stock Register
with a Sample drug kit stock card.

The contents of the kit may change depending on

the needs of the state.

The drug kit is to be re-filled on a regular basis from

the nearest PHC. To keep a record of consumption
of the drugs, and for effective re-filling and ensuring
adequate/timely availability, a drug kit stock card is
maintained. This can be completed by the person
who refills the kit or by you.

18 Induction Training Module for ASHAs

 Section 2

What is a Healthy Community?

Understanding your Village and your Community

You know your community well and are familiar with its health problems. If you
list the common health or other associated problems for your village, it may
look similar to the one depicted below:

Malnutrition

Unsafe drinking water

Improper sanitation and

unclean surroundings

Problems related to pregnancy, lack of skilled

care during delivery and lack of prompt care
for complications leading to Maternal deaths

Common childhood illnesses like

pneumonia, diarrhoea causing infant
deaths & malnutrition

Infectious diseases like, malaria or

Tuberculosis

Other problems affecting the health of individuals -

poverty, alcohol abuse, early age of marriage, etc.

Induction Training Module for ASHAs 19

 What are the Factors that Contribute to Good
Health?
Healthy environment and hygienic habits
Our surroundings and personal hygiene have a direct impact on our
health. Clean living environment and proper hygienic conditions ensure
good health. The place we live, the food we eat, our drinking water and
the air we breathe - needs to be free of pollutants, harmful chemicals
and disease causing germs. This will prevent spread of many illnesses
like respiratory infections, diarrhoea, breathing problems etc.

Socio cultural factors

Both social and economic inequality and deprivation have an
adverse effect on health. Thus poorer households, families from more
marginalised communities with poor education and those in more
health risk prone occupations are more likely to have malnutrition,
illness and deaths. Social beliefs and cultural practices also have a
strong link with the health of an individual. For example, Neglect of
girl child leads to compromised health status of women.

Life style
Life style consists of health behaviours and practices that affect the
health of individuals. Lifestyles that have a positive influence are
regular exercise, a nutritious well balanced diet, etc. Some forms of life
styles may be detrimental to health. These are: Alcohol/drug abuse/
tobacco chewing/smoking etc.

Genetic factors (Heredity)

Genetic make-up is what we inherit from our parents. It plays a role in
determining our physical structure, appearance (body-frame, height,
weight, looks, colour of our skin) and also some mental and emotional
traits of our personality. It is important for you to know that some
diseases are also linked to hereditary factors. They include high blood
sugar, high blood pressure etc.

Availability of and access to appropriate health services

For individuals to remain healthy it is important that health services
are available, accessible and affordable. As a community health worker
your role is not only to promote healthy life practices but also in
facilitating and organising community’s access to health services and
treatment for illnesses.There are several levels at which health services
are provided by the health system and you will learn about this later
in the module.

20 Induction Training Module for ASHAs

Section 3

Understanding Rights and

Right to Health

An “Activist” is person who actively leads her/his community for a

particular cause. Before we discuss your role in detail, you should read the
real life examples of activism in Annexure 4.

As an ASHA you are expected to play the role of an activist primarily to reduce
inequities and improve the access of marginalised and disadvantaged to
public health care services. To do this you should work “along” with them and
not “for” them, and make them understand their health needs, rights and
subsequently avail services. Mobilising the community takes time and is energy
consuming. As you mature in your work, with continuous training and support,
you will gradually learn to mobilise your community for accessing their health
rights. In the meanwhile, try not to lose patience and hope.

“In the broadest sense, a community activist is one who works for
social change in the community.”

Understanding Fundamental Rights

You will often find that people are not aware of their rights and face prejudices.
Thus, knowledge about fundamental rights is important for every individual
including you, the ASHA. It will help you to take appropriate decisions for the
development of your community.

The six Fundamental Rights granted by our Constitution are:

The Right to Equality – This right ensures that same laws are applicable to
every citizen. No citizen can be discriminated against on the basis of religion,
caste, sex, race or place of birth. He/she is entitled to have access to public
places like shops, eating places, public health facilities, wells, tanks, bathing
ghats, roads, playgrounds and places dedicated for the use of general public.

Induction Training Module for ASHAs 21

 Right to Freedom:The Right to Freedom enables us to speak and express
freely, assemble peacefully without arms, form associations or unions, move
freely throughout the territory of India, to live and settle in any part of India,
practice any profession or to carry on any occupation, trade or business.

Right Against Exploitation: This right grants clear provisions to prevent

exploitation of weaker/vulnerable sections of the community and prohibits
“traffic i.e. selling or buying of human beings, (usually women for immoral
purpose). Forced labour, bonded labour or captivity of any human being as slave
is completely barred and employment of a child below the age of fourteen to
work in any factory or mine or any other hazardous work is not allowed.

Right to Freedom of Religion: This right allows every person a right to practice
the religion he or she believes.

Cultural and Educational Rights of minorities: Any citizen with a distinct

language or culture has a right to practice this. No citizen can be denied
admission to any educational institution maintained by government on the
grounds of religion or language. All minorities have a right to establish and
administer educational institutions of their choice

Right to Constitutional Remedies: This right empowers citizens to approach

the court in cases of denial of any of the Fundamental Rights. Under this
right, it is the duty of the Judiciary to attend to all complaints pertaining to
violation or rights.

Understanding the Meaning of Right to Health

Your understanding of the Right to Health will help you to be vigilant and take
action to enable community’s access to avail health care services from the Public
Health System.

Right to Health means

l People should have convenient access to a public healthcare facility which
is functional and implements comprehensive health programmes with
adequate providers, drugs and equipment.
l Health facilities and services must be of good quality and available to
everyone without any discrimination. Nobody should be refused treatment
on the basis of religion, caste, economic status, gender, etc.
l Health services should be affordable for all.

22 Induction Training Module for ASHAs

l Community should have information about the available services
irrespective of their caste/class/religion/sex. They should be aware about their
entitlements from the Public Health System.

Your community’s rights to health are protected if:

l Your community is able to avail free health services in the village on specific
days through public health systems and have access to all kind of preventive
and curative services in public health centres and hospitals with referral to
higher facility when required.

l The community is aware about the health services and entitlements

they can avail from the public health system such as free services in
public sector hospitals, schemes of Janani Suraksha Yojana (JSY) or
Janani Sishu Suraksha Karyakaram (JSSK) and any other health schemes
being implemented by the government. (These two are described in the
section on Maternal health)

l All sections of the community including the marginalised are able to access
the health services and avail entitlements and ANMs visit their villages
regularly provide free services to all.

As an ASHA, you are an important link between the community and the Health
Facility and you also help in creating an empowered community that is aware
about its health rights and entitlement and is able to demand it.

Understanding NRHM
The National Rural Health Mission (NRHM) was launched in 2005, and its vision
was to provide accessible, affordable and quality health care to the rural
population particularly to the vulnerable sections. The NRHM also undertook
the task of ensuring strengthening the health system to a guaranteed set of
services within each district. The NRHM is based on a rights framework, and
the ASHA is the first point through which people can be mobilised to realise
their rights.

Now, we will learn about the public health facilities at various levels, services
offered and the team of providers at each level. Annexure 5 contains a detailed
check list, to enable you to assess the quality of health services being provided
in these facilities. You should also try to map out the distances of each of these
facilities from your village and identify the possible means of transportation for
reaching these centres. This would be useful in undertaking appropriate referral
as and when needed.

Induction Training Module for ASHAs 23

Health Facilities

Name of the Population Providers Available Services

Facility Coverage
Health Sub- 3000 population l One ANM* l Conducts VHND and other outreach services
Centres are of in tribal hilly areas l Multipurpose Here ANM provides the following:
two types. and up to 5000 health worker l Family Planning services like provision of
Type A and Type population in plain in some places OCPs, condoms, IUCD insertion and related
B. The latter areas *(A second ANM counselling
has been placed in
provides all l Complete package of ANC including pregnancy
certain states)
recommended registration, PNC and immunisation.
services including l Growth Monitoring and Nutritional Counselling
facilities for
l Treatment of minor illnesses and childhood
conducting
diseases including prompt referral when
deliveries)
required
l Follow up on treatment for TB, Leprosy, Malaria
and activities for control of vector borne
diseases
l ANM provides delivery services only if she is
trained as SBA
Primary Health 20,000 in hilly, l One MBBS Provides all the services mentioned for HSC plus:
Centre** tribal, or difficult Medical Officer l 24-hour institutional delivery services both
4-6 bedded and areas and 30,000 normal and assisted (if designated as 24X7
l One AYUSH
acts as a referral population in plain PHC)
doctor
unit for 6 Sub- areas l Out-patient care for all ailments is possible
Centres l One staff nurse skills of medical officer
l 1 Sanitary staff l Essential Newborn care (with provision of
**(Your monthly Newborn corner in labour room)
(Many PHCs have
review meetings l Abortion services with linkage for timely
two medical
are conducted referral to the facility approved for 2nd
officers)
here and release trimester of MTP (where trained personnel and
of payments is facility exist)
done through the
l Male/female Sterilisation services where
approval of BMO)
trained personnel and facility exists
l Health check- up and treatment of school
children and adolescent friendly clinic for 2
hours once a week on a fixed day addressing
adolescent health concerns
l Screening of general health, assessment of
Anaemia/Nutritional status, visual acuity,
hearing problems, dental check- up, common
skin conditions, Heart defects, physical
disabilities, learning disorders, behaviour
problems, etc.

24 Induction Training Module for ASHAs

Name of the Population Providers Available Services
Facility Coverage
Community 80,000 in tribal/ 5-6 doctors Apart from all services that a PHC is meant to
Health Centre hilly/desert areas including provide, each CHC also provides clinical care
30-bedded and 1,20,000 specialists for services in some of the specialist areas and
hospital, acts as In plain areas. different types of institutional delivery services. Some CHCs are
referral for healthcare. designated and equipped to provide services of
4 PHCs Nurses and Caesarean Delivery.
Paramedical staff
more than PHC

District Hospital- One per district Specialists for l It is a hospital at the secondary referral level
75 to 500 beds different types of l Generally provides all basic speciality services
depending on healthcare with
l It has Specialised Newborn Care Unit for sick
the size, terrain adequate number
and high risk newborns, blood bank, specialised
and population of of nurses and
labs, and provides services for caesarean
the district. Paramedical staff.
sections, care, safe abortion and family
planning procedures.
l Provides most of the surgical services and has a
well- equipped Operation Theatre.
l It has provisions for dealing with accident and
emergency referrals, rehabilitation, mental
illnesses and other forms of communicable and
non- communicable diseases

Preserving Women’s Right to Health

“The status of women in society can be used to measure the culture

and actual development of any country”

Even today many women in our country are unable to exercise basic rights. It
is important to realise that unlike most men, women have to work hard both
at home and outside. Thus women spend considerable time and effort in
managing the house as well as helping in the income generating activity of
the house-hold, so they end up with twice as much work. It is essential for you
to understand the health status of women in our community, the common
problems they face and your role in addressing some of these challenges.
Women suffer many problems in various stages of their life.

Induction Training Module for ASHAs 25

 Stage of life Problems
Female foetus and female 1. Sex selective abortion
newborn 2. Female infanticide
3. Depriving newborn girls of breast milk or care for illnes

Female child and 1. Depriving girl child of adequate nutrition by

adolescent girl inequalities in food provision
2. Neglecting illness of the girl child by delaying or not
seeking treatment.
3. Girls expected to look after younger siblings and do
household chores also.
4. Girls not sent to schools or withdrawn at an early age
for household work.
5. Marriage before legal age and early motherhood,
6. Vulnerability to sexual abuse and violence
7. Little or no information on health, protection from
violence and sexual abuse
Adult 1. Domestic violence
2. Sexual exploitation at work place
3. Sexual assault and rape even within marriage
4. Dual burden of housework and work for livelihood
5. Dowry demands
6. Blamed and shamed on giving birth to girl child
7. No legal rights, especially for abandoned and destitute.
8. Inadequate care during pregnancy and child birth
9. Nutritional deficiencies on account of gender
discrimination– Women and girls eat last and little.
10. Inability to take independent decisions for her self
even for health care.
11. Infertility ascribed always to women; without proper
medical confirmation.
Old Age 1. Emotional insecurity
2. Financial and social insecurity
3. Inaccessibility to health care services
4. Abandoned by families

26 Induction Training Module for ASHAs

In addition to these problems, caused by social and cultural beliefs, women are
also more vulnerable to certain conditions/illnesses because of their physiology
or body structure and functions. For instance, Women’s reproductive systems
are more vulnerable, so they get more infections than men including sexually
transmitted infections.

Women also bear the burden and pain of childbirth and abortions and are often
solely responsible for family planning. Women have to take approval of the in-
laws or the husband even for a health check- up. They often have no money to
pay for health care on their own. Our health services and providers are also not
fully sensitive to women’s health care needs.

Women are also generally blamed for not giving birth to baby boy, which is
wrong.

All females produce something called “egg” and males produce tiny
cells called “sperms”. They fuse to form a foetus inside the women’s
womb. Inside each egg and sperm are present chromosomes, through
which we acquire our parent’s traits. Woman’s egg has XX chromosome
and man’s sperm has XY chromosome. At the time of fusion, if the X
chromosome from the male sperm meets the X chromosome of the
female egg, it results in a baby girl. If the Y chromosome of the male
sperm meets the X chromosome of the female it results in a baby boy.
So, neither the man nor the woman has any control in making sure that
a baby girl or baby boy is born.

ASHA’s role in addressing these issues

As an ASHA you are expected to help women in
improving their health and social status. You should
motivate women and convince the community to
enhance the integrity of women in the community.
To begin with, you should counsel and convince the
community to change unfair and gender discriminatory
practices. You could make a start by:

l Increasing participation and voice of women in all

village level meetings
l Motivating women to take part in making decisions
in the family.

Induction Training Module for ASHAs 27

 l Encouraging Women to eat well and take enough rest.
l Encouraging girls to complete school education
l Ensuring that women’s’ health problems are given due importance and that
they receive appropriate care

You could also:

l Discuss with men the need to share domestic work and child care.
l Take collective action to stop physical or mental abuse of women.
l Counsel families to raise boys and girls equally in terms of nutrition,
education, and opportunities.
l Increase awareness regarding illegality of pre-natal sex determination as
well as female foeticide and infanticide.
l Raise awareness in the community about delaying age of marriage until the
legal age of marriage
l Promote use of contraceptives for delay in first child birth and maintaining
gap between children.
l Increase participation of men in family planning issues.
l Provide counselling and ensure adequate care is received by women during
pregnancy, child birth and post- partum period.

28 Induction Training Module for ASHAs

Section 4

Skills of an ASHA

Leadership
Leadership as an ASHA involves mobilising people and resources towards
achieving the common goal of health care. Through knowledge and experience
most people have the potential to become a leader in any given situation. As
an ASHA you often have to play the role of a leader. Hence it is important to
understand the meaning of leadership and qualities, which will help you in
being an effective leader

Leadership means to be
l Responsible
l Setting an example so other people follow you.
l Inspiring - provide optimism and confidence in people for their
ability to carve change.
l Non-judgemental with people and transparent in your actions
l Confident, assertive, enthusiastic, passionate and accountable
l Skilled in enabling people to cooperate for getting things done.

Leadership style
People adopt different leadership styles. The two common styles are
a) Authoritarian and b) Participatory

Authoritarian leaders do not welcome cooperation or collaboration from others.

They expect people to do what they are told without question or debate. They are
usually intolerant of what they do not agree with. It is difficult for team members
to contribute their views or empower themselves under this kind of leadership.

A participatory leader creates a positive environment in which all members

can reach their highest potential. They encourage the community to effectively
reach the set goals and simultaneously strengthen the bonds among various
members. This leads to a more productive team. As an ASHA, it is most
appropriate to adopt a participatory leadership style.

Induction Training Module for ASHAs 29

 For participatory leadership you need to

l Establish goals and set the direction: First articulate an achievable goal for
your village. Involve your community through local institutions especially the
village health sanitation and nutrition committee on how, where and when
it would be completed. For example, all children of your village should be
immunised in the next six months.

l Set high standards and high expectations: Be firm

about ensuring high quality health care services from
the sub-centre and the PHC for your village community.
Eg. Make sure that the ANM reaches the village on
the designated VHND, with the requisite equipment
and drugs (weighing scales, BP apparatus, disposable
syringes for immunisation, ice box for vaccines)
and drugs and provides the package of services for
mothers and children. If the health service provider treats a community
member with disrespect or does not provide the services or does not pay
attention to quality, you should feel able to ask her to change behaviour or
practice.

l Be accountable and responsible: to the community and the health care

provider by being an effective link and sharing information. But being
constantly critical of the situation will have no positive outcome. Address the
issue by sharing your grievances with authorities who can take action. For
example, if the ANM is not coming to your village regularly or she is not visiting
the houses of socially backward families, have the courage to tell her that you
have noted her absence and you will take the necessary steps if this continues.
Enlist the help of VHSNC, Sarpanch, Block Medical Health Officer or Chief
Medical Health Officer and ensure that the ANM visits your village regularly.

l Involve others in decision-making: Do not make any decisions alone. A

decision, which affects the community, needs to be taken along with the
community members, with their complete ownership. For example, better
results are attained if priorities and decisions regarding community health
needs are taken as part of collectives such as the VHSNC.

l Motivate others: By involving the Panchayat, SHG members and VHSNC

through regular contact, sharing necessary information, giving them
responsibility and acknowledging their support and efforts in public.
Invite the community to join you in availing of their right to quality health
care. Involve community members in the process when availing for them
their entitlements from the public health system or by giving them some
responsibility to improve the health status of the community.

30 Induction Training Module for ASHAs

l Achieve unity: As a leader you need to promote unity among your
community members and between the community members and health
care providers. Unity comes when community members feel the ownership
for their health and see that they also have a role in achieving the goal.

l Serve as a role models: Always set an example that can be followed. For
example, you are assigned the role of accompanying a pregnant woman
for a referral. If you performed this role and saved the life of woman in your
village, you have set an example. Next time, when the need arises, other
community members will come forward to accompany a pregnant woman
during an emergency. They may also arrange for money and transport, if
required. You should constantly improve your knowledge and skills and try to
be aware of any new developments regarding the health services and new
schemes declared primarily by being in touch with the ANM. Improve your
skills by practising them.

l Represent the community: Make sure you represent the entire community
(including the marginalised sections) while discussing their health concerns
with the health service provider. For example, you have to develop a
comprehensive village health plan along with the Panchayat and VHSNC.
While developing a plan you need to share the concerns of the poorest of
the poor of your community. If some segment of the community has shared
that the source of drinking water is not accessible to them, it should become
a point of discussion while developing a comprehensive health plan for the
village.

Communication Skills
Communication is the exchange or
two-way flow of information and ideas
between two or more persons. People
who do not communicate well, create
confusion, frustration and problems. Your
communication skills will enable you to
counsel women and families on health
promotion, adopting healthier practices
and mobilising them to avail services at health institutions. They also help you
establish rapport with the stakeholders and other health functionaries.There
are three different forms of communication - verbal; non-verbal and written.
Each of these is useful for you.

l Verbal communication: This is the most common way of communicating,

but should be done in a way that the person or persons to whom you are

Induction Training Module for ASHAs 31

 communicating the message has understood it. So you must deliver it in
a way that the person understands what you are saying. To know if your
message was received properly, get feedback from the person whether she/
he understood the message. One-way communication is when only you talk
and the other has not understood. This is incomplete and ineffective.

Effective Verbal Communication has Accuracy;

Clarity and Correctness.

l Non-Verbal Communication: We all know that communication is not only

about words and languages. Silence also communicates, and there are
gestures that people make with their hands, body and eyes. These forms
of communication are referred to as non-verbal communication. Here are
some non-verbal forms of communication:
l Eye contact: with the person to whom you are talking will indicate your
sincerity and confidence.
l Body posture: Facing the person, standing or sitting appropriately close
and holding your head erect gives value or weight to your messages
l Facial expressions: Effective communication requires supporting facial
expressions therefore express appropriate feelings on your face
l Gestures: Use of hand gestures to describe and emphasise adds value
but it should not be overdone in excitement or anxiety.

l Written Communication: As an ASHA you will need to write applications

and letters to the authorities to improve access to health care services. You
also need to document the processes and decisions taken during meetings.
You will thus have to learn to write simply and effectively. (In Annexure 6,
there is an exercise for you on writing). Even if you take the help of others in
the community, you should remember the following important points:
l Address it to the appropriate person
l Check that the letter has a date and topic
l Keep sentences short and avoid unnecessary words
l Use simple and familiar words instead of complex and unfamiliar ones
l Explain facts through evidence and examples

Active listening is also part of communication

Hearing and listening are not the same. Hearing is involuntary, while listening
involves the reception and interpretation of what is heard. Active listening
involves listening with a purpose. It may be to gain information, obtain

32 Induction Training Module for ASHAs

directions, understand others, solve problems, share interests, and see how the
other person feels, or even show support. This type of listening takes the same
amount of, or more, energy than speaking. It requires the listener to hear various
messages, understand the meaning and then verify the meaning by offering
feedback, or confirming by paraphrasing what was heard.

For good listening: Encourage individuals to talk by using positive gestures

and words, remove distractions and try to understand non-verbal signals. Do
not pass judgments or criticise mid-way while some one is speaking. Reflect
on the feeling expressed and paraphrase what has been heard. This will enable
establishing a good rapport with the community.

