The Community-Directed Intervention (CDI) Process - PowerPoint Presentation

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The Community-Directed Intervention (CDI) Process

Module 3Version 2

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Learning objectives

By the end of this module, learners will be able to:Define the

CDI

approach

Describe program coverage benefits of using CDIExplain the role of the health facility (HF) in the CDI process Outline the steps to establish a CDI programList key approaches in gaining community commitment for a CDI programDescribe the steps in selecting and training community health workers (CHWs)Explain how CDI can be adapted for use in controlling malaria in pregnancy (MiP)

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What is CDI?

For many years, health services and nongovernmental organizations have been distributing health commodities to communities

, for example:

Immunizations

Vitamin ABed netsIvermectinGuinea worm filtersCDI happens when communities take charge of distributing health commodities themselves with guidance from the health service2

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What is CDI? (cont.)

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“Ownership” differentiates community-based intervention from CDI:

In a community-based intervention, the ministry of health, HF, civil society organization, community-based organization, faith-based organization can still own the intervention

In a CDI, the community owns the interventionWhen communities are in charge there is often better coverage than when there is centrally organized distribution by a health agency

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Introduction of CDI

to address onchocerciasis (river blindness)

Onchocerciasis

is a

parasitic disease caused by the filarial worm Onchocerca volvulus. It can cause blindness.CDI was first tested for use for the African Programme for Onchocerciasis Control (APOC) by the Special Programme for Research and Training in Tropical Diseases (TDR) sponsored by UNICEF/United Nations Development Programme/World Bank/World Health Organization.

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Image source

:

Raw

Gist. 2015.

Accessed September 24, 2018.

https

://

www.rawgist.com/wp-content/

uploads/2015/09/onchocerciasis2.jpg

.

Slide6

Introduction of CDI to address onchocerciasis (river blindness

), cont.

TDR conducted research

to learn whether communities could deliver the drug

ivermectin more effectively than agencies had in the past.5

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Results of CDI for

onchocerciasis

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The

original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distributionWhen CDI proved successful

, it was adopted as APOC’s official strategy.

There are now

tens of thousands of communities

throughout Africa

benefiting

from annual onchocerciasis control through CDI.

Adapted from:

APOC

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Expanding CDI beyond

onchocerciasisRecently APOC observed that the CDI approach is being used for other

issues

S

tudies have documented CDI being used to promote:Guinea worm controlSchistosomiasis controlImmunization programsVitamin

A

distribution

Water

and sanitation

projects

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Slide9

Using CDI for malaria control

TDR has specifically

tested CDI for malaria control

Seven-site study (CDI Study Group 2010) in

Cameroon, Nigeria, and Uganda:Existing ivermectin distribution continuedThrough CDI, intervention groups received:Vitamin AHome management of malaria (HMM) with artemisinin-based combination therapiesInsecticide-treated bed nets (ITNs)

Tuberculosis case detection and follow-up for case completion

The study showed benefits in malaria control and ivermectin coverage

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Results: Children sleeping under an ITN

9

Roll Back Malaria (RBM) target

2005

Conclusion

: CDI

increased proportion of children sleeping under ITNs

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Results: Pregnant women sleeping under ITN

10

RBM

target

2005

Conclusion: CDI

increased proportion of pregnant women sleeping under ITNs

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Results: Appropriate treatment of children with fever

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RBM

target

2005

Conclusion: CDI

increased proportion of children with fever who received appropriate treatment

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Results: Ivermectin

treatment coverage

12

APOC target

Conclusion: CDI increased basic

ivermectin treatment coverage even when other services were added

Sourc

e:

TDR 2008

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Lessons learned

CDI works when:

The

disease is perceived as an important health problem

that affects all sections of the communityAn intervention or solution is available that is relatively simple to implementThe intervention has a clearly perceived benefitImplementation of intervention is

under full control of the community

implementers

The

intervention materials are made adequately accessible

to the community

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Key lessons

The most critical factors were:

Community empowerment/ownership

Regular, adequate, and timely

supply of the materials to be deliveredNet storage in medical stores. Photo by Bill Brieger, Johns Hopkins University/Jhpiego.