Communicating with stakeholders- Keep in mind the following points

while talking to stakeholders and health functionaries-
l Give due respect to all the stakeholders, whether they are from the
community or from the health care system.
l While sharing information with the stakeholders, make sure that you
prepare with the necessary information, data and evidence.
l Never generalise the information. Be very specific about what you want
or do not want from them, what you want to change and what you
want to continue.
l Be calm while communicating. Do not show your anxiety and do not
use a blaming tone.

You will be surprised by how a simple smile and humility will affect those
around you. And, of course, confidence and assertiveness will help get your
message through.

Points to take care of while communicating:

l When you visit families, greet the individuals and explain the reason of your
visit.
l Maintain eye contact with the person to whom you are talking, act with
confidence but speak in a gentle tone which is loud enough to be heard and
always be respectful
l Stick to the point so that you do not end up using too much time and use
simple words in local language. Do not use technical words or jargon. Your
pronunciation should be clear.
l Be specific, sincere, honest and direct while communicating.
l Be empathetic and try to share the feelings of individuals.

Induction Training Module for ASHAs 33

 l Be open-minded. This will help you understand the other person’s point of
view. In case of talking to your beneficiary check if she has any question and
answer in simple language
l Acknowledge the efforts made by the beneficiaries and never forget to
compliment/appreciate them.

Note: In health communication, while counselling individuals you need to actively

listen to what is being said, analyse all the factors and then dialogue with the
person so that, together, the right choices are made. Counselling involves problem
solving and not merely preaching to adopt correct practices.

Decision Making Skills

Each decision has a consequence and even a small
decision can change many things. All of us can recall
some such decisions taken personally or by others
which have left an important impact. As an ASHA you
will be often required to take decisions, that will affect
the community at large. Hence, you should learn the
skill of participatory decision-making by involving the
community at all levels.

Some basic steps of decision-making are:

l Define the Problem: Examine the situation carefully
and analyse it from all perspectives to find out the
actual problem.
l Gather Information and share with the community: As a next step collect
all the necessary information, seek advice from the appropriate authority
and involve the community. Take information on what exists, what does not
exists and what needs to be there. At this stage of decision-making you need
to arrange a community meeting and discuss the situation to help them
become part of the solution.
l Think of possible solutions: You should work with the VHSNC and even the
Gram Sabha if needed on identifying solutions. At this stage many solutions
will be offered. It shows that people accept and understand the problem, and
are interested in identifying solutions.
l Choose one solution by consensus: Part of effective decision-making is
the ability to select one alternative from the various options available. This
can be done through consensus of the community and approval of the
authorities. To gain consensus and approval you need to discuss this in the
VHSNC meetings and the Gram Sabha. Before selecting the right alternative,
assess all available options.

34 Induction Training Module for ASHAs

l Put the Decisions to Work: An effective decision is one which can be put
into action. Thus, implementation is very important. During this process,
keep checking if it is moving towards the expected solution, and if there is
something else which needs to be addressed. An effective decision should
not leave any unhappy feeling among group members after the meeting
has been adjourned. It does not set up conflict of a debilitating nature
among persons or groups.

Decision-making skills are sharpened through experience and practice. But one
needs to be confident and prepared to take responsibility if the decision fails.

How to handle difficult situations

If you are finding it difficult to take a decision, take a short break and then
continue. After the break ask the group member/s to restate the issue and
review the options. It may be a good idea to adjourn and let people think about
it overnight.

Negotiation Skills
Negotiating is the process by which two or more people/parties with different
needs and goals work to find a mutually acceptable solution to an issue. As
an ASHA you will have to deal with differences. You have to resolve these
differences to achieve the larger goals of village health programmes. You will
have to constantly negotiate with people and situations in order to be able to
fulfil your responsibility. It is important to realise that it is quite a challenge to
negotiate with people in authority but with enough preparation and practice
you can deal effectively with any kind of situation which requires negotiation.

The steps of Successful Negotiation

l Ask for the other person’s perspective: In a negotiating situation use
questions to find out what the other person’s concerns and needs might be.
Some examples of likely questions are: What do you need from me on this?
What are your concerns about what I am suggesting/asking? When you hear
the other person express their needs or concerns, use appropriate listening
responses to make sure you heard correctly.
l State Your needs: In the process of negotiation the other person requires to
know your needs. It is very important to state not only what you need but
also why you need it.
l Prepare options beforehand: Before entering into a negotiation, prepare
some options that you can suggest if your preferred solution is not
acceptable. Anticipate why the other person may resist your suggestion and
be prepared to counter the same with an alternative.

Induction Training Module for ASHAs 35

 l Do not argue: Negotiating is about arriving at solutions. Arguing is about
trying to prove the other person wrong. We know that during negotiation
when each party tries to prove the other one wrong, no progress is made.
If you disagree with something state your disagreement in a gentle, but
assertive, way. Do not demean the other person or get into a power struggle.
l Consider timing: There are good times to negotiate and bad times. Bad
times include those situations where there is a high degree of anger on
either side, a preoccupation with something else, a high level of stress or
tiredness on one side or the other.

Suggestions for effective negotiation

While negotiating as an ASHA you must be patient. Never try to make
the opponent feel low and defeated. Empathise with the other person to
understand her/his perspective. Be positive and open in your approach. Do not
begin the discussion with any set assumptions or negative feelings.

Approach a negotiation with an attitude of, “I accept you as an equal

negotiating partner and respect your right to have an opinion of your own. “
You may think that this is being soft and not effective, but this approach is a
sign of internal strength and confidence.

How to use your negotiation skills effectively?

In your community you may come across several issues that require to be
addressed. For example, VHND does not take place, the Anganwadi is not
functioning well; children and women are not receiving their entitlement of
supplementary food; the midday meal provided is not adequate or cooked
properly; widow pension is not being received despite completion of
formalities etc.
l To change such situations first try to find out if things can be changed
by drawing the attention of people like the Sarpanch, the ANM, the
schoolteacher, AWW through direct dialogue.
l If the situation still does not improve, try to organise people and facilitate
group discussions over the issue. The VHSNC meeting is a good forum to
address such issues.
l If this also does not work, try to identify organisations working on the same
issue and seek their support. If you decide to initiate a movement alongwith
the people to change a situation, organising people who are affected with the
same issues is important and is essential for activism to be effective.

36 Induction Training Module for ASHAs

l Activism/Protest may not always be the best method of changing the
situation but it can be quite useful under the right circumstances. It gives
voice to a cause.

Coordination Skills
As an ASHA you are a link between health care services and the community and
expected to regularly coordinate with various stakeholders and the community.
The coordination with the ASHA and AWW has already been discussed.

ANM and
Anganwadi
Worker Sarpanch
and panch
SHG
Leader

Trained
ASHA Birth
Attendant and
Youth other helpers
Leader

Milk VHSNC
cooperatives Members

You need to coordinate with various health functionaries for:

l Obtaining and updating information on decisions taken at the PHC or at the

Integrated Child Development officer’s level on schemes and programmes
related to health service provision
l Sharing concerns regarding the access to health care and nutrition services
at the village level
l Planning health activities to get optimum outcome like- a health camp at the
village level or organise VHND
l Ensuring timely referrals for pregnant women and sick children when needed.

Induction Training Module for ASHAs 37

 Activity Role of ASHA ANM Anganwadi Worker
Home visits Primary focus is on health Prioritising those families Primary role on nutrition
education, care in illness, with whom the ASHA counselling, and supportive
prioritising households is having difficulty role on childhood illness
with a pregnant woman, a in motivating for
newborn (and post-natal changing health seeking
mother), children under behaviours, those who
two, a malnourished do not attend VHND;
child and marginalised providing home based
households services for post- partum
mothers, sick newborn
and children who need
referral but are unable
to go
VHND Primary Focus on Service provider who Anganwadi centre is the
social mobilisation for delivers immunisation, venue - Anganwadi worker
women and children antenatal care, provides the support
to attend the VHND, identification of in making this possible.
through motivation complications, and family Provides Take Home Rations
and counselling. Special planning services to pregnant and lactating
emphasis on marginalised mothers and for children
groups, and enabling under three. On non VHND
access to health care and days identifies and provides
entitlements. care for registered children
in Anganwadi centre, weighs
children under five years
of age on a monthly basis
and provides nutrition
counselling
VHSNC Convener of the Support ASHA Support ASHA
meetings; preparation of In convening the In convening the meetings
Village health Plans meetings and village and village health planning
health planning
Escort Services Voluntary function
To be done by ASHA on
the basis of requirement
and feasibility
Record Maintains a drug kit stock Primary Responsibility Primary responsibility
Maintenance card, a diary to record Maintain a tracking Maintains a tracking register
her work, a register assist register and record of for record of service delivery
her in organising and service delivery for the to pregnant and lactating
prioritising her work and services she delivers to mothers and children, weighs
for those who need her pregnant women and children under five years of
services. children below two years age and maintains growth
of age. charts.

38 Induction Training Module for ASHAs

How to be an effective coordinator of a village meeting?
As an ASHA you have to prepare adequately before the meeting. Meet the
participants beforehand and inform them about the agenda (can be shared
orally) of the meeting. Have clarity on what you are going to discuss and be
aware about the complexity of the issue.
l While having the discussion, listen and observe carefully. Any change in
a person’s expression communicates a lot. Be prepared with the counter-
arguments. During the discussion, if you need to take some on-the-spot
decision, be prepared for it and articulate the outcome. Give time to each
person to share their views and avoid simultaneous discussions
l At the end of the discussion, briefly articulate the decision taken or actions
to be taken after the meeting. List down the actions along with who is
responsible for the action, who will support it and a time-line for completion
of the action
l Within a few days after the discussion. Ensure that the decisions are put into
action.
l It is very important that each meeting is documented. You may use the
given format to document your meetings. See Annexure 7
l In the process of coordination, each member
plays an important role. As an ASHA you
need to make sure that you are in touch with
all the concerned stakeholders and keep
them informed of the progress.
l Never hesitate to take help of others while
facilitating a meeting. If you need help,
identify the person well in advance and brief
her/him what kind of help you need. You
should have full confidence in the person you
select.

Induction Training Module for ASHAs 39

Section 5

Knowing About Health,

Hygiene and Illness

You have been introduced to various determinants of health. This

section will help you understand in detail the role of food and hygiene in
maintaining good health.

Role of Diet and Food in Maintaining Good Health

We all know that we need food to give us energy, live and grow. Our
regular requirement of food depends on the stage of our life and the
amount of work we do. To grow better we need sufficient amounts of
food rich in all essential elements.

A newborn needs only mother’s milk till six months of age and needs
it frequently. After six months the child needs complementary feeding
and can gradually learn to eat all that adults eat, though it should be
given in smaller amounts and more frequently.

Food requirements of a pregnant mother are higher than other women.

The important qualities of our food are related to the nutrition it
provides, its quantity and frequency.

What constitutes good food?

Major constituents of the balanced diet and their functions are:

l Proteins: Important for body growth and strength. Milk, Pulses and
beans are plant sources and animal sources include eggs, poultry
products, all kinds of meat products and fish.

l Carbohydrates*: Form the bulk of our food and the main source
of our daily energy needs. This we get mainly from cereals like, rice,
wheat, sorghum, maize, ragi, bajra. Tubers like potato also provide
carbohydrates.

Induction Training Module for ASHAs 41

 l Fat (from oils and ghee) – Provide extra energy,
and are good especially for children, as they give
more energy as compared to cereals. Fat cells
stored in our body also act as an insulation to
protect it from heat and cold. They also help in
absorption of certain Vitamins like A and D. Fats
are derived from sources like oil, butter, ghee,
nuts etc.

l Vitamins and Minerals – They are essential

nutrients required in small quantities and help
fight diseases. Present in vegetables, fruits,
sprouts. Calcium, iron, iodine and zinc are some
key minerals required by body.

l Fibres or roughage and plenty of water –

Are also essential for a healthy body

* (Traditionally communities used to eat more coarse

cereals like sorghum (called Jowaar), maize, ragi, and
bajra. Wheat and Rice became popular in our country
only in recent decades. The traditional cereals are richer
in nutritional value and were more easily available to all
sections of society as they were grown easily and were
cheap. All cereals when eaten in less polished form, retain
more nutritional value.)

Good Dietary Practices –These include eating a

balanced diet which is full of all essential components
of food in right proportions. Frequency of meals is
also an important aspect. Children and Pregnant
Women should have more meals. Having a balanced
mix of different food items like cereals, pulses, green
vegetables and fruits is good for our health.

42 Induction Training Module for ASHAs

Role of Personal Hygiene and Clean Surroundings in
keeping Good Health
Personal Hygiene and cleanliness are not only essential to a good quality of life,
they are also closely related to maintaining good health and preventing disease.

“Gandhi Ji said that Cleanliness is next to Godliness.”

Many infections spread either through unhygienic surroundings or poor

personal hygiene.

Faeces

Water Flies Hands

Food

Mouth

The illustration above shows the many ways in which the disease causing
organisms spread from human faeces into the food we eat and the water
we drink. To save ourselves from diseases we have to check these routes of
infection with changes in our day to day hygienic practices.

Common measures adopted to ensure good health

A) Personal measures

i) Hand washing
l The simple practice of hand washing can stop the spread of diseases very
effectively.
l Hands should be washed regularly at all times with soap, especially after
defecation and before preparing, serving and eating food.
l Soil should not be used to wash hands, because it is often contaminated
with harmful micro-organisms.

Induction Training Module for ASHAs 43

 l Hand washing can be done with ash, but for this ash must be fresh from the
fire. Because it is difficult to ensure that the ash we are using is fresh and
uncontaminated, its use must be discouraged.
l For hand washing to be effective it must be done properly and all 6 steps of
hand washing must be followed every time. Refer Annexure 8 for details.
l Hand washing will not be effective, as long as our nails are not cut. Spaces
between the nails and fingers collect dirt.

The two practices of using clean toilets and hand washing, together can stop the
spread of many communicable diseases to a large extent.

ii) Maintaing hygiene of other body parts

l Skin: Cleanliness of skin is essential for overall body hygiene and is
particularly important in a hot country like ours. A daily bath with soap and
water and thorough cleaning of hands, feet and face helps in removing
sweat and accumulated dirt. Dirt makes the body a breeding ground for
harmful bacteria. Wearing clean, dry clothes and footwear help us remain
clean and keep away many skin infections. A daily change of clothes,
particularly undergarments, is a good practice.
l Teeth and gums-Teeth should be brushed regularly at least twice every day,
using a soft bristled brush. Brushing removes food particles accumulated
between our teeth and prevents the growth of bacteria which cause cavities
and gum disease.
l Hair: Keeping hair clean by regular wash with a mild shampoo/soap is
important to avoid infections and infestation by head lice.

B) Measures pertaining to our surrounding

i) Using clean toilets

The practice of open defecation is common in our rural areas as well as in many
of the urban pockets. Due to this, harmful organisms contaminate the soil and
water sources. Use of sanitary toilets by all will stop this faecal contamination. As
an ASHA you should work with the VHSNC in ensuring that all households have
access to sanitary toilets and use them regularly. There are many government
schemes that provide support for construction of toilets.

ii) Safe handling of food and water

Safe handling of food and water also prevents many diseases. This can be achieved
through:
l Cleaning of the food items before cooking or consuming.

44 Induction Training Module for ASHAs

l Keeping the food covered, away from dirt and flies.
l Avoiding consumption of partially cooked meat, eggs and unboiled milk.
l Using clean utensils for storing, cooking and consuming food.
l Drinking water from clean water source.
l Storing water in clean, covered pots.
l Using a long handle ladle or a utensil with a tap to take out water to prevent
contamination. Benefits of clean water source like hand pumps are often
lost when the water is not handled properly.

iii) Sanitary disposal of solid and liquid waste

Accumulated solid and liquid waste is a breeding ground for many disease
causing organisms. This should be checked through:
l Preventing collection of solid waste in the surroundings- Decaying
solid waste is a breeding ground for many vectors like housefly, rats, kala-
azar etc. Support of VHSNC should be taken for arranging regular disposal
of solid waste. You should facilitate community sensitisation against
poor environmental hygienic practices. Waste disposal measure such as
‘composting' can also be encouraged.
l Preventing pooling of wastewater in our villages- It is a health hazard as
it acts as a breeding ground for mosquitoes and other harmful organisms. It
also creates problems in movement of people and is dangerous particularly
for children.
l Stopping water logging around water sources like hand pump or wells-
The waste water from houses also adds to water logging if there are no
provisions for proper drainage.
l Making kitchen gardens and Soak-pits around sources of waste water-
These are easy methods for disposal of wastewater. Kitchen gardens for
growing vegetables and fruits help in absorbing extra water. In villages
finding small places around every house for kitchen gardens may not be
difficult. Soak-pits are a good way to stop pools of water, particularly in
streets and common pathways. They absorb water without forming a pool.
(Annexure-9 shows you how make a soak-pit)
l Creating drainage systems- Apart from these measures, the village may
still need a proper drainage system. These can be both open and covered
type. Open drains require much more regular cleaning to avoid chocking
of water flow.

Induction Training Module for ASHAs 45

 What is Illness/Disease/Sickness
Disease is an abnormal condition affecting the body. Disease is often used
to refer to any condition that causes pain, dysfunction, distress, or death to
the person afflicted. It usually affects people not only physically, but also
emotionally and psychologically, as diseases can alter one’s perspective on life
and their personality.

Diseases can also be classified as communicable and non-communicable

disease.

Communicable diseases – These are diseases that spread from one person to
another either directly or through a carrier such as a mosquito or flies. Some
examples of such diseases are: Common colds, (directly) Diarrhoeal diseases
(flies), Malaria (mosquitoes), and Tuberculosis (directly). Steps must be taken
to prevent their spread from the persons affected to other people in the
community.

Non Communicable diseases – They are usually associated with people’s life
styles (tobacco, alcohol, obesity), pollution, and deficiency or excess of some
nutrients. They never spread from one person to another. Some common
examples are high blood pressure, diabetes, cancer, stroke, and many other
illnesses.

In our community we may notice some people living with various physical and
mental disabilities such as deafness, blindness etc. Physical and mental injuries
due to accidents such as road accident/accidents which occur at work and
animal bites also belong to this category.

Healing

Our body has its own defence, or way to resist diseases and heal itself. In most
cases, these natural defence mechanisms are more important to our health than
medicines.

Have you seen how a tree heals its axe injury? First the gum fills the gap. The gum
hardens and gradually becomes wooden. A similar effect occurs in human body for
many illnesses.

Even in a case of more serious illness, when a medicine is needed, it is the body
that must overcome the disease; the medicine only helps. Cleanliness, rest,
adequate nutritious food and water are essential to help the patient recover
from the disease and live a healthy life.

46 Induction Training Module for ASHAs

Our body has its own defence mechanism (immunity) which fights against
germs or diseases causing organisms. This system matures as body learns how
to fight germs. This helps us recover from an illness. The severity and duration of
illness vary with the type of the pathogen and defence mechanism of the body
to resist the infection.

Note – Components of mother’s breast milk enable baby to fight many illnesses.
The first thick milk (colostrum) is a priceless shield for the baby and should
never be discarded.

In case of non- communicable diseases adopting an active and healthy life

style is the key to prevent, reverse or minimise the symptoms of the diseases.
Medications and supplements may also provide help in reducing the effects of
such diseases. In some severe conditions surgeries may be required.

Treatment for Diseases

Healing with traditional medicines
There are certain traditional ways of healing and treating illnesses.
The traditional systems of medicines include Ayurveda, Yoga, Unani,
Siddha and Homeopathy. There are also home remedies which are
passed on through generations. Many of these are of great value,
cheaper and do not have harmful side effects as only natural herbs
and therapies are used in making them. Some common herbs
and home remedies have been mentioned in Annexure- 10. Some
diseases are helped by traditional medicines, while others can be
treated better with modern medicines.

Treatment with modern medicines

For first contact care we need very few medicines. As an ASHA
you will learn to use some medicines/drugs. For example:
Paracetomol, Chloroquine, Iron Folic acid and ORS.

The use of each drug; its dose, how many times to be given,
side effects, and precautions are given in Annexure11. Read this carefully before
using the drugs. These medicines are safe, cheap and very effective. We will
learn about some more medicines in the subsequent trainings.

Modern medicines have side effects. Thus it is important to use them rationally
and prevent injudicious usage.

Induction Training Module for ASHAs 47

 ASHAs Role in Promoting Rational Drug Use
Spread awareness in the community on
Avoiding overuse of injections and saline (bottle)

Try to overcome the prevalent belief that injections and saline are always necessary. Some
patients insist on injections and saline bottles. Many doctors are also driven by profit
motives. You should educate people that these are useful only in certain conditions. People
can save expenses with help of simple remedies. The saline in the bottle is just water, salt
and some sugar. If we prepare it at home and take orally the effect is the same.

Preventing misuse of Tonics

Many doctors prescribe these tonics, because patients ask for them. Tonics are not
necessary for the growth of body or to give energy. They are just a combination of
water, sugar, vitamins and some minerals. The cost is often very high. In most of the
cases, for gaining strength and ensuring growth a simple nutritious home cooked meal
is enough.

Avoiding self-medication

People often buy medicines by themselves or use any medicines lying in the house for
conditions such as fever, diarrhoea, abdominal pain, and headaches. This should not be
done. Most drugs cause side effects, and some are harmful. The side effects of some of
the commonly used medicines used in self-medication are:
l Drugs used as pain killers: Almost all painkillers cause irritation of stomach and
many of these, when taken over long periods, can cause internal bleeding and
stomach ulcers.
l Anti-allergic drugs: Are used in the treatment of cold and cough and can cause
sleepiness, which can sometimes cause accidents.
l Antibiotics: Antibiotics might cause life-threatening ‘reactions’ if a person is allergic to
them. Some antibiotics can disturb intestinal bacteria and induce diarrhoea.

Many drugs affect our vital organs, like the liver and the kidney as these organs flush
out drugs and toxins from our body. Some people also treat children with the same
medications which have been prescribed to adults. This is dangerous since children
need much smaller doses. Doses are given according to the body weight. Most
importantly, pregnant women should not take any medicine without consulting a
qualified doctor, as these could harm the unborn baby.

Taking correct dose of medicines

Both overdose and inadequate dosage can be harmful, especially in children. People
should strictly adhere to dosage and schedule of drugs as recommended by the doctor.
Education about rational drug use in community will help you in your work.

48 Induction Training Module for ASHAs

Section 6

Dealing with Common Health

Problems

Fever
Fever is a common symptom of many diseases and not an illness on its
own. Some mild fevers subside without any treatment or treatment at
home. Such fevers are not accompanied by cough, ear discharge, rash
diarrhoea or any other sign of obvious infection in any organ. However,
in many cases it may be a symptom of an acute severe illness.

For healthy individuals of 18-40 years of age, the mean normal oral
temperature is just above 36.8°C (plus or minus 0.4 degree celsius) or 98.2 °F
(plus or minus 0.7). After an attack by germs, our body reacts by generating
more heat and hence causing fever. But excess fever may be harmful and may
lead to distress and several complications.

Thermometer is used for measuring temperature and it is wise to take a sick

person’s temperature before deciding on further action.

Managing fever
l Fever associated with self- limited infections and lasting for one or two
days duration: Needs no specific treatment. It is managed through taking
rest, drinking plenty of fluids like water, rice water, soup, buttermilk etc. and
light meals. One should avoid taking oily or spicy food.

If patient is uncomfortable or has body ache or headache you can provide

Paracetamol* tablet for controlling fever and relieving symptoms. One
tablet thrice a day is enough for adults. Give tablet Paracetamol for two days
and refer if the fever persists (See Annexure 11 for details)

l Persisting fever or fever with chills, rashes, drowsiness, stiff neck etc.
This is associated with serious infections and needs immediate referral to a
hospital.

(*Paracetamol tablet or syrup is a general remedy for fever. It only brings down the
temperature. It is not a fever-cure since it does not eliminate the causative factors
from body.)

Induction Training Module for ASHAs 49

 In case of newborns or small infants, any fever should be taken seriously. A baby
has fever if the temperature is above 99 degree Fahrenheit( 37.2 degree celsius).
If you are approached for the baby having fever; you should give the first dose
of paracetamol and immediately refer to a hospital. See Annexure 11 for
specific dosage and schedule.

Note: Fever above 39.5°C (103°F) is high fever. Refer immediately any person
with high fever after sponging and giving tablet Paracetamol.

For high fever in a child sponge the whole body with tepid water. Do not use cold
water as it causes shivers. Do not cover with a blanket. Keep windows open and give
enough water and fluids to drink.

Remember
Several serious illnesses may be connected with fever e.g. Malaria, Pneumonia,
Pus (anywhere) Typhoid, TB, Kala-Azar, Filariasis, Brain Fever, HIV/AIDS etc.
We will learn about them later. Even when we think it to be a mild fever and
there is no sign of infection in any organ or loss of conciousnesess, do not wait
for more than 2 days and refer. If any danger signs are seen refer at once to an
ANM or a PHC.

Pain
Aches and Pain are one of the most common complaints and are sometimes
associated with fever and other illnesses.

What is pain?
Pain is a signal that something is wrong inside our body. It is an unpleasant
sensation which is associated with tissue damage.

The role of the ASHA in pain relief

Pain is only a symptom of illness, we need to find out the illness and treat it as
soon as possible.

In mild forms of pain where there is no injury or other symptoms like swelling,
fever and body pains like headache, backache etc. you can give Paracetamol
Tablet from your Drug Kit (Refer – Annexure 11 for dosage) and advise rest.
Ayurveda suggests gentle oil message for body aches and back aches.

If the pain does not subside in a day or two or gets worse, you can refer to the PHC.
Immediate referral to a hospital is needed in the following cases:
l Any pain with convulsion, any severe chest or abdomen pain
l Headache with neck stiffness
l Any pain associated with burn injury and in joints.
50 Induction Training Module for ASHAs
Common Cold and Cough
l It is the most frequent infectious disease in humans.
l No specific treatment exists but one can relieve the symptoms
l Common home remedies can be used for relieving the symptoms like
honey, ginger, tulsi tea. For details refer Annexure-10
l Giving lukewarm water to drink and maintaining proper nutrition is helpful.
l If the symptoms are severe, and if there is body-ache, or headache, tablet
Paracetamol can be given. Refer annexure-11 for details.

First Aid for Injuries and Wounds*

Wound care
You may come across situations, where you will have to manage common
wounds and injuries. This section would help you understand the management
of different types of wounds.

Types of wound

Wounds are of three categories:

1. Wounds without bleeding
2. Wounds with bleeding
3. Infected Wound

1. Care of the wounds with no bleeding

These wounds include small abrasions, small cuts, scrapes and other small
wounds. Prompt first aid can help nature heal small wounds and deal with
germs. Bleeding is usually limited to oozing and is due to damage to minute
blood vessels. Even these types of wounds need to be attended immediately as
they may get contaminated and become infected.

Take the following steps while managing these wounds:

l Wash your hands using soap and water
l Clean the wound, using pre boiled and cold water (Soap can be used if the
wound is contaminated with dirt. But remember excess soap may damage
the flesh.)

Or, gently wipe the dirt away using cotton without rubbing it. Rubbing
disturbs the clot and restart bleeding, thus delaying the healing process. Use
different cotton swabs each time.
* Certain parts of this section have been taken from the book Where There is no Doctor.

Induction Training Module for ASHAs 51

 l Place a piece of clean gauze or cloth over the wound. Cloth should be light
enough to allow passage of air for quick healing.
l Advise the person to change the gauze or cloth every day.

Remember
Any bit of dirt that is left in a wound can cause an infection. A clean wound
will heal without any medicine. Cleanliness is of first importance in preventing
infection and helping wounds to heal. If a person gets a cut, scrape or wound,
he/she should be referred immediately to take Tetanus Toxoid injection.

Family members should be warned to:

l Avoid using animal or human faeces or mud on a wound. These can
cause dangerous infections, such as tetanus.
l Never put alcohol, tincture of iodine, or any medicine directly into a
wound; doing so will damage the flesh and make healing slower.
l Avoid disturbing the scab (a dry covering over the wound) that has
been formed.
l Visit a health facility if there is a deep/sharp cut for which stitches may
be needed.

Refer persons to nearby health facility immediately in case the cut is large.

2. Care of the wound with bleeding:

Minor bleeding is readily controlled by pressure and elevation. In such cases

a small ashesive dressing is all that is necessary. Medical aid need only be
sought if the bleeding does not stop or if the wound is
at special risk of infection.

Steps to control severe external bleeding from wound:

l Raise the injured part

l Apply pressure on the wound directly by using
your fingers or palm preferably over a clean sterile
cloth/bandage.
l Hold the pressure. Don't keep checking to see if the
bleeding has stopped because this may damage
or dislodge the clot that's forming and cause
bleeding to resume.
l If the bleeding is severe take patient to the hospital
immediately and keep the pressure on.

52 Induction Training Module for ASHAs

l If the bleeding can not be controlled by pressing on the wound, or the
presure point, and if the person is losing a lot of blood you can tie the limb
as close to the wound as possible, keeping the wounded part raised.

Do not make the tie so tight that the affected area becomes blue. For
the tie, use a folded cloth or a wide belt; never use thin rope, string, or wire.

3. Care of the infected wounds

Any wound which is red, swollen, hot, and painful with pus, or a foul smell is an
infected wound.

A deep bullet or knife wound runs a high risk of dangerous infection. You can
know that the infection is spreading to other parts of the body if there is fever
and a red line above the wound.

Wounds which may become dangerously infected are:

l Wounds with debris or made with dirty objects
l Puncture wounds and other deep wounds that do not bleed
l Wounds made where animals are kept: in cowsheds, pigpens, etc
l Large wounds with severe laceration or bruising
l Wounds due to bites, especially from dogs or other animals
l Bullet wound or knife wound

Management of infected wounds

Infected wounds are serious and need immediate medical
attention. Quick referral to a health facility for treatment with
an antibiotic and injection for Tetanus Toxoid is needed. Leave
the wound open and avoid covering the wound with bandages.
Fresh air enables these wounds to heal faster.

Animal Bites
Dog bite and other animal bites
Dog bite is greatly feared because it can give rise to a deadly
illness, which is called rabies. Rabies comes from the bite of a
rabid or ‘mad’ animal, usually a rabid dog, cat, bats, fox, wolf,
or jackal. This illness, affects the brain and nervous system. No
cure is available for rabies. Anti- Rabies Vaccine (ARV) immediately
after the dog bite can prevent this fatal illness. These vaccines are
available in government hospitals.

Induction Training Module for ASHAs 53

 Signs of Rabies
In the animal
l Acts strangely –sometimes sad, restless and irritable
l Foaming at the mouth, cannot eat or drink
l Sometimes the animal goes wild (mad) and may bite anyone or anything
nearby. The animal may also become sleepy.
l The animal dies within 10 days

In People
l Pain and tingling in the area of the bite
l Irregular breathing, as if the person has just been crying.
l Initially, the person is afraid to drink water. Later he becomes afraid of water.
l Pain and difficulty in swallowing. A lot of thick, sticky saliva.
l The person is alert, but very nervous or excitable. Fits of anger between
periods of calm.
l As death nears, fits (convulsions) and paralysis.

Note
l A bite can cause illness only if the animal itself is infected. Even a scratch on
the skin or a lick on the open wound may give rabies infection.
l Rabies infection is likely if the dog dies within 10 days of the bite or if it
shows or develops any signs of rabies.
l First symptoms of rabies in bitten person may appear, within 10 days or
more after the bite.
l Bite or saliva of a rabies patient is also infective.
l The effect of Anti Rabies Vaccine reduces after a period of six months, so for
any further occasions of dog-bite, fresh vaccination is necessary.

Role of an ASHA
In case you are approached, provide immediate wound care and take the
following steps:
l Wash the wound well with soap and water
l Leave the wound open or tie a loose dressing
l Refer to a health facility where an anti-rabies vaccine is available and doctor
present will decide whether this vaccine is to be given. Advice to take TT
injections in case not vaccinated for tetanus before.
l If the bite is in the head, neck, shoulders and chest, bring the person
immediately to the health centre for anti-rabies injection. Don’t wait for
15 days.

54 Induction Training Module for ASHAs

l Suggest the family to keep the dog under watch by keeping it tied for 15
days. If the dog dies within this period or develops abnormal behaviour,
there is an increased risk in the individual to develop serious infection.

You should build awareness in the community regarding

l Vaccination of the dogs and other animals against rabies, as per the schedule.
Usually rabies vaccine is effective for a period of six months or an year.
l To keep children and family members away from any animal that seems sick
or acts strangely.
l To avoid contacts with saliva, urine, or perspiration of the bitten person as
these secretions are infectious.
l Identifying and killing rabid dogs is essential. Inform the appropriate
authority if you suspect a sick or a rabid dog.

Spread awareness to avoid direct contact of saliva of such animals. It is the

saliva of the animal that contains germs if infected by rabies

Snake bite
All snakes are not poisonous, nor can they outrun man as commonly believed.
Snakebites are common in rainy seasons and night hours. There are only four
common poisonous snakes in India. These are Common Cobra (Hindi : Nag);
Common Krait (Hindi : Bangarus); Russel’s Viper (Hindi : Daboia); Saw-
scaled Viper (Hindi : Phoorsa)

Identification of poisonous and non-poisonous snake bite

l Poisonous Snake :The bite of a poisonous snake leaves marks of
the two fangs ( and at rare times, other little marks made by the teeth).
l Non – Poisonous Snake : The bite of a snake that is not poisonous leaves
only 2 rows of teeth marks, but no fang marks. This Identification is most
reliable if we know the species of the snake.

Sign of poisonous snake bite

l Pain at the site of bite. There may also be pain in abdomen and sometimes
diarrhoea
l There may be local swelling.
l Blister formation around the site and spreading blister suggest a large dose
of venom.
l Local tissue necrosis with an offensive, rotten smell
l Weakness of the muscle around the eyes (drooping of eyelids) . The person
may start seeing double (double vision) and may develop a squint. He may
not be able to swallow anything.

Induction Training Module for ASHAs 55

 l Cough, difficulty in breathing leading to death. (Cough indicates severe
poisoning and may not appear until 10 hours after the bite)
l Abnormal bleeding
l There may be vomiting and collapse
l Shock and haemorrhage may occur up to a week after the bite if anti venom
is not given.

First aid in any snake bite

The effective and quick first aid can save most patients. No magic or temple
prayers can undo the poison bites.

l Make the person lie down and relax. Do not make the patient walk.

l In case of non-poisonous snake bite, it is sufficient to clean and disinfect the

wound.

Poisonous Snakebite is dangerous – refer to the health centre immediately after

following first aid:
l Keep the bitten area still, do not allow it to move.
l Wrap the bitten area with wide elastic bandage or clean cloth to slow the
spread of poison.
l Put on a splint to prevent the limb from moving.
l Carry the person, on a stretcher or a bed to the nearest health centre.
l If the snake has been killed, you can take along the snake, because different
snakes require different treatment (anti-venom). If an anti-venom is needed,
leave the bandage on until the injection is given. Bandage should be
removed in hospital only after the doctor advice.

You should know about the hospitals in your area, where anti snake venom
drugs and doctors are available to undertake the treatment.

56 Induction Training Module for ASHAs

Burns
Burns are common injuries in India and women and children generally are
the common victims. This is often due to the handling of gas or the pressure
stove while cooking. Children may suffer scalds due to spilling of boiling liquids
— like milk, oil, dal, tea etc.

Common causes of burns

l Kitchen accidents - commonly bursting of pressure stoves
l Fire crackers
l Explosion in work places
l House fires
l Chemical burns
l Electric burns
l Suicide attempts
l Murder attempts

Types of burns and care

l Minor Burns: Pour plenty of cold water on the affected part, apply gentian
violet and use Tablet Paracetamol for pain relief. (Annexure 11 for dosage).
If it gets infected or the healing is slow then refer.

l Deep Burns: These destroy the skin, expose raw flesh and cover large areas
of body. Apply gentian violet, wrap the burnt part with clean cloth or towel
and immediately refer to a health facility.

If you do not have Gentian violet, then cover it loosely with a cotton cloth or
sheet and immediately refer.

l For Burns of joints or skin folds: i.e. between the fingers, in the armpit, or
at other joints, insert gauze pads with Vaseline between the burned surface
to prevent this from sticking together as they heal. Also, fingers, arms, and
legs should be straightened completely several times a day while healing.
This is painful but helps prevent scars that limit movement.

Inform the individual about the following burn care:

l Keep the burn as clean as possible and protect it from dirt, dust and flies.
These can lead to infections in burns. Signs of an infection in a burn include
- pus, bad smell and fever. Infected burns need special care with antibiotics.
Refer the patient to the ANM or the nearest PHC.

Induction Training Module for ASHAs 57

 l Never put grease, fat, hides, coffee, herbs, or faeces on a burn
l Any person who has been badly burned can easily go into shock because of
pain, fear, and the loss of body fluids due to oozing from burn.
l Badly burned person should eat foods rich in protein and drink plenty of
liquid during the recovery period. In case of acute burns it is suggested that
the burned person should try to drink four litres of fluid in a day for a large
burn, and 12 litres a day for a very large burn.

Spread awareness in the community to adopt following safety measures

l Don’t let small babies go near a fire
l Keep lamps and matches out of reach of children
l Stoves and hot pans should be placed in a way that children cannot
reach them
l Synthetic clothes catch fire quite quickly. They stick to the skin more
easily. Advise people to always take care regarding their clothes and sari
‘pallus’ etc. during cooking.
l Over-pumping the stove before pinning and igniting is dangerous. ‘First
pin and then pump’ is the correct method to light the stove.
l Sometimes burn injuries are intentionally inflicted (most often, on women).
In such cases if you are aware of NGOs or counsellors that help such women,
you should let the woman know. If necessary, the doctors will initiate legal
measures in these cases.

58 Induction Training Module for ASHAs

Section 7

Infectious Diseases - Tuberculosis

(TB, Leprosy and Malaria)

In this session you will learn about three infectious diseases - TB, Malaria and
Leprosy

Tuberculosis
A minute germ (Mycobacterium tuberculosis) causes TB, and it can affect
any part of our body. But lungs TB is the most common form.

Modes of spread
It spreads from one person to other through tiny droplets in air, when
breathing. A TB patient’s sputum has thousands of TB germs, and while
coughing or sneezing the TB germs spread in the air. The germs also stay
in dust for long and affect people. TB germs enter the lungs of healthy persons,
when they breathe. Not all persons so affected will manifest disease. In a weak
person the germs multiply and produce an illness. It may take months to
develop illness after the germ has infected the person.

Common signs and symptoms

The symptoms of lungTB are:
l Cough with sputum for two weeks or more
l Pain in chest
l Sometimes the presence of blood stained sputum (haemoptysis) with
symptoms like:
l Rise in evening temperature
l Night sweats
l Loss of weight
l Loss of appetite.

A person with cough for two weeks or more is a suspect for TB and should be
referred to a PHC/CHC/DH for the confirmation of diagnosis. Sputum examination
is main tool for diagnosing lung TB. X-ray and other investigations may be needed
in cases when sputum test is negative and the patient continues to exhibit disease
symptoms.

Induction Training Module for ASHAs 59

 Management of TB
Both drugs and
nourishment is needed for
cure of persons infected
with TB. Under current
‘DOTS treatment’ one has
to take the medicines in
front of a non-related DOTS
provider who could be an
ANM or MPW or an ASHA.
The improvement occurs
in few weeks. However, the
full treatment takes 6 to 8
months in most cases. It is critical to make sure that the patient completes the
full treatment, otherwise he/she will not be fully cured and illness will come
back and will still spread the TB germs. During treatment the sputum is tested
periodically for germs of TB.

Table B in Annexure 11 contains the details on side effects of common TB Drugs.

ASHAs role
l Identify and refer patients for suspected cases of TB
l If you are a DOTS provider you need to ensure compliance for the
treatment- Make sure that medicines are taken regularly by the patient for
6-9 months
l Counsel on patient taking extra nutrition
l Build awareness to prevent spread of TB by telling infected persons:
l To cover the mouth with handkerchief while coughing and sneezing to
halt spread of germs.
l To eat and drink from a separate set of utensils which should be washed
separately.
l To avoid spitting in nearby open space and prevent spread of infection
covering his or her mouth with a clean cloth, especially while coughing.
This prevents spread of droplets in the surroundings. The cloth should be
washed in hot water or with disinfectant thoroughly on a regular basis.
l To avoid close contact with spouse, children and infants and the elderly
within the family for at least first two months after starting treatment.
l About BCG vaccination at birth that prevents serious forms of TB.
l Providing support and care to persons with TB and not stigmatising those
affected.

60 Induction Training Module for ASHAs

Leprosy
What is Leprosy?

l It is a chronic infectious disease caused by a bacteria Mycobacterium leprae.

l It usually affects the skin and peripheral nerves, but has a wide range of
clinical manifestations.

Common signs and symptoms of Leprosy: The signs differ greatly according
to the person’s natural resistance to the disease. The first sign of Leprosy is
usually in the skin:
l One or more white spots or dark coloured patches, with loss of sensation in
the affected area of the skin.
l Body parts usually affected include hands and feet, face, ears, wrist, elbows,
buttocks and knees. Loss of sensation could be so severe that persons with
Leprosy sometimes burn themselves without knowing it.
l In advanced cases hands and feet become partly paralysed and claw-like.
Fingers and toes may gradually become shorter and become stumps.

Modes of spread
Leprosy is spread by skin to skin contact, through sneezing and coughing. The
germs are found in the inner lining of the nose and in the skin of untreated
persons. Germs once inside may not manifest the disease up to a period of
5-7 years.

Types of Leprosy
Paucibacillary: Usually single skin lesion is seen or those with two to five skin
lesions

Mulitbacillary: When more than five lesions are present

Management
It Involves: Multi Drug Therapy (MDT) using combination of drugs. It is a long
treatment and requires constant follow ups.

ASHAs role
l ASHAs are involved in the eradication programme for Leprosy to mobilise all
suspected individuals for a medical examination and further management
which includes completion of the long course of treatment. A good way to
do this is ask anyone with skin lesion to show to a doctor especially if there
is diminished sensation.

Induction Training Module for ASHAs 61

 l Counselling for leprosy patients for regularity/completion of treatment and
prevention of disability.
l You must include following key messages when you talk to people about
Leprosy:
l It is the least infectious of all infectious diseases, and it does not spread
through casual touch.
l It is completely curable with MDT.
l Early detection and regular treatment with MDT prevents deformities
and disabilities due to leprosy.
l MDT is available free of cost at all Govt. health centres/dispensaries/
hospitals on all working days.
l Social rehabilitation of the leprosy afflicted persons should be
supported by all individual to prevent any sort of discrimination.
l Treated leprosy patients can continue to live at home and do normal work.
l Former leprosy patients with mutilated hands/feet who received
treatment earlier do not suffer from active disease and do not transmit
leprosy. They do not need MDT again.