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Learning how to implement CDI

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Partners:

Each partner has well-defined roles*In the CDI process, the project belongs to the

community

and the

health service:Communities:Community leadersCommunity membersCHWsHealth service:Ministry of health maternal and child health or reproductive health divisionsNational malaria control or elimination programSubnational and district health offices, especially malaria-related onesFrontline HF staff and health care workersCDI focal personsPartners in CDI include:Implementing partners

Relevant civil society organizations:

Donor agencies

Community-based organizations

Faith-based organizations

Nongovernmental organizations, such as President’s Malaria Initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria

Multilateral agencies, such as UNICEF and World Health Organization

Media

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*

See

Community Intermittent Preventive Treatment for Malaria in Pregnancy: Implementation Guide

chapter “Roles and responsibilities” for more detail.

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Start-up components

of CDI for malaria control

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Abbreviations: c-IPTp,

community-directed intermittent preventive treatment in

pregnancy; DOT,

directly observed

therapy; SP,

sulfadoxine-pyrimethamine

.

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1. Approaching

the health service

Photo by Emmanuel Otolorin, Jhpiego.

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Start at

the facility nearest to the community

This may be:

Community primary health care facility

District comprehensive health centerThese facilities may offer services such as:Antenatal care (ANC)Safe delivery and postnatal careFamily planningAppropriate integrated management of childhood illnessesRoutine immunizationVitamin A distributionCommodities to prevent malaria such as ITNs/LLINs (long-lasting insecticidal nets),

SP

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Photo by Gabriel Alobo, Jhpiego.

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Meet facility in-charge

Explain the purpose of the program:

Importance

of health service staff as

CDI facilitators/trainersBenefits of CDI to the health systemReduced workload for health workersIncreased contact with communityMap facility catchment areas*Train health care workersChoose CDI focal persons for further training*See Module 5 for more detail.

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Training CDI focal persons for their roles as trainers of CHWs

Teach skills for training adults and semiliterate CHWs based on

adult learning principles

(see Module 10 for details):

Pre- and post-testsIllustrationsMotivationInteractive learning methods such as:Role-play (e.g., health education counseling)Demonstration (e.g., how to set up ITNs/LLINs)Observed practice and feedbackTeach skills for monitoring and evaluation (see Module 8 for details)

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Training CDI focal persons for their roles as trainers of CHWs

, cont.Teach skills for

supportive supervision

(see Module 11 for details)

:Clearly define performance standards before initiating supervisionUse checklists to assess performanceAppreciate the information from the fieldProvide immediate feedback to CHWsCoach the CHW to use the feedback; if possible, have the CHW try again and then immediately evaluate

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Training health workers for their roles

Planning and documentation

Just addressing the initial objectives after the job was done

Goal

definition (e.g., women getting three or more doses of intermittent preventive treatment in pregnancy [IPTp] increased to 50%) Setting timeline for CHW trainingsReportingPassing information to supervisors and supervisees (e.g., from district health office to HF to CHWs)How was it documented and transmitted (e.g., training information)22

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Roles of the CDI focal person

Ensuring that all communities in the facility’s catchment area

participate in the program

Organizing meetings

to mobilize support and commitment for CDIFacilitating community census and mapping Reviewing census and mapping results to estimate needed commodities, suppliesProviding drug box so CHWs can keep commodities 23

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Roles of the CDI focal

person, cont.Buy supplementary medicines

for the community (e.g., analgesics)

Advocacy visits to facilities and local government headquarters

to ensure adequate and timely supplies of commoditiesMaintaining stocks of basic health commodities for CDI, for example: Quality-assured SPITNs/LLINsCommunity registers24

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Roles of the CDI focal person, cont.