Malaria
What is Malaria?
Malaria is one of the major public health problems of the country. It is an
infection caused by a parasite (micro-organsim) called Plasmodium. But it can
be treated if effective treatment is started early. Delay in treatment may lead to
serious consequences including death. Prompt and effective treatment is also
important for controlling the transmission of malaria.

There are two types of malaria: Vivax and Falciparum. Vivax is not very
dangerous but falciparum malaria can cause damage to the brain, liver and
lungs.

How does it spread?

When the mosquito bites an infected person, the parasite enters the mosquito’s
stomach. It multiplies in the insect’s stomach and later when it bites another
person, the parasite enters the blood of the person along with the insect’s saliva
and infects him/her.

Signs and symptoms

l The patient can have fever, high shivering and sweating, which can occur on
alternate days (in Vivax type of malaria) and every day at a certain time with
Falciparum type infection. Sometimes the patient has continuous fever.

62 Induction Training Module for ASHAs

l Malaise and headache usually accompanies fever.
l Malaria affects more frequently and more severely children below five years,
pregnant women, or patients who are already ill.
l Falciparum malaria can affect the brain: causing clouding of consciousness,
fits, or paralysis leading to death.

In areas where malaria is highly prevalent, pregnant mothers and malnourished

children are at greater risk.

Any person living in a malaria affected area, who develops fever must be
suspected as having malaria. If fever is with chills and rigor and headache, it is
even more likely.

Managing Malaria
How to confirm: There are two ways of confirming malaria through blood test;
(This will be taught to you in future trainings)
l Making a blood smear- Annexure 12
l Using the Rapid Diagnostic Test (RDT) kit- Annexure 13
RDT is to be done or smears are to be taken before starting treatment.

Treating Malaria
Paracetamol should be given for fever, and sponging with warm water should
be done to bring down temperature when needed. If RDT is positive for
malaria- Chloroquine or Artesunate Combination treatment (ACT) treatment
should be given. Your local health department would tell you which of the
two possible treatments should be chosen. If despite treatment fever does not
begin to come down within two or three days, or persists even after a week,
the patient must seek treatment from a hospital. (Treatment guidelines for
Malaria are provided in Table C – Annexure 10)

Prevention of Malaria
Mosquitoes thrive in warm and wet climates. There are many types of
mosquitoes, but only very few of them transmit the disease. The mosquito
that transmits malaria is called Anopheles and it bites almost exclusively at
night. It does not bite during the day. That is why sleeping under a bed net is
a good way of preventing bites. The mosquito that spreads malaria breeds in
clean water. In rainy season, wherever water collects, it forms a good breeding
place for mosquitoes. It also breeds in well in streams, rice fields and
over-head water tanks.

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 Ways of controlling malaria: There are two ways:

Do not allow mosquito to

multiply
l Not allowing water to
stagnate, and pouring a
spoon of oil over the water
surface in small collections.
This is enough to kill the
mosquito larvae.
l Drying up or filling breeding
pits.
l Enable cultivation of
Gambusia fish or larva eating
fish in ponds and Wells - these eat up the mosquito larvae. Also remove the
grass and vegetation from banks of pond. Larvae find it difficult to breed if
there is no vegetation and the pond edges are vertical.
l Water in drains and canals should not be allowed to remain stagnant in one
place and it should be flushed and cleaned once in a week.

Do not allow mosquitoes to bite by using

l Clothes that cover the body, like full sleeves shirts.
l Mosquito nets treated with insecticides so that infected mosquitoes do not
reach the sleeping person. The mosquitoes coming in contact with the net
may die later.
l Mosquito repellent, eg.burning neem leaves to drive mosquitoes away.
l Insecticide spray on walls and places where mosquitoes sit so that they do not
reproduce and die before biting more people.

The role of ASHA in prevention of Malaria

l In the National Vector Borne Disease Control Programme ASHAs are
involved in diagnosis and treatment of malaria cases on a day to day
basis. You are expected to screen for fever cases suspected to be suffering
from malaria, using RDTs and blood slides and to administer anti-malarial
treatment to positive cases
l During house visits and in the village meetings you should inform the
community about malaria, how to prevent it and what to do for fever.
Encourage and help the village health and sanitation committee and the
women’s groups or other community organisations to take appropriate
collective action to prevent malaria in that area. Where possible, ask
those with fever, who you suspect of having malaria to go to the primary
health centre.

64 Induction Training Module for ASHAs

Section 8

Maternal Health

8.1 Care During Pregnancy/Ante Natal Care

Pregnancy is a natural event in the life of a woman. If a pregnant woman is in
good health and gets appropriate care she is likely to have a healthy pregnancy
and a healthy baby.

Pregnancy diagnosis
Diagnosis of pregnancy should be done as early as
possible after the first missed period. The benefit of
early diagnosis of pregnancy is that the woman can be
registered early by the ANM and start getting antenatal
care soon.

There are two ways to diagnose pregnancy early

l Missed Periods
l Pregnancy testing- through use of the Nischay
home pregnancy test kit (Annexure14)
l The Nischay test kit can be used easily by you to
test if a woman is pregnant. The test can be done
immediately after the missed period.
l A positive test means that the woman is
pregnant. A negative test means that the woman
is not pregnant.
l In case she is not pregnant and does not want to
get pregnant, you should counsel her to adopt a
family planning method.
l The result of the test should be kept confidential.

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 Schedule and services to be provided during ante natal care
and check-up
Schedule of ANC visits

Four antenatal visits must be ensured, including registration within the first
three month period. The suggested schedule for ANC is as below:

l 1st visit: Within 12 weeks—preferably

as soon as pregnancy is suspected—for
registration of pregnancy and first antenatal
check-up. This is also the time when
maternal and child protection card is to be
made.
l 2nd visit: Between 14 and 26 weeks
l 3rd visit: Between 28 and 34 weeks
l 4th visit: After 36 weeks

ANC can be done at Vilage Health and

Nutrition Day (VHND) or the nearest health
institution such as the Sub centre. It is
advisable for the pregnant woman to visit the
Medical Officer (MO) at an appropriate health
centre for the third antenatal visit, as well as
availing of the required investigations.

Services to be provided during ANC (at the VHND or in the facility)

l Complete history of the current and previous pregnancy, and any

medical/surgical problem in the past should be obtained.
l Weight, blood pressure, blood test for Haemoglobin (to detect
anaemia), urine test and abdominal examination should be recorded on
every ANC visit.
l 100 Iron Folic Acid (IFA) tablets and Tetanus toxoid (TT) Injections. In the
first pregnancy first TT injection is given as early as possible and the second
is given four weeks after the first one. In the next pregnancy only one dose
(booster) is to be given if the pregnancy happens in first three years of
previous one.
l Counselling on nutritious diet and proper rest.

By carrying out a complete pregnancy check-up, the ANM is able to detect

problems and decide on referring the woman to a doctor.

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Danger signs during ante-natal period
Women with the following conditions should be referred to a health facility for
appropriate treatment

l Vaginal bleeding l Mal-presentation - Baby is upside

l Swelling of face and hands down or in abnormal position inside
l High blood pressure, headache, dizziness or the uterus.
blurred vision l If the previous delivery was through
l Convulsions or fits abdominal operation or woman had
l Baby stops moving or kicking inside the other abdominal operation in the
womb. past.
l Severe Anaemia l Pain or burning when urinating
l Multiple pregnancies l Malaria
l Previous history of neo-natal deaths, stillbirths, l Other Illnesses such as Heart
premature births or repeated abortions disease, jaundice or fever etc.

Anaemia - Anaemia is very common among IFA tablets), which have to be taken daily
women, adolescent girls and malnourished for many months during pregnancy or by
children. giving injections.
l Anaemia is due to a reduced level of l If the anaemia is severe, hospitalisation
haemoglobin in the blood. Haemoglobin for blood transfusion will be required.
is a substance in the blood that carries l All pregnant women should be
oxygen which is important for all body encouraged to take iron rich foods. These
functions. The amount of haemoglobin include as green leafy vegetables, whole
can be tested by a simple blood test, which pulses, jaggery, ragi, meat and liver etc as
the ANM in the health sub-centre or a lab well as fruits rich in Vitamin C – mango,
technician in a health facility will do. Low guava, orange and sweet lime etc.
haemoglobin can lead to complications in l While giving iron tablets, the woman
pregnant women and can even result in should be advised that some side effects
the death of mother and baby. A woman might occur. However, they can be
with anaemia looks pale, feels tired, managed in the following ways:
complains of breathlessness on doing l Nausea, occasional vomiting, mild
routine work, and might have swelling on diarrhoea - can be reduced by
the face and body. taking the tablet after meals.
l To prevent anaemia, all pregnant women l Constipation - can be reduced by
need to take one iron tablet daily, starting drinking more water and eating fruits.
after three months of pregnancy. In this l Black coloured stools - reassure the
way, she must take atleast 100 IFA tablets. woman that it is not abnormal.
l Anaemia which is mild or moderate is l Iron tablets should not be taken with
treated with iron tablets (more than 200 tea, coffee, milk or calcium tablet.

Induction Training Module for ASHAs 67

 Role of ASHAs
l List all pregnant women: Ensure that you cover the women in the poorest
families, and in the sections which tend to get left out, e.g. women from
SC/ST communities, women living in hamlets far from the main village, or
in hamlets that fall between villages, newly migrant women and women
headed households.
l Early registration: Help pregnant women getting registered as early as
possible but within 12 weeks of pregnancy.
l Ensuring full ANC: You should educate women about the importance of
the four ANC visits. Remind them when next ANC is due and/or escort them
to VHND if they need such support. Ensure that all components of ANC are
delivered and the Maternal Card is updated.
l Counselling for ante-natal care: Counsel the pregnant women and
family on:
l Importance of a balanced and nutritious diet: The diet of the
pregnant woman should contain a mix of cereals, pulses (including
beans and nuts), vegetables, milk, eggs, meat and fish. If possible, the
mother should be encouraged to add oils, jaggery and fruits to the diet.
You should explain to the mother and family that no foods should be
forbidden during pregnancy.
l Importance of adequate rest and harmful effects of heavy manual
labour: Pregnant women should not carry out heavy manual labour, like
working on construction sites, brick kilns, etc and take adequate rest for
better growth of the baby.
l Danger signs during pregnancy: If she has any of the danger signs
discussed earlier she should be referred to the appropriate health
facility.
l Supplementary Ration from Anganwadi Centre (AWC): Ensure that all
pregnant women receive this entitlement from their nearest centre.
l Extra care for pregnant adolescent girls: They are more likely to be
under-nourished and therefore suffer problems during delivery. They
need extra help for safe delivery at a health facility.
l Safe institutional delivery: You should promote safe institutional
delivery for all pregnant women in the community and help them in
making birth plans for the time of delivery. During the pregnancy period
itself, you should discuss this with the family.
l The available institutions providing different levels of care close to the
village.

68 Induction Training Module for ASHAs

l Transport options available in the area.
l Estimated expenditure and possible funding sources if required.

Some women are at a higher risk of developing complications during

delivery and they must be specially counselled to go for institutional
delivery. These include:
l Adolescent girls (below 19 years of age)

l Women who are over 40 years of age

l Women who already have three children

l Women who do not gain enough weight or have excessive weight gain.

Delivery Care
Delivery occurs normally after nine months of
pregnancy. In case the delivery happens before
time, special care for baby is required. You should
motivate every pregnant woman in your area to go
to an appropriate health facility for delivery since
labour complications may suddenly occur even if
the pregnancy was normal. These complications can
threaten the life of mother, baby or both. The priority
is to ensure that the mother is shifted immediately to
a well-equipped hospital.

In case the family needs you to accompany them to

the institution for delivery and it is feasible for you to
do so, you should escort the family to the institution
at the time of delivery. Pregnant women should get benefits under schemes
like the Janani Sishu Suraksha Karyakaram (JSSK), and the Janani Suraksha
Yojana (JSY). These are described in next section.

Some women choose to give birth at home even after much persuasion.
Your responsibility in these cases to help the woman have a safe and
clean labour, delivery and post-partum experience. The most important
component of making a home delivery safe is to ensure that the delivery
is conducted by a Skilled Birth Attendant such as ANM, staff nurse or
doctor. Another important component is to have a plan for referral if
complication arises.

Induction Training Module for ASHAs 69

 In case of a home delivery it is essential that five cleans are followed:

l Clean hands l Clean cord stump - Nothing

l Clean New blade should be applied on the cord
l Clean surface stump after delivery
l Clean cord

Two important health schemes of the Government for the

mothers and newborn
Janani Suraksha Yojana (JSY)

Janani Suraksha Yojana (JSY) is an entitlement under the National Rural

Health Mission (NRHM), whose objective is to reduce maternal and neo-
natal mortality by promoting institutional delivery among poor pregnant
women. The entitlement is available to all women who deliver in public
health facility regardless of their age and parity. JSY scheme provides for
a cash payment for any poor woman who delivers in any public health
institution or in any JSY accredited private institution. You as the ASHA
are also entitled to an incentive of Rs. 300, if you motivate women for
completing all ante-natal check ups and Rs. 300 for facilitating her delivery
in health institution. Escort is voluntary and not mandatory for ASHA. In case
of an urban area ASHA will get Rs. 200 incentive for motivating women for
completing all ante-natal check ups and Rs. 200 for facilitating her delivery
in health institution. In case of home deliveries only the BPL women are
entitled for the cash payment. You will be told by your trainers during
training about the specific scheme related entitlements in your state.

JSSK – Janani Sishu Suraksha Karyakaram

JSSK entitles all pregnant women who deliver in public health institution and
all sick newborn to completely cashless services. The scheme was launched
to eliminate the high out of pocket expenditures made by poor families for
accessing health care services at public health institutions.

70 Induction Training Module for ASHAs

The following services would be provided free at the public health institution
for all pregnant and delivered mothers and for sick newborn and infants up
to one year of age:

Entitlements for Pregnant woman and sick newborns and infants up to

one year of age
Free and zero expense delivery and caesarean section
Free transport would be provided from home to the government facility,
between facilities (from one hospital to another) and free drop back facility to
home
Free drugs
Free consumables like gloves, syringes etc
Free diagnostics – Blood test, urine test, ultra-sonography etc.
Free provision of blood
Free diet (upto 3 days for normal delivery and 7 days for caesarean
Exemption from all kinds of user charges

Your role – You should inform the community about these schemes and their
entitlements. You should make them aware that they do not have to make any
formal or informal payments at the facility for accessing delivery services or for
treatment of sick newborn (0-30 days of birth). You should help them in getting
these entitlements and also start action if there is any denial of services or
demand for payment.

Post-natal Care
Post-natal period is the period after delivery of the placenta up to six weeks
(42 days) after birth. During this period mother and newborn could get some
problems. You should be aware of these, so that they
can be guided for treatment and referral.

Tasks of ASHAs during this period

Home Visits
l You should visit the mother and newborn from
the time of birth till six weeks after the delivery
and provide counselling for appropriate care of
the mother and newborn.

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 l You should at least make six/seven visits as per the following schedule -
l For Home Delivery visit on Days - 1, 3, 7, 14, 21, 28 and 42.
l For Institutional Delivery visit on Days - 3, 7, 14, 21, 28 and 42.

Important messages for post-natal mothers

Counsel the mother on following:
l Nutritious diet: Counsel the mother to eat more than her usual diet .She
can eat any kind of food but it is important to include high protein food like
pulses and legumes, foods of animal sources etc. and plenty of fluids.
l Adequate rest: Encourage her and the family to let her rest for at least six
weeks after birth
l Exclusive breastfeeding: (details would be discussed in subsequent
chapter)
l Adopting family planning methods/contraceptives: Help the couple in
deciding the method best suited for them and help them in accessing the
required contraceptive services.
l Postnatal check-ups: Counsel the mother that she must be seen by the
ANM for at least three post-natal check ups.
l Timely birth registration: This is done by the Panchayat. Support her if she
needs it.
l Free supplementary food from Anganwadi centre: You should inform
and ensure that every lactating mother is aware of this entitlement and gets
the services, by working with the Anganwadi worker.
l Possible complications of this period: You should inform mother for signs
of complications (discussed below) and ensure appropriate referral

Complications during post-natal period

Some women can develop complications after the child birth. You should look
for the following symptoms during this period to identify complications :

l Excessive bleeding l Anaemia – lack of haemoglobin in blood

l Fever l Sore breasts/cracked nipples/any other
l Foul smelling problem related to breastfeeding
discharge l Perineal swelling and infection
l Severe abdominal pain l Mood changes/abnormal behaviour
l Fits/Convulsions after delivery

All these complications and symptoms will be explained in detail in subsequent

trainings

72 Induction Training Module for ASHAs

Section 9

Newborn Care

Every newborn needs care immediately at birth and in the first 28 days of life,
irrespective of mode of delivery or weight of baby. In this section you will learn
the basic aspects of the newborn care. Future rounds of training will cover
this topic more extensively and help you build additional skills for providing
newborn care.

Care of the Normal Baby

Immediate care of the newborn at birth
Immediate care at the time of birth involves clearing the nose and
mouth of mucous, to allow the baby to breathe. Sometimes, the
newborn can die immediately after birth due to asphyxia (difficulty in
breathing). The ANM or the doctors attending the birth usually clear
the airway and resuscitate the baby. In case of a home delivery, where
there is no skilled birth attendant you should immediately refer the
baby to the nearest health facility, as in such circumstances the time to save the
baby is very short.

Normal care at birth

l Drying the newborn: Baby should be cleaned gently with a clean soft
moist cloth and the head wiped dry with a dry soft clean cloth.

l Ensuring warmth: The baby should be kept warm and in close skin to skin
contact with the mother. It should be wrapped in several layers of clothing
or woollen clothing depending upon the season. The room should be warm
enough for an adult person to just feel uncomfortable; free from moisture
and strong wind. The family and mother should be counselled to avoid
bathing the baby till at least first seven days after birth. A newborn loses
body heat very quickly and if it is left wet or exposed, its body temperature
may fall suddenly and cause sickness which can kill the baby.

l Early initiation of breastfeeding: Mother should be encouraged to start

breastfeeding immediately after delivery. This is beneficial for both the

Induction Training Module for ASHAs 73

 mother and baby since it not only makes the baby stronger but also helps
in quick delivery of placenta and reduces bleeding. The first yellow thick
milk of the mother known as colostrum should be fed to the baby and not
discarded as it prevents the baby from infections.

l Avoiding pre lacteal feeds: Honey, sugar water etc. should not be given
to the baby since they can cause infection or diarrhoea. Only breast milk
should be fed to the baby.

l Weigh the baby: Baby should weighed immediately after birth. If the
weight of the baby is 2500 gms then it is a normal baby. But if the weight is
less than 2500 gms then special precautions have to be taken, which will be
taught to you subsequently.

Home visits for the care of newborn

You should undertake home visits to ensure that the newborn is being
kept warm and breastfed exclusively. Encourage the mother to breastfeed,
discourage harmful practices such as bottle feeds, early baths, giving other
substances by mouth. Frequent home visits will help you to identify early signs
of infection or other illnesses in the newborn.

For institutional births-visit on Days - 3, 7,14, 21, 28 and 42.

For home deliveries visit on Days - 1, 3, 7, 14, 21, 28 and 42.

Care of the High Risk Baby

A high risk baby is the one who is:
l Having less than 2000 gms birth weight
l Not able to suckle or breast feed properly on day 1.
l Pre term baby - born before completion of
8 month 14, days.

These babies need extra care. You should visit such

babies on daily basis in the first week after birth. Visit the baby once every
three days until she is 28 days old. If the baby is improving then one visit is
undertaken on the 42nd day.

Care for the high risk baby includes:

l Extra warmth: You can advise mother and family to adopt the Kangaroo
care (Skin to skin contact)- method to keep the baby warm. Request the

74 Induction Training Module for ASHAs

 mother to sit or recline comfortably if possible in a private place, and loosen
her upper garments. Place the baby on mother’s chest in an upright and
extended posture, between her breasts, so that the baby skin is in direct
contact with the mother skin. Turn baby’s head to one side to keep airways
clear. Cover the baby with mother’s blouse, ‘pallu’ or gown; wrap the baby-
mother together with an added blanket or shawl. If mother is not present
then you can advise father or any other adult of the family to provide
kangaroo care to the baby. The head of the baby should be covered with a
cloth or cap to prevent heat loss.

l Caution during bathing: For Low birth weight and Pre-term babies,
bathing should be delayed after the usual seven days, till a steady weight
gain is recorded and the baby attains a weight of over 2000 gms.

l Frequent breast feeds: Babies with low birth weight may not be able to
breastfeed in the beginning and need to be given expressed breast milk
using a spoon. As they gradually learn to suckle they should be put to breast
as often as possible.

l Early identification and referral for danger signs: Counsel the

mother to identify the following danger signs. If any of the following
danger signs appear in the baby then it should be immediately referred
to a well -equipped health facility for proper care.

l Poor sucking of breast l Remains excessively drowsy or

l Pus on Umbilicus cries incessantly

l Pus filled boils l Feels cold or hot to touch

l Develops fever l Bleeding from any site

l Fast breathing/difficulty in l Abdominal distension/vomits

breathing/chest wall in drawing often

l Develops diarrhoea or has l Abnormal movements

blood in stool (convulsions)

l Pallor of palms/soles (jaundice) l No urine passed in 48 hours

l Blue palms/soles l Cracks or redness on the skin

folds (thigh axilla/buttock)

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 Precautions during referral:
l Choose the fastest mode of transport.
l Keep the baby warm during travelling.
l Mother should accompany and stay close to the baby and breast feed the
baby whenever required.

Other precautions to be taken for newborn care:

l The cord of the baby should be kept clean and dry at all times. Nothing
should be applied on the cord of the baby, it should be kept clean and dry at
all times.
l Nothing should be put in the eye of the baby.
l Newborn baby should be kept away from people or children who are sick.
l The newborn baby should not be taken to very crowded places.

Breastfeeding
Breastfeeding should be started within half an hour after the birth. Baby should
be put to the breast even before the placenta is delivered. The first thick milk
– colostrum - should always be fed to the baby. Many people discard this milk
due to cultural beliefs but it should never be discarded. Colostrum builds the
immunity of the baby and protects from diseases.

Facts about breastfeeding

l The baby should be exclusively breast fed till six months of age and
no other outside feed should be given.

l Breast milk provides for all the dietary needs of the baby. It also
provides sufficient water to the baby, thus baby should not be given
water even on summer days.

l It is safe, builds immunity against illnesses, helps in keeping the

baby warm and helps develop a bond between mother and baby.

l Feeding other than breast milk may cause infections and malnutrition due
to poor nutritious content. The baby may have difficulty in digesting such
foods resulting in diarrhoea and vomiting.

l Breastfeeding should be done as often as baby wants and for as long as the
baby wants, through the day and night.

76 Induction Training Module for ASHAs

l The more often the baby is fed, more milk will be produced.

l Breastfeeding helps in contraction of the uterus, expulsion of the placenta

and also reduces the risk of excessive bleeding after delivery.

l At six months of age other foods should be introduced. Breastfeeding can

be continued till the child is 1-2 years of age.

Correct positioning for breastfeeding

The mother’s hand should hold the baby supporting the baby’s bottom, and
not just the head or shoulders. The baby’s face should face the breast, with nose
opposite the nipple, chin touching the breast, mouth is wide open and the lips
upturned.

To obtain maximum benefit of breastfeeding, the baby should be held in the

correct position and be put correctly to the breast. Explain to the mother the
correct position for breastfeeding. The pictures below explain how the baby is
held in different positions.

Breastfeeding Positions

Cradle Position Side-lying Position

Underarm Position Alternate Underarm Position

Induction Training Module for ASHAs 77

 Mother should follow the following steps while breastfeeding the baby every
time:
l Clean the nipple of the breast with warm water before feed.
l Hold the baby horizontal on the lap or besides if the mother is lying on side.
l Hold the breast at the root of the nipple. Put the baby’s mouth to the breast
so that the baby gets a full hold of the nipple now.
l Make sure the baby’s head and body is held facing the breast without turn
and twist. Support the baby’s head and bottom.

Common problems in breastfeeding

Some mothers may find it difficult to breast feed their baby normally. You
should counsel such mothers and encourage them. Listen to them, understand
their problems and give advice clearly and simply.

The common problems reported are:

l Not enough milk
l Sore nipples and
l Engorged and painful breasts

Encourage the mother to continue breastfeeding when she complains of not

enough milk. Maintaining the correct position during breastfeeding will prevent
sore nipples. If the baby is not able to attach, apply warm compresses to breast,
gently massage from outside toward the nipple and express some milk until the
areola is soft, then put baby to the breast, making sure that the attachment is
correct. If the problem persists refer the mother to ANM for advice.

78 Induction Training Module for ASHAs

Section 10

Infant and Young Child Nutrition

Malnutrition
One-third of the world’s undernourished children live in India. About 46% of the
children below three years in India are underweight. This means that roughly
one out of two children weigh less than they should for their age. Under
nutrition in early child hood is associated with poor academic performance,
reduced work capacity, and poor health and nutrition status through childhood,
adolescence and adulthood.

Facts about malnutrition in young children

l Malnutrition increases susceptibility to disease. Malnutrition is one of the
contributory factors to over half of all child deaths.

l Malnutrition is highly related to poverty. Poor families have less money to

spend to get the quantity and variety of food, they find it more difficult to
get healthcare and also there is less time for child care.

l Counselling can help the family in making the right choices on using their
scarce resources to feed their children and protect them from malnutrition.

l Families are more comfortable when issues of feeding are discussed in

their homes. Also at the home, not only the mother, but the father and the
grandparents of the child, all become part of the dialogue.

l It is easier to prevent a child from slipping into malnutrition than to reverse

it once it is severely underweight. Hence, the focus should be on counselling
every family with a young child below one year of age, because it is this
time, especially in the age of 6 to 18 months that most children become
malnourished.

Recognising malnutrition
It is difficult to recognise malnutrition just by looking at a child. Only very severe
cases would show obvious signs of weakness or wasting by which time it is too

Induction Training Module for ASHAs 79

 late. Most children look normal but their height and weight when measured
is less than expected for their age. It is therefore essential to weigh every child
monthly, so as to detect malnutrition in time. Depending on the weight the
child can be classified as mild, moderate or severely underweight.

Sick children need special attention. However, families of all children especially
children below two should be counselled on feeding the child so as to prevent
malnutrition.

Six important messages for preventing child malnutrition

1. Exclusive Breastfeeding
l Till the age of six months, give only breast milk; not even water
should be added.
2. Complementary Feeding
l At the age of six months, add other foods. Breastfeeding alone is
not enough, though it is good to continue breastfeeding for at least
one to two years more. There are five things to remember about
complementary feeding:
l Consistency: Initially the food has to be so_ and mashed. But
later, anything that adults eat can be given to the child, with less
spices. Do not dilute food. Keep it as thick as possible, for e.g.
‘give daal not daal ka pani’.
l Quantity: Gradually increase the amount of such foods. Till at
about one year, the child gets almost half as much nutrition as
the mother.
l Frequency: The amount of complementary foods given
should be equal to about half what the adult needs in terms of
nutrients. But since the child’s stomach is small, this amount has
to be distributed into four to five, even six feeds per day.
l Density: The food also has to be energy dense, low in volume,
high in energy, therefore, add some oil or fats to the food. Family
could add a spoon of it to every roti/every meal. Whatever
edible oil is available in the house is sufficient.
l Variety: Add protective foods – green leafy vegetables. The
rule is that the greener it is, or the more red it is the more its
protective quality. Similarly meat, eggs, fish are liked by children
and very nutritive and protective.
3. Feeding during the illness
l Give as much as the child will take; do not reduce the quantity of food. After
the illness, to catch up with growth, add an extra-feed. Recurrent illness is a
major cause of malnutrition.

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4. Prevent illness
l Recurrent illness is a major cause of malnutrition. There are six important
things to remember which could prevent illness:
l Hand washing: before feeding the child, before preparing the child’s
food, and after cleaning up the child who has passed stools. This is the
single most useful measure to prevent recurrent diarrhoea.
l Drinking water to be boiled. Though useful for everyone, it is of
particular importance to the malnourished child with recurrent diarrhoea.
l Full immunisation of the child: Tuberculosis, diphtheria, pertussis and
measles are all prevented by immunisation and are the diseases that
cause severe malnutrition. In malnourished children, these diseases are
more common and life threatening, than in normal children.
l Vitamin A: To be given along with measles vaccine in the ninth month
and then repeated once every six months till five years of age. This too
reduces infections and night blindness, all of which is more common in
malnourished children.
l Avoid persons with infections, especially with a cough and cold picking
up the child, and handling the child, or even coming near the child during
the illness. This does not apply to mother, but even she should be more
rigorous in hand washing and more careful in handling the baby.
l Preventing Malaria: In districts with malaria the baby should sleep
under an insecticide treated bed net. Malaria too is a major cause of
malnutrition. You should encourage parents and other family members
to spend time with the child as it matters a lot. Time has to be spent in
feeding the child. Time has to be spent in playing and talking with the
child. Such children eat and absorb food better.

5. Access to health services

l Access to health services makes for prompt treatment of illness. On the
very first day of the illness, if you help the mother decide on whether it is a
minor illness for which home remedy would be adequate, or to be referred
to a doctor, such a decision would save lives. Early treatment would prevent
malnutrition.
l Access to contraceptive services is important. If the age of mother is less
than 19, or the gap between two children is less than three years, there is a
much higher chance of the children being malnourished.

6. Access to anganwadi services

l The anganwadi provides a food supplement for the child up to the age
of 5. This could be a cooked meal, or in the form of take – home rations.

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 Malnourished children are to be given additional food supplements. For
children below the age of two, take – home rations are to be given. Even
pregnant women and lactating mothers up to six months are entitled to
get food supplements in the anganwadi centres. _ Weighing the baby
and informing the family of the level of malnutrition is another important
anganwadi service.

l The anganwadi is also the site where the Village Health and Nutrition Day
(VHND) is conducted. The ANM visits every month and the child is given
immunisation, Vitamin A, paediatric iron tablets, Oral Rehydration Salts (ORS)
packets or drugs needed for illness management.

Note
Wasted expenditure on unnecessary services is also an issue. Families
tend to spend a lot of money in commercial health foods which are very
costly. This money is better spent in buying cheap, lower cost locally
available nutritious foods. Tonics and health drinks are also a waste for
the poor family. Unnecessary and costly treatments by local doctors
for the recurrent bouts of diarrhoea and minor colds and coughs could
also be a drain. One of the important services that you can perform is in
making people aware that such expenditures are unnecessary.

Counselling on Malnutrition
All the above messages are important for managing malnutrition also. But there
are too many points to list out and the family members may not register it. Also,
many of the messages may not be applicable to that particular child, or may not
be possible for that family. For these reasons, we have to do it in two steps; first
an analysis of why a child is malnourished and once we have an understanding
of this, then a dialogue with the family to see what can be done.

For an analysis, we need to know the following

l What is the nutritional status of child – is it normal, underweight,
moderately underweight or severely underweight?
l What is the child being fed as compared to what needs to be given?
l What is the recent history of child’s illness, and whether enough has been
done to treat it promptly and to prevent further illness?
l What is the family’s access to the three key services? (ICDS, Health Services
and Public Distribution Services)

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Skills in Eliciting Information
There is a skill of asking each question so as to get the right
information.

What the child is being fed

l Ask specifically what was fed in the last one day, starting from
now and recalling backwards, till the previous day.

Things to notice: how many feedings in a day, how much in each feed,
whether the child’s food included pulses, vegetables, oil.
l Ask specifically about protective foods which are not given daily.
l Ask about feeding during illness

Illness and treatment

l Ask whether the child fell ill during past six months (ask
specifically about diarrhoea, fever, cold and cough). Start with
most recent illness, and then ask them to recall backwards –“
before this when was he/she sick? etc.
l What actions did the family take during illness?
Which provider did they go to?
l What difficulties did the family face in accessing
healthcare and how much did it cost?
l What are the likely inessential services or
expenditures which they are getting into?

Access to Anganwadi Services

l Is the child taken regularly every month to the
Anganwadi Centre (AWC) for weighing? Have they
seen the growth curve?
l Is the family availing of food supplements from the anganwadi, is it regular,
reliable and of variety needed and reasonable quality?

Skill in analysis
Based upon the replies to these questions, you will form an understanding of
the multiple causes of malnutrition in that specific c child. It is never one factor,
it is many. Do not jump immediately to some point and start giving your advice.
Ask all the questions, listen to the replies fully, think about it and then only give
your advice.

Discuss what measures are needed in each case and how this is to be conveyed?

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 Given below are examples of understanding that
ASHA formed in two children
Banu was a nine month old girl with moderate malnutrition. She is
being breastfed and only this month was started on complementary
food. She eats rice and dal from her parents’ plate while they are eating,
once at about 10.00 am and then about 6.00 p.m. She had diarrhoea
once, one month ago, but no other illness. You gave her ORS and she
became alright with it. She does not go to the anganwadi or get rations
from there. Her immunisation is on schedule.
Rafay is an 18 month old boy who is severely underweight. He has
no odema, but there is some wasting. He cannot go to the hospital
because his mother cannot leave her younger child and she also has
to go to work as she is the only earning member. Rafay is not being
breastfed, but gets to eat roti, dal and vegetables. He eats about half a
roti or one roti thrice a day. But his mother complains that he does not
eat a lot and has very poor appetite.
He has frequent episodes of respiratory infection but no other illness.
His immunisation schedule is complete.

How to give advice

l First praise the mother for how well she is coping with the child and
reinforce the good practices she is following. Praise must always precede
any other advice.

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l Then deliver each message as needed for that child in the form of a
suggestion and ask whether they could implement it. Dialogue with the
family explaining why the step is needed and how they could achieve it. If
they are convinced, they would agree. If not convinced or unable to agree,
move on to the next message. It takes more than one visit and one dialogue
for families to agree, even if it was possible.
l Then point out any harmful or wasteful practices, explaining why you say so.
l Arrange for a follow-up visit to see how many practices have changed and
to further reinforce the messages. Each family with a malnourished child
needs to be met about once or twice a month.
l Arrange for mother and child to meet the ANM or the doctor as required.
Such a visit is required in the following circumstances:
l Any child who is severely underweight. If, in addition, there are danger
signs, admission in a facility which manages such children would be
desirable.
l Any child who is underweight, who does not gain weight even after a
few months of trying to follow the advice.
l Any child who is underweight, who has fever, or chronic cough or
persistent anaemia.

Even if the family is not going to see the doctor or ANM, do inform the
Anganwadi Worker (AWW) and the ANM so that they can follow-up too.

This work is equally their work also.

How you should NOT give advice

Do not prescribe advice without dialogue—just telling families what to do
would not help…

Do not give very broad and what can be perceived as ‘insulting’ advice like–
“you must take care of your child, or you must keep the child clean, or you must
give nutritious food etc.”

Anaemia in the young child

Anaemia is important to diagnose because it commonly comes
along with malnutrition. It may be a cause of poor appetite. Blood
testing is essential, but even in its absence based on observation of
pallor alone, treatment can be started.

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 Looking for anaemia in children
Unusual paleness (Pallor) of the skin of the soles or palms is a sign of anaemia.

l To see if the child has anaemia, look at the skin of the child’s palm. Hold the
child’s palm open by grasping it gently from side to side.

l Do not stretch the fingers backward. This may cause pallor.

l Compare the child’s palm with your own palm and the palm of other
children. If the skin is paler than of others, the child has pallor.

Treatment for anaemia is to give one tablet of paediatric iron daily. And also
give one tablet of Albendazole for deworming once in six months. For a child
less than two years, give half a tablet of Albendazole (Refer Annexure11 ). Iron
rich foods are also needed for the young child. If anaemia does not improve,
the child must be referred to a doctor for more complete blood tests and
treatment.

Feed 4 to 6 times/
day

3
Don’t Dilute
unnecessarily Add Fats
‘Not daal water 2 4 and Oils.
but Daal’.
Seven Messages
Red and Greens
for The greener- the
Start at
six months 1 Complementary 5 redder the better.

Feeding

7 6
Continue feeding
during illness and Milk, Eggs, Meat & Fish.
extra feed after! Children Love it:
and its good for health

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Assessment of Malnutrition
ALL sick children should be assessed for signs suggesting malnutrition.

Check for Malnutrition

Look and Feel:
l Look for visible severe wasting.
l Look for oedema of both feet.
l Determine grade of malnutrition by plotting weight for age (with AWW)

Identifying visible severe wasting

l A child with visible severe wasting is very thin, has no fat, and looks like skin
and bones. Some children are thin but do not have visible severe wasting.
This assessment step helps you in identifying the children with visible
severe wasting who need urgent treatment and referral to a hospital.
l To look for visible severe wasting, remove the child’s clothes. Look for severe
wasting of the muscles of the shoulders, arms, buttocks and legs. Look at the
child from the side to see if the fat of the buttocks is missing. When wasting
is extreme, there are many folds of skin on the buttocks and thigh.
l The face of a child with visible severe wasting may still look normal. The
child’s abdomen may be large or distended.
l Look and feel to determine if the child has swelling of both feet. Use your
thumb to press gently for a few seconds on the upper surface of each foot.
The child has oedema if a dent remains in the child’s foot when you lift your
thumb.

Determine grade of malnutrition

The AWW uses a growth monitoring chart for every child. Every child in the
village should be weighed and his/her weight plotted on the growth chart.
There is a separate chart for boys and for girls under the age of five years.

How to plot weight for age and identify malnutrition

l The left hand vertical line is the measure of the child’s weight.
l The bottom line of the chart shows the child’s age in months.
l Find the point on the chart where the line for the child’s weight meets the
line for the child’s age.

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 Decide where the point is in relation to the curves
l If the point is below the bottom most (-3SD) curve, the child is severely
underweight.
l If the point is between 2nd and 3rd curve or exactly on the 3rd curve, the
child is moderately underweight.
l If the point is on or above the curve marked zero or between the curve
zero and -2SD (second curve) or exactly on the 2nd curve, then the child is
normal.

Community level care for a malnourished child

All children who are underweight, should receive the following
l Nutritional counselling as discussed earlier
l Prompt treatment for all illnesses
l Periodic weight measurement to ensure weight gain and detect worsening
early.
l De-worming tabs (Albendazole): Half tablet of albendazole for a child
less than two years old and one tablet for all children above two.
l Based on the prevalence of worm infestations in the different areas
the State as per their guideline will decide the deworming regime for
malnourished/anaemic children. (see-Annexure-11)
l Paediatric Iron and Folic Acid Tablets: Daily one for three months.
l A dose of Vitamin A: If this has not been given.

Remember
Those children who are moderately underweight should be taken to a
24x 7 PHC or a higher facility for medical consultation. Children who are
severely malnourished need prompt hospitalisation in a centre which
manages such children. This is often the District Hospital.

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Induction Training Module for ASHAs 89
90 Induction Training Module for ASHAs
Immunisation
Immunisation is one of the most well-known and cost effective methods of
preventing diseases. The six vaccine preventable diseases are:
l Tetanus
l Poliomyelitis
l Diphtheria
l Pertussis (whooping cough)
l Measles
l Childhood tuberculosis

The vaccines must be given at the right age, right dose, right interval and the
full course must be completed to ensure the best possible protection to the
child against these diseases. The schedule that tells us when and how many
doses of each vaccine are to be given is called immunisation schedule given in
table below.

If a child is not given the right vaccines in time, it is necessary to get them
started whenever possible and complete the primary immunisation before the
child reaches its first birthday.

National Immunisation Schedule

At the time of At 6 weeks At 10 weeks At 14 At 9-12
birth (within the weeks months
first 24 hours)
BCG DPT DPT DPT Measles
OPV OPV OPV OPV OPV
Hepatitis B Hepatitis B Hepatitis B Hepatitis B
–zero dose –first dose –second dose –third dose
Booster Doses At 16-24 months At 5 Years
DPT Booster-1 DPT Booster- 2
OPV Booster
Measles 2nd Dose

Tetanus Toxoid is to be given at 10 years of age and again at 16 years of age.

Vitamin A is to be given at 9 months along with the measles and its booster and
then every six months thereafter till the fifth year of life, i.e is the 18th, 24th, 30th,
36th month and so on till the 60th month.

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 Role of ASHA in Immunisation
(a) Make a list of pregnant women, newborns
and children up to two years eligible for
different vaccines.
(b) Visit all families once in six months
at least to update this list. After every
immunisation session (VHND) update both
the village register and the child’s health
card.
(c) Ensure that immunisation is discussed
during every home visit in homes where
there is a child under one year of age.
(d) Remind mother when the immunisation
is due and alert her to the date when the
VHND is being held.
(e) If needed, escort the mother and baby to the VHND on the date when the
vaccine is due. This is important for families who do not access services such
as those from poor and marginalised communities.
(f ) Ensure that first dose of BCG and oral polio is given soon after the baby is
born.
(g) Mobilising children for VHND:
(i) Find out from the ANM when her next visit is due. If ASHA has her
mobile number, confirm it on previous or same day.
(ii) You must ensure that poorest and most distant households receives
special attention to access the service.
(iii) Some children are more likely to be left out than others. This includes
physically or mentally challenged children, children of migrant families,
children belonging to families considered of ‘lower status’ or different
from the majority of the village. Such children and such families are said
to be ‘marginalised’. They need your special attention and assistance.
(iv) Some hamlets or urban slums/basti have neither ANM or Anganwadi
centre/worker taking care of their health needs. As an immediate step
to address the issue. This needs to be corrected. As an immediate step,
a women representative of the hamlet/slum can be included into the
‘village health and sanitation committee’.
(v) The village health plan should help identify hamlets and communities
that are under-serviced. We will learn about village health plans in a later
module.

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Common Childhood Illnesses
Diarrhoea
Diarrhoea is defined as passage of liquid or watery stools more
than three times in a day. Passage of even one large watery
motion among children can be labelled as diarrhoea. Normally
there are three types of diarrhoea:
l Acute watery diarrhoea starts suddenly and may continue for
a number of days. Most of these are self-limiting and will last
for three to seven days.
l Persistent diarrhoea: If the diarrhoea is of 14 days or more duration, the
child has severe persistent diarrhoea and should be referred to hospital.
l Dysentery: The child who is passing blood in the stools has dysentery. This
child also needs immediate referral

Diarrhoea is a major cause of death and disease among children under five years.
Majority of the deaths in diarrhoea are due to dehydration (loss of water and
minerals). Germs are the main cause of childhood diarrhoea. These germs come
from unsafe drinking water, unclean feeding practices, bottle feeds etc. We can
avoid these problems with help of families and the village community in tackling
hygiene and sanitation issues.

Four golden rules to observe if a child has diarrhoea

l Continue feeding
l Give extra fluids
l Give ORS (Oral Rehydration Solution)
l Refer in case of danger signs

l Continue Feeding
l If the child is breastfed, mother should continue breast-feeding
whenever the child wants.
l If the child has started consuming other foods, continue feeding small
quantities of these items.
l After the child has recovered from diarrhoea, it should be given more
food than normal to recoup from the illness.

l Give extra fluids: like Dal ka Paani, lassi and plain boiled water etc.
l Give ORS: Advise the mother to give Oral Rehydration Solution (ORS) to
the child in adequate quantities. Guide the mother for preparing ORS in the
following way.