Coordinating:CDI training:

Training

community-selected

CHWsProviding retraining to refresh CHWs and replace dropoutsSupervision:Conducting supportive supervisory visitsCommodity storageRecordkeeping:Ensuring communities and CHWs submit data in a timely mannerIncorporating community data with facility data for onward transmission25

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2. Reaching

out to the community

Mothers Savings and Loans Club members in Nigeria.

Photo by Karen Kasmauski.

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Meetings with the community

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1. Community entry meeting

Make contact with the community leaders (gatekeepers):Send word that

health staff would like to meet with leaders

to introduce the program

Start with four or five key leaders whose support is needed to proceedJointly define the problemInform them about available services to address the problemIdentify community roles in accessing the available services28

Community leaders are gat

ekeeper

s

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1. Community entry meeting, cont.

Explain CDI to the leaders and answer their questions

Obtain

a clear sense of

commitmentArrange a larger CDI orientation and facilitation meeting with community representatives29

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2. CDI orientation and facilitation

meetingIt may not be possible to do everything at one meeting

Reach out to the entire community through representatives

Leaders should invite representatives for all villagers: men, women, youth, and even “visitors” like farm laborers

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2. CDI orientation and facilitation

meeting, cont.Jointly

define the problem

Inform

them about available services or solutionsIdentify potential community roles in accessing the available services or solutionsDecide on criteria for CHW selectionDiscuss and gain commitment for community roles31

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Roles for the community

Map the communityConduct village census to aid in estimating commodity needs

Develop and help maintain village register

of pregnant women

Support the CHWs in their activities (provide incentives). 32

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Roles for the community, cont.

Monitor implementation process (community self-monitoring); indicators to measure might include:

Referrals to ANC clinic

Community compliance with ITN/LLIN use, follow-up

IPTp doses CHW performance (adherence to treatment procedures, treatment of all eligible persons)33

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Roles for the CHW

Collect health commodities at nearest HFDistribute intervention commodities and deliver services in the community (including referral)

Keep good records and

summarize information from the CHW register

to report back to the HF34

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3. Community-wide meetings

Request community meet on its own to discuss community implementation plan, including distribution of commodities

This

meeting is intended to engage everyone

in the CDI processIt may not be possible to do everything at one meeting; the community should hold follow-up meetings as needed35

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Discuss and gain commitment for community roles including...

CHW selection: Developing criteria of type of residents best suited to the work of CHWCensus/mapping exercises

Conducting village

census to aid in estimating commodity needs

Mapping the community (see Module 5 for more detail)36

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4. Feedback meeting: Incorporating feedback from the community

Community representatives report back

from community-wide meetings

Decide convenient days, times

, and means for distribution of health commoditiesDocument the community action planReiterate the importance of community playing its roles37

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4. Feedback meeting: Incorporating feedback from the

community, cont.

Select CHWs:

Use basic selection criteria as well as criteria community members developed in community-wide meetings

Create list of selected CHWsPlan training of CHWs:Sponsor/support CHWs to attend c-IPTp trainingIdentify timing, venue, requirementsShare information on training logistics with CHWs and training facilitators38

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Training CHWs for their roles

Recruitment,

commitment, responsibilities

CHW Training Session in Nigeria.

Photo by Eno Ndekhedehe39

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Make a training plan for CHWs

Venue: should be open,

within the community, not classrooms

, to create community awareness

Involve community leaders in the training (e.g., to declare sessions open and closed)Identify training requirements and materials Ensure information, education, and communication materials are appropriate to the CHWs’ education levelPlan for refreshmentMake training and trainers lively and supportive40

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Make a training plan for CHWs, cont.

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Module #

Proposed dates

No. of CHWs

Venue

Training facilitators

Resources needed

Training plan template

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Training content for CHWs

Make sessions interactive, starting with CHW’s knowledge (prompt for issues not mentioned)Start with general discussion on participants’ experience with malaria

Discuss

experience with

MiP42

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Training content for CHWs, cont.

Discuss the management of malaria in the community.