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 Making ORS
Nowadays, one litre plastic water bottles are available and can be used to
measure the correct quantity of water.

Demonstration of preparation of ORS

(a) (b) (c) (d)

Wash your hands Pour all the ORS powder into Measure 1 litre of drinking Stir well until the
with soap a container having capacity water (boiled & cooled) & powder is mixed
of 1 litre pour it in a container thoroughly

If the ORS packet is not available, teach the mother how to make home-made
ORS: For one glass (200 ml) of water, add a pinch of salt and a spoon of sugar.
(See in the diagram how a pinch of salt is taken with three fingers and how
a spoon of sugar is measured). Alternatively, one litre of water with 50 gm of
sugar (8 spoons) and 5 gm (a teaspoon ) of salt. A juice of half a lime can be
squeezed in. Taste to see that it is not too salty, or too sugary. It should taste of
tears. Spoon is taken as 5 ml. Measure this amount and ensure it comes to 5 ml.

+ +
1 Glass of Water 1 tea spoon of sugar 1 pinch of salt

+ +
1 liter of Water 8 tea spoon of sugar 1 tea spoon of salt

Note: Discard ORS fluid if it is kept for more than 24 hrs.

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 How much ORS to give? In addition to the usual fluid intake; give

l If the child is up to two months of age: five spoonfuls after every loose stool
l I
f the child is 2.1 months- 2 years of age - give about half a cup after every loose
stool (100 ml).
l Older children can have up to one cup (200 ml) after every stool.

l Need for referral: You should counsel the mother to call you immediately if
the:
l Child’s condition worsens.
l Not able to breastfeed.
l Drinks poorly.
l Develops a fever.
l Has blood in the stool.

Diarrhoea can be prevented by

l Giving exclusive breastfeeding for THE FIRST six months.
l Maintaining personal hygiene and ensuring safety of water and food and
keeping our surroundings clean.

Acute Respiratory Infection (ARI)

Acute Respiratory Infection (ARI) is an important cause of
mortality and morbidity in children. Most children up to the age
of five years are susceptible to ARI. If not treated in time some of
them develop pneumonia, which can result in death. If the child
has some or all of the following symptoms along with cough then
you should refer the child immediately to the health centre:
l Fever
l Difficulty in breathing
l Chest Wall in-drawing

Serious morbidity and death are preventable if it is identified early

and referred and treated in time.

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 Care during illness– You should visit such households frequently and monitor
the status of the child’s health. Counsel the mother to take the following
measures in order to take care of the child:
l Keep the child warm.
l Give plenty of fluids and continue breast-feeding.
l Feeding should be continued during illness and the frequency of feeding
increased after illness
l Clear the nose if it interferes with feeding (use saline and a moistened wick
to help soften the mucus).
l Soothe the throat and relieve cough with a home remedy such as lemon
with honey and ginger, tulsi, warm water etc.
l Control fever using Paracetamol. (See Annexure 11 for details)
l Keep the baby warm

If the child has any of the following danger signs then you should refer the parents
urgently to the nearest health facility or accompany them to the health facility if
required:
l Fast breathing.
l Difficulty in breathing.
l Unable to drink.
l Lethargy
l Chest wall indrawing

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Section 11

Adolescent Health

What is Adolescence?
Adolescence (10-19 years) is a phase of life characterised by acceleration of
physical growth and psychological and behavioural changes which brings
transformation from childhood to adulthood. It is a transition period of life
where an individual is no longer a child, but not yet an adult

Developmental changes during adolescence

As a part of growing up, adolescents go through puberty. Puberty is the time in
life when body changes from that of a child to an adult. These developmental
changes occur under the influence of chemicals in our body called hormones.
The changes are:

l Physical Changes

In Girls: The body changes shape by becoming more rounded, the breasts
grow, the hips widen, hair grows in the armpits and private parts. This
happens between 10-16 years of age. The onset of menstruation (bleeding
every month) is an important change occurring among girls during the
adolescent years.

In Boys: The shoulders widen, height increases suddenly, the voice changes
and becomes deeper and hair begins to grow in the armpits, private parts
and the face.

l Emotional Changes: Include shyness, rapid mood changes, lack of

confidence, attention seeking behaviour, strong peer influence, sexual
attraction, desire to establish own identity and independent thinking. During
this period unhealthy habits like smoking and drinking or experimenting with
drugs and unsafe sex can also set in.

l Social Changes: Conflicts with the family over control, strong influence of
the peer group on behaviour and the formation of new relationship.

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 Note:
l The normal time for onset of puberty is 10-14 years in girls and 12-16
years in boys.
l These changes start 1-2 years earlier in girls as compared to boys. The
rate and extent of change is variable in different individuals. In a group
of individuals who are growing together this variation often leads to
anxiety –“Am I normal?” and needs reassurance.
l Any cases showing delay, such as- menstruation not starting by 16
years in girls needs referral to a doctor.
l Early onset of puberty signs in girls (before eight years) and boys (before
nine years) is also a matter of concern and should be referred for further
examination.

Why is it Important to Focus on Adolescent Health?

Adolescent years are formative years and set our physical, emotional, and
behavioural patterns. Foundations of future health are laid in this period.

Increasing awareness, practice of healthy behaviours, building self- esteem and

confidence in this age group results in confident healthy adults.

Major adolescent health concerns

There are certain health issues which are specific to this age group and have to
be managed appropriately. These include:

Menstruation in girls

(Understanding Menstruation and Problems during menstruation)

Menarche: The onset of puberty, when the girl has her first period is called
Menarche and generally takes place between 9-16 years of age. During this
period, most girls have bleeding for the first time from the vagina which
becomes a periodic occurrence in a girl’s life. Each cycle of bleeding is observed
in a gap of 28-40 days.

Why does menstruation occur?

In a girls’ body at puberty, every month, or about once in 21-40 days, one of
the eggs from the ovary, travels through pipes called fallopian tube. This is
called ovulation. As the egg travels in the fallopian tube, a soft spongy lining

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 Fallopian Tube

Ovary
Utreus Lining

Cervix
Vagina

gets formed within the uterus. This lining is mostly made of tiny blood vessels.
In case an egg and sperm meet to form an embryo, or a baby, that begins to
grow in the uterus this lining provides the nutrition for the baby. If the egg is
not joined by a sperm, the lining of the uterus begins to break. The unfertilised
egg along with broken uterine lining is released as blood and flows out of
the vagina. This bleeding is the menstrual period. This whole cycle is called
menstruation.

Menstrual Cycle
A menstrual cycle lasts from the first day of one period to the first day of the
next. The typical cycle of an adult female is 28 days, although some are as short
as 22 days and as long as 45 days. Periods usually last about 3-7 days, which
can vary too. During a period, a woman passes about 2-4 tablespoons (30-59
millilitres) of menstrual blood.

Problems faced by girls during menstruation

The difficulties that girls may experience during menstruation are:

Irregular Periods: For the first few years of menstruation, cycles are often
irregular and usually become regular within two to three years after menarche.
They may be shorter (3 weeks) or longer (6 weeks).

Heavy periods: Adolescents may have heavy periods lasting longer than eight
days, often saturating the pad within an hour or passing large blood clots. This
happens because of a slight imbalance in hormone secretion. It should normally
stabilise in year or two. However, if this happens regularly, it leads to exhaustion
as body is losing more blood than it is producing. The girl should then consult a
doctor immediately.

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 Painful period: Some girls may experience nausea, headaches, diarrhoea
and severe cramps during menstrual period. Usually, this lasts only for a day
or two. For relief from these symptoms, a girl should try the
following methods:
l Fill a plastic bottle with hot water, wrap it in a towel and place it on the
abdomen,
l Massage the abdomen
l Local remedies such as drinking hot ginger tea

Premenstrual Syndrome (PMS)

This refers to a combination of physical and emotional symptoms
experienced by women and girls during the menstrual cycle, usually just
before bleeding begins. These symptoms include- temporary weight gain,
feeling of heaviness in the body particularly breast, headaches, cramps, pain
and mental irritability. It is important for you to make the girls understand
that these symptoms begin five to seven days before the period starts and
disappear before the bleeding begins. This can be managed with remedies
for pain described above and eating a diet that is low in salt, and includes
foods like leafy green vegetable and raw fruits and vegetables, which are
low in sugar and high in fibre.

It is important for you to help the girls understand that

menstruation is part of every woman’s life and there should be no
shame or embarrassment around this. It is not to be seen as an obstacle
to daily activities. There is no impurity or pollution associated with
menstruation. Practices such as seclusion or staying away from school
must be discouraged.

Staying clean during menstruation

Commonly women use a cloth which is folded and placed within the
underwear, or passes over the private parts by means of a string tied around
the waist. This cloth is washed and reused most of the time. A sanitary napkin
is a pad worn within the underwear during menstruation to absorb the flow of
blood. Disposable sanitary napkins are more convenient and easier to use than
reusable cloth. The blood is absorbed better and there is a feeling of dryness.
When changed often, it can prevent infection and allows more mobility. It
allows girls to take part in school activities.

100 Induction Training Module for ASHAs

 In some districts, government has launched a scheme to promote
menstrual hygiene through distribution of Sanitary napkins.
If it is being implemented in your area you can obtain a stock of sanitary
napkins from the ANM and store it for distribution to girls. Under this
scheme, napkins are to be sold to the girls at a cost of Rs six per pack and for
each pack sold you will get an incentive of Re 1.1 The fund collected after the
sale of the napkins needs to be returned to the ANM who will then provide
you with more napkins (based on the demand) for further distribution.

Important facts related to menstrual hygiene

You should explain to adolescent girls:
l Change the used napkin once it is wet. Wet napkin can cause irritation on the
inside of the thighs and lead to infections.
l Wash the body and private parts daily and during menstruation, the outer
genitals should be washed from time-to-time to remove any blood that is
left. Girls should wash their hands every time they change the napkin.
l If the underwear is soiled, it must be changed. Otherwise this makes
bacteria grow and cause infection.
l Use a clean cloth pad if sanitary napkins are not available. Cloth should be
changed three to four times a day in case of heavy periods and should be
washed with hot water and soap and dried under the sun, stored in a clean
dry place.
l Keep a track of their menstrual cycle so that they are prepared for the time
when the bleeding starts. As periods can be irregular in the early years, they
should be encouraged to be alert for the bleeding. If they are school going
girls or plan to be out of home for a long time they should carry a sanitary
napkin with them for changing.
l To dispose sanitary napkins either by deep pit burial or by burning. In areas
where waste disposal mechanisms are in place, it can be wrapped in a used
newspaper and thrown in the community dust-bins.

Role of ASHA pertaining to menstrual hygiene

l Organise monthly meetings on a fixed day with adolescent girls to provide
health education on issues of menstruation and hygiene, sell and promote
the use of sanitary napkins and communicate other adolescent health
information. The venue of VHND and VHSNC can be used for this purpose.

Operational Guidelines on Scheme for Promotion of Menstrual Hygiene issued by MOHFW in August 2010

Induction Training Module for ASHAs 101

 Specific concerns of adolescent boys
The boys also may experience anxiety related to that adolescent changes.

Some of these include:

l Erection of Penis- In response to thoughts, fantasies, temperature, touch or
sexual stimulation, the penis fills the blood and becomes hard and erect.
In young adolescents erections may take place even in absence of sexual
thoughts or stimulation and is a natural phenomenon.
l Ejaculation- The release of semen from the penis is called ejaculation. This
may occur at night and is commonly called a ‘wet dream’. It is a natural and
normal phenomenon- not a fault.

Building the awareness of boys pertaining to the genital hygiene is useful. It is

important to tell them that the genitals need to be washed daily as secretions
accumulate under the foreskin of the penis and can cause infection if not
cleaned regularly. They should wear dry, cotton undergarments which are
washed and dried in the sun every day.

Although you may not be consulted by boys directly, the information could be
communicated to mothers of adolescent boys who seek your help for these
concerns.

Nutritional anaemia
From our previous sections you know about Anaemia. Nutritional anaemia
is common in adolescence and may be due to deficiency of Iron, Folic Acid,
Vitamin C or Vitamin B 12 in the diet.

Adolescence and nutritional anaemia

Adolescence is a phase of rapid growth and development and the body needs
extra iron for increased production of blood due to rapid increase in body mass.
When this extra requirement of iron is unmet through proper diet and nutrition
it leads to Nutritional Anaemia. It is more common in girls because of loss of
blood through menstrual bleeding.

Anaemia has a serious negative impact on growth. Checking anaemia during

this stage may help in correcting the deficits of childhood and lay down the
foundations for better future health.

When girls enter reproductive age group with low iron stores there is an
increased risk of anaemia in pregnancy- leading to low birth weight of the

102 Induction Training Module for ASHAs

baby and with serious implications on maternal health. This also leads to a
deficit of iron in early childhood which is carried on till adolescence and the
cycle continues.

If anaemia is suspected it is important to refer the adolescent girl/boy to the

nearest health facility for further examination. In case anaemia is established
the adolescent will be given of IFA Tablets for few weeks or months till
haemoglobin level improves.

ASHAs role in preventing nutritional anaemia

l Counsel the adolescents and families and ensure compliance with IFA
tablets as described in section on Ante natal care during pregnancy
l Promote measures to control malaria and other parasitic infections like
hookworm infestation by taking a six monthly dose of deworming tablet.
l Promote hygienic measures like hand washing to prevent infections like
diarrhoea.
l Mobilise girls to avail services such as WIFS* at the Anganwadi Centre.
l Bring about early Identification and Referral

*Weekly Iron and Folic Acid Supplementation

Programme
This is a government run programme to address nutritional anaemia
in adolescents. It includes the following target groups-
l School going Adolescent girls and boys in government/
government aided/municipal schools from classes 6th -12th
l Out of school adolescent girls in the age group of 10-19 years.

Under this programme, IFA supplements are distributed free on

a fixed day of the week to the target groups. In addition to IFA
supplements, Albendazole tablets for deworming are administered
twice a year. The school based distribution is done through nodal
teachers and AWWs will provide these supplements to the out of
school adolescent girls.

Induction Training Module for ASHAs 103

 Behavioural changes

As a part of growing up many behavioural changes are noticed

during adolescence. This may make them more prone to
confrontations with the parents and others. You may notice
some adolescents being aggressive while others may be shy.
Some may experience complete lack of confidence while some
display attention seeking behaviour. Different changes are
manifested in different individuals. You need to understand
that problems in this age are related not only to the physical
changes but also to emotional development, a search for
identity and risk taking behaviour. These changes should not
be ignored. Such problems if not recognised and managed
timely may lead to serious consequences such as alcohol/drug abuse, juvenile
delinquency etc. Family environment and peer influence are the two most
important factors influencing the behaviour of the adolescence

Role of ASHA in addressing behavioural challenges

l Build awareness and enable access to the Adolescent Friendly Health
Services available in your area by letting parents and adolescents know that
these centres have counsellors which interact with adolescents at the times
of crisis or concern and help them in sorting a way out of their problems.
l Counsel parents to be sensitive to these changes and adopt a strategy of
parental supervision with good rapport building to avoid and solve such
issues. They need to recognise and address the signs of anxiety in their
children.

Concepts of sexuality are laid during this phase and it is important that
the adolescents have access to the correct and complete information
related to this. This information is provided by the trained counsellors at
the AFHS Centres based in the District Hospital/CHC. Failure to provide
adolescents with appropriate and timely information represents a
missed opportunity for reducing the incidence of unwanted pregnancy,
sexually transmitted infections and HIV/AIDS and their negative
consequences.

104 Induction Training Module for ASHAs

Section 12

Reproductive Tract Infections and

Sexually Transmitted Infections

What are Reproductive Tract Infections

Reproductive Tract Infections (RTIs) are infections of the reproductive organs
that are caused by various germs. Though RTIs can occur both in men and women,
they are more common in women, because their body structure and functions
make it easier for germs to enter. RTIs that spread through sexual contact are
called Sexually Transmitted Infections (STIs).Women are more vulnerable to these
infections due to biological factors. Unequal power relations in matters of sex i.e.
sexual violence, non-use of condoms by men also expose women to risk..

Why are these Diseases not Addressed?

Women are usually shy and unwilling to talk about problems such as abnormal
vaginal discharge and genital ulcers. There is a reluctance to seek medical
treatment because of inadequate sex education and less access to medical care.
The ‘decision-makers’ at home, like the mother-in-law, would allow a woman
to be taken to a health worker if she suffers from pregnancy-related problems
or infertility, but not for seemingly ‘trivial’ symptoms like excessive vaginal
discharge. Even our health system does not adequately respond to these needs.

Mode of Spread of RTI and STI

You need to know not all the reproductive tract infections are sexually
transmitted but all the sexually transmitted infections are reproductive tract
infections. Those which are sexually spread are commonly observed in cases
when individuals indulge in casual sex usually with infected individuals or have
sex with multiple partners.

In women these infections are due to:

l Trauma during delivery
l Use of unclean instruments during childbirth or during abortions

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 l Lack of genital hygiene particularly during menstruation
l Sometimes also due to gastro-intestinal infections
l Having unprotected sex with infected partners

Mothers can pass sexually transmitted infections to babies during delivery.

Signs and Symptoms of RTI

l Abnormal vaginal discharge, which is discoloured (bloody-yellow, greenish
or curdy) and foul smelling – Some discharge from vagina during inter-
menstrual period, and pregnancy is normal.
l Ulcers or sores over the external genitals
l Lower abdominal pain
l Pain or bleeding during intercourse
l Painful swelling in the groin
l Burning pain on passing urine
l Itching around the genitals

Consequences of STIs
l Infertility in men and women
l Babies to be born too early, too small or blind; and
l Long lasting pain in lower abdomen, or even cancer
l Death from severe infection or AIDS

It is important that you make the women understand that these signs and
symptoms could manifest very late. It is best to be aware that a woman can
be at risk for a STI if the husband has signs of STI, has more than one sexual
partner or where they could engage in casual sex in long period of travel.

Prevention of RTIs and STIs

l Safe Deliveries in hospitals only by skilled attendant
l Safe abortions done at registered hospitals only
l Maintenance of genital hygiene during menstruation
l Avoiding unsafe sex by use of condoms

106 Induction Training Module for ASHAs

Role of ASHA in Managing and Preventing RTI and STI
l Counsel women at risk on preventive measures.
l Counsel women with symptoms of RTI/STI to go to the health facility
for treatment. All 24X7 PHCs or higher facilities are equipped and skilled
to provide necessary care. Tell them that they should take the course of
medicine fully (all courses are for a week or ten days).
l You should motivate the woman to complete the course of medicines. Not
completing the course of medicines makes the bacteria resistant and can
cause a worse infection that does not respond to drugs the next time.
l Ensure that the husband also gets treated.
l Counsel a woman to abstain from sexual activity during the period of
treatment.
l If the husband is known to indulge in extra-marital relationships, counsel
the woman to avoid having unprotected sex.

HIV and AIDS

Its important for you to know the following:
l HIV is transmitted through:
l having unprotected sex (sex without condom);
l receiving HIV infected blood or blood products;
l using/sharing unsterilised needles or lancets; and
l from HIV infected mother to her baby.

l It does not spread through any other mode such as kissing and
touching, holding hands, mosquito bites, sharing clothes, or
through saliva, nose fluids, tears.
l Who is at higher risk: Commercial Sex Workers (CSWs), Injecting
Drug Users (IDUs), Men who have Sex with Men (MSM), migrant
labourers, persons with multiple sexual partners, babies born to
mothers who are HIV infected, and persons with other STIs.
l Persons with HIV are at greater risk of getting Tuberculosis. Every 1
in 20 persons suffering from TB in India is also HIV infected.
l HIV can be prevented by using condom during sexual intercourse
(protected sex), using safe blood (when blood transfusions are
necessary) from blood bank of government hospitals or recognised
hospitals only, using sterilised needles/avoid sharing of needles,
and by avoiding sex with multiple partners.

Induction Training Module for ASHAs 107

 l HIV testing and management facility is available in the District Hospital free
of cost. Treatment services for AIDS are available in some district hospitals or
in the main government hospital in the big cities.
l You should encourage persons at high risk to go for HIV test. If women who
are at high risk become pregnant, they must be motivated to gets tested, as
timely treatment may prevent transmission of HIV from HIV infected mother
to baby.

108 Induction Training Module for ASHAs

Section 13

Preventing Unwanted Pregnancies

It is important for you to build awareness on delay in the age of marriage,

delaying the birth of first child and ensure spacing between children for
overall healthy survival of women. The main focus of this chapter is to help
you counsel woman to adopt the right method of family planning. You should
be able to provide information about where, when and how to access services
for sterilisation, Intra Uterine contraceptive Device (IUCD), Condoms and Oral
Contraceptive Pills.

Women’s Need for Family Planning Differ

Different women and couples have different needs for contraception. When you
counsel a woman on family planning, you should keep in mind the following:

l Marital status
l Unmarried: condoms or pills or emergency pills
l Newly married and wanting to delay the first child: condoms or pills

l Just delivered (post-partum) or just had an abortion (post-abortal):

condoms, pills, IUCD, injectables

l Wanting to space children: condoms, pills, IUCD, injectables. (Currently not

available in the public sector, but being used in the private sector)

l Not wanting more children: Long acting (10 years) IUCD and sterilisation for
the man or the woman.

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Details of spacing methods of contraception

Type of Indications Side Effects To be avoided in Name of the

contraceptive provider
method
Birth control pills like l Unmarried or l Nausea l Breastfeeding Only to be started
Mala N or Mala D recently married mothers on advice from a
l Headaches
women wanting Doctor.
l Woman with
to delay/space l Swelling of legs OCP are available
jaundice, recognised
child birth in your drug
l Changes in by yellow skin and
monthly period eyes kit, and at the
Sub-Centre,
(Side effects often l Woman with history Primary Health
get better after
of stroke, paralysis, Centre (PHC)
first two or three
months. If they do
heart disease, blood and Community
not, you should clot in the veins of Health Centre
advise the woman legs and high blood (CHC)
to see the doctor) pressure (more than
140/90)

l Woman who
smokes and is over
35 years old
Emergency Only for emergency Occasional lower l After 72 hours of Available in your
Contraceptive Pills use, when the abdominal pain and intercourse drug kit, at the
couple has not used heavy bleeding Sub-Centre, PHC
l Already pregnant
a contraceptive and CHC. You
woman from having
and have had are provider but
sex more than three
unprotected sex. make sure it is
days earlier
May be used in used only for
instances of rape, or l Other instances- emergency cases
accidental breaking same as mentioned as specified
of the condom above for birth
control pills
Condoms To be used by men None None Available in your
for delay/space child kit and at all
birth health facilities
Specially indicated
in cases of STI/HIV

110 Induction Training Module for ASHAs

Type of Indications Side Effects To be avoided in Name of the
contraceptive provider
method
IUCD l Long acting l Some light l Woman who Must be inserted
(10 Years) IUCD bleeding during has never been by a trained
indicated for the first week pregnant Auxiliary Nurse
women not after getting an Midwife (ANM),
l Woman with
wanting to have IUCD. nurse or a doctor
anaemia (Low Hb)
more children. after doing a
l Longer, heavier
l Woman prone pelvic (internal)
l As a spacing and more
to danger of examination
method for painful monthly
getting a Sexually
newly delivered bleeding, usually
Transmitted
post-partum stopping after
Infection.
mothers the first three
months l Woman having
history of infection
in tubes or uterus,
post- partum
infection, pregnancy
in her tubes, heavy
bleeding and pain
during monthly
periods.

Limiting method of contraception

Sterilisation (the operation when the couple wants no more children)

l Indicated -for those women or men who are certain that they do not want
any more children.

l Services available at PHC or CHC on certain days and mostly all days at
district hospital. (You must know the nearest site where this service is
available and on what days).

The surgery is fast and safe, and does not cause side-effects.
l Accompanying is desirable, but not mandatory. When needed, you can
accompany the woman to the facility for the tubectomy procedure. Often
because of the case overload, quality of services is not assured and the
ASHA should help the woman receive good quality care.

Induction Training Module for ASHAs 111

 The operation for the man (Vasectomy)

A vasectomy is a simple operation, with only a small puncture to block the

tubes that carry the sperm. It takes only a few minutes to do. The operation
does not change a man’s ability to have sex or to feel sexual pleasure. He
still ejaculates semen but there are no sperm in the semen. The couple must
be advised to use condoms or other contraceptives for 90 days following
vasectomy.

The operation for the woman (Tubectomy)

A tubal ligation is a slightly more difficult operation than a vasectomy, but it is

still very safe. It takes about 30 minutes. A trained doctor makes a small cut in
the woman’s abdomen, and then cuts or ties the tubes that carry the egg to the
womb. The woman can have the operation within seven days of the start of the
menstrual cycle, 24 hours after delivery, or six weeks after the delivery.

Important

Sterilisation and pills do not protect against sexually transmitted infections

and HIV infection. So for protection from STIs and HIV, a condom should be
used during every sexual intercourse, if the woman is at risk of contracting
them.

Remember
In motivating individuals for adopting an appropriate family planning
method, issues such as marital status, age, parity and overall health
condition of the individuals should be considered first. Promotion of
contraceptive use based only on the money as incentives offered by the
government should be discouraged and individuals should be encouraged
to choose the right method independent of the money offered as
compensation for wage loss.

112 Induction Training Module for ASHAs

Section 14

Safe Abortion

A Woman Seeks Abortion Because

l She does not want more children and has not used a contraceptive method
properly or the method failed.
l A pregnancy can endanger her life.
l She has no partner who will help support child.
l She got pregnant after rape.
l The child will be born with serious birth defects.

When a woman is faced with an unwanted pregnancy, she should be able to get
a safe abortion.

Legality: In India, abortions are legal up to 20 weeks and if done by a qualified

practitioner. Up to 12 weeks, one doctor can do it. After 12 weeks, two doctors
need to sign the consent form. Abortion services are free in all government
hospitals. Women over 18 do not need anyone else to sign a consent form.

Safety: In India, only a doctor can perform an abortion, and this should be done
under clean conditions, and with proper instruments.

Safe abortion services are often difficult to get because, there are not enough
service providers and facilities. Those providers who do provide abortion
services may charge a lot of money or not even be legal providers of safe
abortion services.

Methods
All these methods can only be done by a trained, legal provider

l Medical Abortion: This can be done only in very early pregnancies

less than seven weeks or 49 days after last missed period. The drugs
should be prescribed by and taken under the supervision of a
legal provider.

Induction Training Module for ASHAs 113

 l Manual Vacuum Aspiration: This method involves the woman staying
in the health facility for a few hours. It can be done up to eight weeks of
pregnancy.

l Dilatation and curettage (D and C): This

method can be done up to 12 weeks of
pregnancy. It is associated with a higher risk
of complications.

Post-Abortion Care
You should advise women
l To avoid sexual intercourse or putting anything in the vagina for at least five
days after the abortion.

l Drink plenty of fluids for faster recovery.

l That some bleeding from vagina for up to two weeks is normal, but it should
be light. Next monthly period will be after 4-6 weeks.

l That the risk of pregnancy exists as soon as intercourse is resumed

regardless of monthly period. Therefore a contraceptive should be used.

Warning signs after abortion, for which you should advise

immediate referral
l Heavy bleeding

l High fever

l Severe pain in the abdomen

l Fainting and confusion

l Foul smelling discharge from the vagina.

Tasks for you to be involved in are

l Counselling women who want abortion service or need more information
to take a decision. Find out the nearest legal and safe public and private
providers of such care.

l Visit the mother at home on Days 3 and 7 after the abortion.

114 Induction Training Module for ASHAs

l Providing information on the signs of complications and the need for
immediate referral.

l Motivating the woman for use of contraception after the abortion

ACT against pre conception and pre-natal diagnostic

technique
A strong preference for a male child in our society often compels married
couples to bear more children, till they have a boy. In cases where they
already have female children, couples may indulge in practices like pre-
natal sex determination of the foetus, followed by an abortion, in case it is
a female foetus. You must build awareness in the community that prenatal
sex determination is a criminal offence and any individual found guilty for
disclosing or seeking information about the sex of the foetus is punishable by
court under the act of PCPNDT.

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Annexures

Induction Training Module for ASHAs 117

118 Induction Training Module for ASHAs
Annexure 1: Topics for Health Communication During
the Village Health and Nutrition Day (VHND)

l Care in pregnancy, including nutrition, importance of antenatal care

and danger sign recognition.
l Planning for safe deliveries and postnatal care.
l Exclusive breastfeeding and the importance of appropriate
complementary feeding.
l Immunisation: the schedule and the importance of adhering to it.
l Importance of safe drinking water, hygiene and sanitation, and
discussion on what actions can be taken locally to improve the
situation.
l Delaying the age at marriage, postponing the first pregnancy and the
need for spacing.
l Adolescent health awareness, including nutrition, retention in school
till high/higher secondary level, anaemia correction, menstrual hygiene
and responsible sexual behaviour.
l Prevention of Malaria, TB and other communicable diseases.
l Awareness on prevention and seeking care for RTI/STI and HIV/AIDS.
l Prevention of tobacco use and alcoholism.

Induction Training Module for ASHAs 119

 Annexure 2

Sl No. Heads of Compensation Amount in Rs/case

I Maternal Health
1. JSY financial package (NEW uniform package)
a) For ensuring antenatal care for the woman 300 for Rural areas
200 for Urban areas
b) For facilitating institutional delivery 300 for Rural areas
200 for Urban areas
2. Reporting Death of women (15-49 years age group) 200 for reporting within
by ASHA to Block PHC Medical Officer. (New Revised 24 hours of occurrence of
incentive) death by phone to Block
Medical Officer
II Child Health
1 Undertaking six (in case of institutional deliveries) and 250
seven (for home deliveries) home - visits for the care of
the newborn and post- partum mother1
III Immunization
1 Social mobilisation of children for immunization 150/session
during VHND
2 Complete immunization for a child under one year 100.00
3 Full immunization per child upto two years age (all Rs 50
vaccination received between 1st and second year age
after completing full immunization after one year
4 Mobilising children for OPV immunization under Pulse 75/day
polio Programme
IV Family Planning
1 Ensuring spacing of 2 years after marriage 500
2 Ensuring spacing of 3 years after birth of 1 child
st
500
3 Ensuring a couple to opt for permanent limiting 1000
method after 2 children
4 Counselling, motivating and follow up of the cases for 150
Tubectomy

This incentive is provided only on completion of 45days after birth of the child and should meet the following
1

criteria-birth registration, weight-record in the MCP Card, immunization with BCG, first dose of OPV and DPT
complete with due entries in the MCP card and both mother and newborn are safe until 42nd day of delivery.

120 Induction Training Module for ASHAs

Sl No. Heads of Compensation Amount in Rs/case
5 Counselling, motivating and follow up of the cases for 200
Vasectomy/NSV
6 Social marketing of contraceptives- as home delivery 1 for a pack of three
through ASHAs condoms
1 for a cycle of OCP
2 for a pack of ECPs
V Adolescent Health
1 Distributing sanitary napkins to adolescent girls Re 1/pack of 6 sanitary
napkins
2 Organising monthly meeting with adolescent girls 50/meeting
pertaining to Menstrual Hygiene
VI Nirmal Gram PanchayatProgramme
Motivating households to construct and use a toilet 75/Toilet constructed
VII Village Health Sanitation and Nutrition Committee
Facilitating monthly meetings of VHSNC followed by 150/meeting
meeting with women and adolescent girls
VIII Revised National Tuberculosis Control Programme
Being DOTS Provider (only after completion of 250
treatment or cure)
IX National Leprosy Eradication Programme
1 Referral and ensuring compliance for complete 300
treatment in pauci-bacillary cases of Leprosy
2 Referral and ensuring compliance for complete 500
treatment in multi-bacillary cases of Leprosy
X National Vector Borne Disease Control Programme
1 Preparing blood slides 5/slide
2 Providing complete treatment for RDT positive Pf 20
cases
3 Providing complete radical treatment to positive 50
Pf and Pv case detected by blood slide, as per drug
regimen
XI Attending Monthly Review Meeting 150/day
XII Attending Training Programme 150/day

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 Annexure 3: ASHA Drug Kit Stock Card

Month & Date of Refill 1 2 3 4

S. Name Symbol *
Balance Refill Balance Refill Balance Refill Balance Refill
No. of Drug given given given given

Balance: This is what was left in kit at the time of refill after recovering
explained drugs/supplies.

Refill: This is what was put into the kit.

*Symbol is a pictorial symbol that could be used to denote a drug, since often
the drugs comes labelled only in English.

Card is to be updated by person providing the refill.

122 Induction Training Module for ASHAs

Annexure 4: Anti Arrack Movement

This is the true story of how women from Dubagunta in Nellore district Andhra
Pradesh, drove away the liquor contractors from their village.

The main participants in the early struggle were poor rural women, predominantly
from scheduled castes and backward classes, supported by voluntary organisations
and, later, by politicians from opposition parties. It is about a miracle that ordinary
women were able to achieve collectively. It is about a community of hard-working
women who laboured in the fields to earn their living. The menfolk of this village
were so addicted to liquor that they not only spent money on it, but also sold the
hard earned food materials, pulses, chillies, rice, butter and ghee (clarified butter), in
exchange for liquor. At times, when their earnings were not enough, they incurred
debts or stole household articles like glasses, plates or even their wives’ saris. After
drinking arrack they would use foul language, beat their wives and children making
their lives miserable. The women felt extremely helpless. There were two liquor shops
in the locality. The village men used to go straight to these shops in the evening
after returning from work. They came home late at night, completely drunk They
would hand over some money for household expenses only if there was any left. The
situation reached a climax when one man, in an intoxicated condition, stabbed his
father to death. Apart from this incident, Vijayamma, a woman of this community
also had an alcoholic husband, when her relatives visited her house they were
scared away from the village by the obscene language of her closest neighbour,
a heavy drinker. She felt ashamed and thought that the village would be a much
better place without arrack.

Everyday while working in the fields and at the community wells the women
discussed the arrack menace. One day the women joined together and approached
the village president (Sarpanch) and the village elders. They expressed their problem
and asked them to get remove the arrack and toddy shops. The elders and the
Sarpanch, although agreeable, were unable to do anything. The next day one
hundred women gathered together. They went to the outskirts of the village and
stopped a toddy-cart.‘You cannot come into the village’, they told the cart driver
strongly in unison and stood in front of it. ‘Throw all the toddy away.’ Each of them
offered him a rupee to do so. The driver got scared and left the village.

Then a jeep with arrack packs arrived. The women surrounded it and demanded
that it returned without unloading the arrack. After two days the police came to the
village and said that all those who bid at auctions had the right to sell arrack. The
women stood unmoved. They said that they would go to the Collector and would
not keep quiet if arrack was sold in their village. The arrack contractors got cold feet.

Induction Training Module for ASHAs 123

 They made several plans, but nothing worked and they gave up. These events gave
strength to the women. All this happened only because the women united and
struggled strongly to get rid of arrack from their village.

The story of Dubagunta spread in the form of an agitation to other parts of the
district.

In the literacy classes of other villages teachers started sensitising the community
through puppet shows about the problems caused by arrack. They also shared the
story of Dubagunta village, with the result that women in other villages did the
same.

The women in Dubagunta started a movement in which ultimately the situation

changed for the better.

In 1991 was the beginning of the Anti-Arrack (local liquor) Movement, which finally
led to the prohibition of alcohol in the state on 16 January 1995.

124 Induction Training Module for ASHAs

Annexure 5: Checklist for Assessing Quality of
Services at Health Facilities

Observation Checklist for Sub-Centre

General information
Name of the sub-centres village_____________

Total population covered by the sub-centre_____________ Distance from the

PHC _____________

Availability of staff at the sub-centre

l Is there an ANM available/appointed at the centre? Yes/No

l Is there health worker-male (MPW) available/appointed? Yes/No

l Is there a part-time attendant (female) available? Yes/No

Availability of infrastructure at the sub-centre

l Is there a designated government building available for the sub-centre?
Yes/No

l Is the building in working condition? Yes/No

l Is there a regular water supply at this sub-centre? Yes/No

l Is there regular electricity supply at this sub-centre? Yes/No

l Is the blood pressure apparatus in working condition in this sub-centre?

Yes/No

l Is the examination table in working condition in this sub-centre? Yes/No

l Is the steriliser instrument in working condition in this sub-centre? Yes/No.

l Is the weighing machine in working condition in this sub-centre? Yes/No

l Are there disposable delivery kits available in this sub-centre? Yes/No

Availability of services at the sub-centre

l Does the doctor visit the sub-centre at least once a month? Yes/No

Induction Training Module for ASHAs 125

 l Is the day and time of this visit fixed? Yes/No

l Is facility for delivery available in this sub-centre during a full 24-hour

period? Yes/No

l Is treatment of diarrhoea and dehydration offered by the sub-centre? Yes/No

l Is treatment for minor illness like fever, cough, cold, etc. available in this sub-
centre? Yes/No

l Is facility for taking a blood slide in the case of fever for detection of malaria
available in this sub-centre? Yes/No

l Are contraceptive services available at this sub-centre? Yes/No

l Are oral contraceptive pills distributed through this sub-centre? Yes/No

l Are condoms distributed through the sub-centre? Yes/No

Observation Checklist for PHC Centre

General information
l Name of the PHC village _____________

l Total population covered by the PHC_____________

l Is there a designated government building available for the PHC? Yes/No

l Is the building in working condition? Yes/No

l Is water supply readily available in this PHC? Yes/No

l Is electricity supply readily available in this PHC? Yes/No

l Is there a telephone line available and in working condition?

Availability of staff in the PHC

l Is a Medical Officer available/appointed at the centre? Yes/No

l Is a Staff Nurse available at the PHC? Yes/No

l Is a health educator available at the PHC? Yes/No

126 Induction Training Module for ASHAs

l Is a health worker-male(MPW) available/appointed? Yes/No

l Is a part time attendant (female) available? Yes/No

General services
Availability of medicines in the PHC

l Is the anti-snake venom readily available in the PHC? Yes/No

l Is the anti-rabies vaccine readily available in the PHC? Yes/No

l Are drugs for malaria readily available in the PHC? Yes/No

Are drugs for tuberculosis readily available in the PHC? Yes/No

Availability of curative services

l Is cataract surgery done in this PHC? Yes/No

l Is primary management of wounds done at this PHC? (stitches, dressing etc.)

Yes/No

l Is primary management of fracture done at this PHC? Yes/No

l Are minor surgeries done at this PHC? Yes/No

l Is primary management of cases of poisoning done at the PHC? Yes/No

l Is primary management of burns done at the PHC? Yes/No

Reproductive and maternal care and abortion services

Availability of reproductive and maternal health services

l Are ante-natal clinics regularly organised by this PHC? Yes/No

l Is facility for normal delivery available in the PHC 24 hours a day? Yes/No

l Are facilities for tubectomy and vasectomy available at the PHC? Yes/No

l Are internal examination and treatment for gynaecological conditions and

disorders like leucorrhoea and menstrual disturbance available at the PHC?
Yes/No

Induction Training Module for ASHAs 127

 Is facility for abortion- Medical Termination of Pregnancy (MTP)available at
this PHC? Yes/No

Is treatment for anaemia given to both pregnant as well as non- pregnant

women? Yes/No

How many deliveries have been conducted in the last quarter (three
months)? _____________

Child care and immunisation services

l Are low birth-weight babies treated at this PHC? Yes/No

l Are there fixed immunisation days? Yes/No/No information

l Are BCG and measles vaccine given at this PHC? Yes/No

l Is treatment for children with pneumonia available at this PHC? Yes/No

l Is treatment of children suffering from diarrhoea with severe dehydration

done at this PHC? Yes/No

Laboratory and epidemic management services

l Is laboratory service available at the PHC? Is blood examination for anaemia
done at this PHC? — Yes/No

l Is detection of malaria parasite by blood smear examination done at this

PHC? Yes/No

l Is sputum examination to diagnose tuberculosis conducted at this PHC?

Yes/No

l Is urine examination of pregnant women done at this PHC? Yes/No

128 Induction Training Module for ASHAs

Annexure 6: Learning How to Write a Letter

For example if you need to bring to the notice of the person concerned the
conditions that deprive the village women of the ANC services and also suggests
solutions to overcome this problem. What should you do to write a clear,
specific, effective letter?

Before starting to write an application/letter, you should:

l Have a clear subject in mind

l Know whom exactly it needs to be addressed to

l Have clarity on the reason for writing the letter

Read the letter given below

Date

To

___________(Name and address)

Sub: request to organise VHND Day at two locations in the village

Dear CDHO (write the name of the concerned person):

I am working as ASHA for the village________of________Block. My village has

a population of________. The houses are scattered across the areas. The ANM
regularly comes and organises VHND. However, it is organised at a place which is not
accessible for all the pregnant women. A large number of women living on the other
side of the village, are not able to attend the antenatal clinic, due to the distance.

I suggest that the antenatal clinic may be conducted in two places of the village
on different dates. I had a discussion about the same with the ANM. She informed
me that she needs permission from you. I request you to look into this matter. As an
ASHA I take the responsibility to bring all the pregnant women so they have their
antenatal check-up. You are welcome to visit our village.

Thank you.

Yours sincerely,
___________(write name of ASHA and the village)

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 Annexure 7: Documenting a Meeting

Documentation of the Meeting

Date: Time: Venue:

Purpose of the meeting

Members present during the meeting Absent members

1)

2)

Decisions taken

Action to be taken

Actions Who will take Who will support Date of completion

it? of the action

Signatures of the members

This report needs to be appropriately filed and should be referred to during the next
meeting, to review the progress.

130 Induction Training Module for ASHAs

Annexure 8: Skills Checklist: Hand Washing

Number of Practices
Checklist 1 2 3 4 5
l Remove bangles and wrist watch
l Wet hands and forearms up to elbow with clean water (Fig. 1)
l Apply soap and scrub forearms, hands and fingers
(especially nails) thoroughly (Fig. 2 to 7)
l Rinse with clean water
l Air dry with hands up and elbow facing the ground (Fig. 8)
l Do not touch with your hands the ground, floor or dirty
objects after washing your hands

Note: Use the checklist while observing the skills being implemented.

When a step is performed correctly, place a tick () in the box.

When a step is not performed correctly, place a cross (X) in the box.

Make sure to review the steps where crosses appear, so that performance can be improved.

Induction Training Module for ASHAs 131

 Annexure 9: Making of a Soak-pit

l To make a soak-pit we need to dig a pit of 1.5 meter length breadth and depth.

l Fill the bottom 1/3 depth loose stones and brickbats, and fill the next 1/3 of the with
smaller half size brickbats.

l Fill the top third of the pit with even smaller brickbats. To stop rain water from
entering the pit raise its borders by 10 centimetres above the ground level.

l Fill it with dry grass or coconut coir on top.

l Putting a used earthen pot at top with hole in bottom helps in straining water.

l Connect the wastewater into this pot by using a pipe. Cover entire area with coir.The
coir works like a filter. Clean or change the coir every month.

132 Induction Training Module for ASHAs

Annexure 10: Home Based Remedies for Common
Illnesses

Neem
Parts used are- leaves, fruits and outer portion of the stem. Leaves are used for
skin diseases like eczema, infection. The oil and decoction of crushed neem
leaves, is useful in itching and wound healing as it is a great antiseptic. Also
used as pest-control medicine.

Making neem oil: make 100 ml fresh juice of neem leaves. Add 25 cc sesame
oil to this. Slow boil the mixture under cover. The water part will completely
evaporate in half an hour. Cool and filter it. This is neem oil for wound care. Keep
it in a well-capped bottle. It will stay for one year. Apply this to wounds 2-3
times a day. This heals the wound well. For childbirth injuries, neem water bath
is a healing treatment. Crush some leaves of neem and put them in warm bath
water. Let the mother sit for fifteen minutes in this bathtub.

Tulsi
Tulsi leaves are useful in cough and cold. Give the tulsi juice with honey. The
leaves are hot in nature that is why they are used in kafadosha. The decoction of
Tulsi leaves is also useful for cough. The leaves are chewable. The seeds of tulsi
are cold in nature. Hence the seeds are used in heat (pitta) disorders like heart
burn, bleeding from nose, Burning feet, bleeding piles, sore mouth etc. Give the
seeds with milk or ghee. Soak 20-30 seed grains in water or milk. This is a dose
for once. Take it 2-3 times a day. Take about a cupful of tulsi leaves. Soak them
in water for five minutes. Then crush them on a stone. Strain in cloth and collect
about 20 ml juice (half a cup). Crush more leave if necessary to make 20 ml. This
makes 3 doses for one day for an adult. This is good for cold and fever illnesses.
Give it for 3 days. For children the dose could be 10 leaves juice, 2-3 times a day.

Kumari
Kumari (Aloe) is a garden plant. In wounds, we can apply aloe in place of a
medicated dressing. Take a piece of aloe about the size of the wound. Cut it into
a slice. Clean the wound with water. Apply the aloe slice on it and tie up with
a clean cloth bandage. Change the dressing every day. It heals faster. It is very
useful for burns treatment as dressings. Kumari is used in several Ayurvedic
preparations. It is useful for liver disorders and women’s illnesses like pain in
the periods. It is also used for dandruff and for the growth of hair. You can grow
kumari in your garden and ask people to grow in the kitchen garden. It is hardy
plant and stays for years.

Induction Training Module for ASHAs 133

 Adusa
Adusa is small shrub grown for fencing. It is good remedy for coughs. Use fresh
juice or decoction of leaves. Fresh juice of leaves is used with honey. It is useful
for bleeding disorders e.g. blood in cough, blood in stools, urine etc.

Take 50-60 gms of adusa leaves and wash them clean. Slow boil the leaves in
one litre of water for half an hour. About one fourth water should be left. This is
adusa Kawatha for coughs. Cool and filter it. Give 20 ml once, 2-3 times a day for
three days. One can add sugar or honey as per requirement.

Kuda
This is a forest tree with typical fruits. The fruit is black in colour when fully ripe.
The fruit is like thin double drumstick but in twins. The bark or cover of the
tree-stem is used for medicine. This is a good medicine for loose motions and
dysentery. You can simply grind a piece of bark and mix with a spoon of honey
and give as medicine. Kadha (Kawatha) also is useful. For this take a 10 gm (2
teaspoon full) of bark powder, add one glass (200 ml) of water and boil. Boil it till
¼ water remains. Cool and bottle it. For an adult 20 ml kadha (Kawatha) for
3 times a day is useful to stop dysentry.

Mushroom
English - Field mushroom, Edible mushroom: Ayurvedic - Chhatraka,
Bhuumichhatra; Unani -Kammat; Siddha - Venkodiveli.It is a protein supplement
and an excellent source of vitamins of B complex. Vitamins K, C and D are also
present. Extracts of mushroom is known to lower blood pressure and help in
healing digestive problems.

Other simple home remedies

Haldi (turmeric) is a powder of a root and has antiseptic properties. Haldi
Powder pressed on bleeding wounds stop bleeding and helps in wound
healing. Also used for cuts and abrasions after mixing with oil. Improves
complexion when applied with milk and chana dal flour (besan) at the time of
bath, as UBTAN.

Triphala is a combination of three fruits: Aamla, Hirda, and Beheda. Triphala

powder can be used in constipation, to reduce obesity, diabetes and as external
application for healing wounds. It is applied on skin at the time of bath. Its
decoction is useful for gargling in illnesses such as sore throat, inflammation in
mouth, and bleeding gums (as tooth powder) and vision disorders.

134 Induction Training Module for ASHAs

Pudina leaf has stimulant and astringent action and is useful in controlling
diarrhoea, dyspepsia, flatulence, intestinal colic, and liver disorders. Peppermint
oil relaxes gastrointestinal muscles in dyspeptics.

Ginger Dried rhizomes are recommended in dyspepsia, loss of appetite,

anaemia and cough. Fresh rhizomes are recommended in constipation, colic
and throat infections. Both fresh and dried rhizomes suppress gastric secretion
and reduce vomiting. Gingerol and shogaol have gained importance due to
their sedative, anti-inflammatory, antipyretic and analgesic.

Garlic is antibiotic and antifungal in nature. It is widely used for upper

respiratory tract infections. It promotes the well-being of the heart and
immune systems with antioxidant properties and helps maintain healthy blood
circulation.

Kali Mirchi is a spice which acts as a diuretic and encourages our bodies to
sweat and get rid of harmful toxins. It aids digestion and help prevent the
formation of intestinal gas and reduce stomach upset. Taken with hot tea with
mint, it helps to break-up. It has antibacterial properties, promotes healing and
kills germs.

Drumsticks - All parts of the tree are reported to be used as cardiac and
circulatory stimulant. Fried pods are used by diabetics. Flowers are diuretic. Root
juice is used for nervous debility, asthma, enlarged liver and spleen. Decoction
is used as a gargle in sore throat. Drumsticks are a rich source of calcium. Its
soup helps ease chest congestions, coughs and sore throats. Inhaling steam of
water in which drumsticks have been boiled helps ease asthma and other lung
problem.

Papaya has antioxidant nutrients which include vitamin A, C, E, and beta-

carotene, are very good at reducing inflammation. The ripe fruit is easily
digestible and prevents constipation. The juice of the papaya aids in relieving
infections of the colon. The seeds are used for expelling worms when given with
honey. Chew and swallow two teaspoonfuls of seeds after each principal meal
(three times a day). It is a good source of fibre and has been shown to lower
high cholesterol levels.

Oils like Sesame oil or coconut oil are considered good for massage and
used for pain in the joints. Medicines may still be necessary for joint pains.
Massage improves blood circulation in the skin. Head massage with oil helps to
overcome sleeplessness.

Induction Training Module for ASHAs 135

 Mulethi is very a useful plant and available as small dry sticks. It is used to
improve hoarse voice and is given with honey. Mulethi powder is useful in
cough and hyper acidity. It improves the brain function when given with cow’s
milk. It is also used in pitta disorders-because as it has cooling properties. It is
used as an external application to improve skin glow when applied with haldi
powder and milk. It serves as a tonic when taken with shatavari (Asparagn)
powder and milk especially in lactating mothers.

Aamla Powder with ghee is useful in Hyperacidity.

Gulkand (Rose Petal in sugar) + Ghee is also useful in heartburn.

Honey and warm water/hot water sips it helps to reduce dry cough. Honey is
good for cough, and use as a vehicle for medicines.

136 Induction Training Module for ASHAs

Annexure 11: Drug kit; Dosage and Drugs Dosage and
Dispensing Schedule

Content of ASHA Drug Kit

ORS Dicyclomine

Paracetamol Tablet and syrup Albendazole

Oral Contraceptive Pills Nischay Kit

Condoms Thermometers

IFA Bandages

Chloroquine Cotton Swab

Paediatric Cotrimoxazole syrup Betadine; Gentian Violet

and tablet

Table A- Drug Dosage and Dispensing Schedule

Sl. Medicine Action & Use Age Specific Dose Side effects
No.
1a) Tablet Paracetamol Reduces fever More than 12 years : 1 to 2 tablets 3 to 4 No side effects. If too
1 tablet=500mg and pain. times a day many tablets are taken
Useful in fever, 8 to 12 years : 1 tablet 3 to 4 times a day at one time, it can
Duration: To be headaches, cause damage to liver.
given for 3 days 4 to 8 years : ½ tablet 3 to 4 times a day
backaches, Keep the medicine
only body aches away from children.
2 months -3 years
Frequency: etc. Should be taken only
(Wt 4-14 kgs)- ¼ tab (One fourth);
Maximum four after meals.
maximum four times a day
times a day at an
interval of six hours
3 yrs -5 yrs. (Wt 14-19 kgs) -½ tab (Half
tablet) –maximum four times a day.

Induction Training Module for ASHAs 137

Sl. Medicine Action & Use Age Specific Dose Side effects
No.
1b) Paracetamol syrup Newborn<3kg; Same as above
Duration: To be 1.25 ml or ¼ tsp (One fourth tea spoon)
given for 3 days >1 year (>3kg-8kg);
only 2.5 ml or ½ tsp (Half tea spoon)

Frequency: 1-3 yrs (>8-14 kgs);

Maximum four 5 ml or 1 tsp (One tea spoon)
times a day at an >3 yrs>14 kgs-
interval of six hours. 7.5 ml or 1 ½ tsp (One and Half tea
spoon)
5 ml or (1 tsp)
Syrup=125 mg/
5ml (Each 1 ml
contains 25 mg of
paracetamol)
Per kg dose of
paracetamol=10-
15mg/kg/dose
2 Iron tablet (adult) Prevention One tablet daily for 100 days, for Should be taken after
60mg elemental of Anaemia prevention of anaemia. meals, Can cause
iron. and Anaemia Two tablets for 100 days for treatment stomach upset. Stool
treatment (motions) may be hard
and black coloured.
Paediatric IFA( 20 Prevention <4 months On doctor’s advice Side Effects:
mg elemental iron). of Anaemia Constipation
and Anaemia 4 months-12 months (Wt 6-10 Kg) 1 tab In case of diarrhoea
To be given for 14 treatment in Once a day* take doctor’s advice
days in anaemic infants and
1 yr-3 yrs (Wt 10-14 Kg) 1½ tabs Once a In case of abdominal
child and then children
day* pain tablet should be
reassess
3 yrs-5 yrs (Wt 14-19 Kg) 2 tabs- once a consumed after food.
day
*Can be increased on doctor’s advice
3 Albendazole Tablet Deworming Less than one year- not to be given. Side Effects: Dizziness
1-2 years – half a tablet (400 mg) once in rare cases
a day Contra-indicated in
More than 2 years- one tablet( 400 mg) child less than 1 year
once a day and in pregnancy

138 Induction Training Module for ASHAs

Sl. Medicine Action & Use Age Specific Dose Side effects
No.
4a) Syrup Acute Birth upto<1 months (<3 kg) One fourth Rarely nausea,
Cotrimoxazole Respiratory teaspoon syrup (1.25 ml)* vomiting, stomatitis,
5ml or infections in Twice a day rashes, headache.
(1 teaspoon) Syrup: children and 1 month up to 2 months (3- 4 kg weight) Caution: The dose
Sulphamethoxazole Sepsis ½ teaspoon (2.5 ml) is 5 to 8mg/Kg of
200 mg+ Twice a day Trimethoprim per day
Trimethoprim 2 months-12 months (4-10 kgs weight) in two divided doses.
40 mg Full teaspoon (5 ml) Tablets come in 20mg.
Duration: To be Twice a day 40mg, 80mg or
given for 5 days sometimes 160mg
12 months-5 yrs (10-19 kgs weight)
Frequency: Two Trimethoprim.
2 Full teaspoon (10 ml)
times a day Depending on what
Twice a day
tablet is given to you,
4b) Tablet Acute For Birth upto<1 months (less than 3 kg you would be taught
Cotrimoxazole Respiratory weight)- Tablet is not to be given. the number of tablets
infections in
1 Tablet: 1 month up to 2 months (3- 4 kg weight) to be dispensed.
Sulphamethoxazole children and One tablet- Twice a day *Avoid Cotrimoxazole
100 mg + Sepsis in infants less than
Trimethoprim 2 months-12 months (4-10 kgs weight)- one month who
20 mg Two Tablets are premature or
Twice a day jaundiced
Duration: To be
given for 5 days 12 months-5 years (10-19 kgs weight)-
Frequency: Two Three Tablets
times a day Twice a day.
5 ORS packet Replaces salt As required. In adults: Half a glass after Throw ORS solution
and water in every stool. after 24 hours. Make
our body it fresh. Do not use a
packet if it is like a cake
In diarrhoea < Two months of age: five teaspoon full
with no after every loose stool
dehydration 2.1 months- 2 years of age - Half a cup
after every loose stool (100 ml).
Older children can have up to one cup
(200 ml) after every stool
In diarrhoea Up to 4 months; weight less than 6kg-
with 200-400 ml or two cups
dehydration 4 months-12 months; with weight
between 6-10 kgs- 400-700 ml or three
cups
12 months-2years; with weight between
10-12kgs- 700-900 ml or five cups
2-5 years; with weight between 12-
19kgs- 900-1400 ml or seven cups

Induction Training Module for ASHAs 139

Sl. Medicine Action & Use Age Specific Dose Side effects
No.
6 Gentian Violet Kills many For application on wound inside mouth, Stains clothes. Let it
liquid germs vagina etc dry before putting on
clothes.
7 Antiseptic lotion/ Kills wound Only for external use, wound wash etc can cause irritation if
ointment germs too much is used.

Table B– Side Effects of Common TB Drugs

Side effects Drug( Abbreviation) Management
Drowsiness Isoniazid(H) Reassure the patient
Red-orange urine, tears Rifampcin (R) Reassure the patient
Gastro-intestinal upset Any oral medication Reassure patient
Give drugs with less water
Do not give drugs on empty stomach
Severe itching Isoniazid(H) and other drugs Reassure patient;

Stop all drugs & Refer to MO

Burning in hands & feet Isoniazid(H) Refer to MO who will give pyrodoixine
100mg/day till symptoms subside
Severe joint pains Pyrazinamide(Z) Refer to MO
Impaired vision Ethambutol STOP treatment & refer for evaluation
Jaundice Isoniazid(H) STOP treatment & refer for evaluation
Rifampcin(R)
Pyrazinamide(Z)
Ringing in the ears Streptomycin(S) STOP Streptomycin and refer for
evaluation
Loss of hearing Streptomycin(S) STOP Streptomycin and refer for
evaluation
Dizziness & loss of balance Streptomycin(S) STOP Streptomycin and refer for
evaluation

140 Induction Training Module for ASHAs

Table C- Treatment Guidelines for Malaria
Age-specific drug schedules
1. Chloroquine tablets (150 mg base)

Age (in years) Day 1 Day 2 Day 3

Tab. Chloroquine Tab. Chloroquine Tab. Chloroquine
<1 1/2 1/2 1/4
1-4 1 1 1/2
5-8 2 2 1
9-14 3 3 1+1/2
15 & above 4 4 2

2. Primaquine tablets (7.5 or 2.5 mg base)

Age (in years) P. falciparum P. vivax

Primaquine 0.75 mg/kg on day 1 Primaquine 0.25 mg/kg daily
dose for 14 days*
mg base No. of Tablets mg base No. of Tablets
(7.5 mg base) (2.5 mg base)
<1 Nil 0 Nil 0
1-4 7.5 1 2.5 1
5-8 15 2 5.0 2
9-14 30 4 10.0 4
15 & above 45 6 15.0 6
*
Primaquine is contraindicated in children under one year and pregnant women.

3. Artesunate 50 mg tablets + Sulfadoxine-Pyrimethamine 500 + 25 mg

tablets (ACT) combination

Age (in years) 1st Day 2nd Day 3rd Day

(number of (number of (number of
tabs)* tabs) tabs)
<1 Year* AS 1/2 1/2 1/2
SP 1/4 Nil Nil
1-4 Yeas* AS 1 1 1
SP 1 Nil Nil
5-8 Year* AS 2 2 2
SP 11/2 Nil Nil
9-14 Year* AS 3 3 3
SP 2 Nil Nil
15 and above AS 4 4 4
SP 3 Nil Nil
* till such time as age-wise blister packs are made available for all age groups

Induction Training Module for ASHAs 141

 Annexure 12: Preparing Malaria Slide

For preparation of blood smears following items are required:

1. Clean glass slides

2. Disposable Lancet

3. Spirit or Cotton swab for cleaning the finger

4. Cotton

5. Clean piece of cotton cloth

6. Lead pencil

After the patient information has been recorded on the appropriate form, the
blood films are made as under:

l Take a clean glass slide free from grease and scratches

l Clean the finger of the patient using a spirit swab

Take the following steps for preparation of the blood smear

i. Select the second or third finger of the left hand

ii. The site of the puncture is the side of the ball of the finger, not too
close to the nail bed

iii. Allow the blood come up automatically. Do not squeeze the

finger.

iv. Hold the slide by its edges

v. The size of the blood drop is controlled better if the finger touches
the slides from below

142 Induction Training Module for ASHAs

 vi. Touch the drop of blood with a clean slide, three drops are
collected for preparing the thick smear.

vii. Touch another new drop of blood with the edge of a clean slide
for preparing the thin smear.

viii. Spread the drop of blood with the corner of another slide to
make a circle or a square about 1 cm

ix. Bring the edge of the slide carrying the second drop of blood to
the surface of the first slide, wait until the blood spreads along the
whole edge

x. Holding it at an angle of about 45o push it forward with rapid but

not too brisk movement

xi. Write with a pencil the slide number on the thin film, Wait until the
thick film is dry. The thin film is always used as a label to identify the
patient.

Remember
l The blood should not be excessively stirred. Spread gently in circular or
rectangular form with 3 to 6 movements.

l The circular thick film should be about 1 cm (1/5 inch) in diameter.

l Allow the thick film to dry with the slide in the flat, level position protected
from flies, dust and extensive heat.

l Label the dry thin film with a soft lead pencil by writing in the thicker
portion of the film the blood slide number and date of collection

The lancet and cotton swab should be disposed off.

Induction Training Module for ASHAs 143

 Annexure 13: Technique for Performing Rapid
Diagnostic Test
Procedure
l Check that the test kit is within its expiry date. If not discard it. Read the
instructions of the test kit, as there may be minor variations in the procedure
between different kits. Place a small box, jar or bottle for trash next to the kit.

l Open a foil pouch and check that the desiccant inside it is still blue. If not,
discard the test.

l Remove the test strip and the small glass tube or loop from the foil pouch
and place them on a clean dry surface.

l Take out the buffer solution and the dropper. Place a new test tube in the
multiple well plate.

l Clean a finger with the swab and let the skin dry completely in the air. Prick
finger on the side with a lancet. Place lancet in trash container. Let a drop of
blood come out on the skin.

l Touch the tip of the glass tube or the loop to the blood drop on the finger
and let a small quantity of blood (a small drop) come up in the tube or the
loop.

l Touch the tube or the loop to the test strip just below the arrow mark to
place the blood there. If there is a paper, where Plasmodium falciparum is
written, remove it and place the blood, where it was. Place tube/loop in trash
container.

l Using the dropper, place 4 drops of buffer solution into a new test tube.
After this, place the test strip containing blood in the buffer solution with
the arrow pointing down. While waiting, a slide can be prepared.

Materials in the Rapid Diagnostic Test kit

l Spirit (alcohol) swab (one for each patient)

l Disposable Lancet (one for each patient)

l Capillary tube (one for each patient)

l Test strip (one for each patient)

144 Induction Training Module for ASHAs

l One multiple well plastic plate

l Test tube (one for each patient)

l Buffer solution or reagent solution

l Desiccant

Observe after 15 minutes – if any red line does not appear in the test strip then
the test strip is not working: discard it and use another one.

l If a single red line appears, it is not falciparum malaria. If two red lines
appear, the test result is falciparum malaria.

l The test should be read 15 to 20 minutes after blood was taken. Earlier or
later readings may lead to false results.

l Place test strip and test tube in trash container. Make sure this container
is kept out of reach of children. When it is full, if in a village, bury it in the
ground, or send it with the MPW to the PHC for safe disposal.

Induction Training Module for ASHAs 145

 Annexure 14: Instructions for Pregnancy Test using
Nischay Kit
The Nischay Kit contains the following:

l A test card

l A disposable dropper

l A moisture absorption packet (not required for testing)

l Collect the morning urine in a clean

and dry glass or in a plastic bottle.
l Take two drops of urine in the sample
well.
l Wait for 5 minutes.

l If two violet colour lines come in the

test region (T), the woman is pregnant.
l If she wants to continue with the
pregnancy, advise her to undergo
antenatal care.
l If she does not want to continue with
the pregnancy this time, advise her for
safe abortion.

l If the violet colour line in the test

region (T) is one only, the woman is not
pregnant.
l Tell her about family planning methods
and help her in choosing the most
appropriate one.

l If there is no colour line in the test region

(T), repeat the test next morning using a
new Pregnancy Test Card.

146 Induction Training Module for ASHAs

 Induction
Training Module
for ASHAs

Ministry of Health & Family Welfare

Nirman Bhavan, New Delhi