Note the different modes of management, for example:

Prevention by sleeping inside ITNs/LLINs

Provision of a minimum of three doses of SP to all pregnant womenEarly detection of malaria fever and treatment with appropriate antimalarial drugs in accordance with national guidelinesDiscuss drug availability within the communityDirect discussion to management of MiP, especially c-IPTp with quality-assured SP43

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Skills training for CHWs

Emphasize the limits of the skills CHWs will acquire (not to go beyond their scope of work)

Identification of eligible pregnant women

Health education

to community:Using Interpersonal Communication for Prevention and Control of Malaria in Pregnancy: Community Health Workers’ Counseling Flip Chart (the Counseling Flip Chart)Targeting all segments of community separately (especially pregnant women but also including men) Share appropriate job aids:Job aids for IPTp provisionPregnancy wheel for gestational age estimation

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Skills training for CHWs, cont.

Prevention:

How to hang ITNs/LLINs

How to assess women for

IPTp eligibilityGiving IPTp with SP by DOTTreatment:Drugs available (artemisinin-based combination therapies)Treatment modes, regimen, requirements, possible reactions, reaction managementReferral:Conditions for referralReferral points

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4. Implementation of

c-

IPTp

with SP

Slide49

Review of major

MiP interventions

Remember—

prevention

of malaria in the pregnant woman reduces low birthweight in babiesITNs/LLINs:Get a net early in pregnancySleep inside this net every nightIPTp: Minimum of three doses recommended:First dose of SP between 13 and 16 weeks or after quickeningSecond dose at least 4 weeks laterThird dose at least 4 weeks after second doseFourth to sixth doses, if possible, with

at least 4 weeks between each

dose

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ITN/LLIN distribution

There are two possible modes of distribution:CHWs collect supplies from nearest facility and

distribute for free directly to pregnant women

CHWs

provide an ITN/LLIN coupon to pregnant women and refer them to nearest facility to collect the ITN/LLINFor both modes:Start with small supplyIf CHW is found capable, increase supplyCHW maintains village register of pregnant womenCHW collects ITNs/LLINs or coupons from health serviceCHW records delivery of ITN/LLIN or coupon for each woman who received it48

Slide51

IPTp

through CDICHW: Informs community leader of readiness to begin distribution

of drugs

Collects SP

from the agreed point (usually from the HF)Gives health education to the women (home visits, women’s society meetings, marketplace, etc.) using the Counseling Flip ChartIdentifies pregnant women eligible for IPTp dose49

Slide52

IPTp through

CDI, cont.Issues drug to eligible women

and ensures they swallow full dose

(DOT)

*Records the information about giving IPTp in CHW registerRefers pregnant woman to ANC for follow-up doses and ITN/LLIN if she has not already received one *Important note: In Madagascar and Mozambique, all pregnant women must receive the first dose of IPTp through ANC at the HF.50

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Notes on

IPTp dosingWhen gestational age can be accurately determined (by known date of last normal menstrual period, ultrasound, or clinical exam), the

first

IPTp

dose should be given as early as possible in the second trimester (at 13 weeks). When in doubt, wait till the mother can feel the baby move inside her womb (quickening usually occurs by 16 weeks).It is best for the woman to get the second dose at the ANC clinic, where trained staff can check and test the mother and baby to ensure that the pregnancy is going well.51

Slide54

Key health education messages on

IPTpCHW delivers key messages using the

Counseling Flip Chart

:

Malaria parasites may be in your blood even if you don’t feel sickMalaria makes your blood weakWhen the mother has malaria, the newborn is too small at birth and can get sick easilyIPTp with SP prevents MiP52

Slide55

CHWs and referrals

CHW refers woman to nearest ANC clinic to get comprehensive ANC and other commodities

CDI focal persons should spot-check CHW register

against ANC beneficiaries at monthly supportive supervision meetings

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Slide56

Summary and conclusions

CDI was first tested for use by TDR for APOC and the approach proved successfulCommunities

CAN

carry out the task of distributing health commodities very well

Community-directed distributors or CHWs do not replace HF workers but rather complement their servicesCDI happens when communities take charge of distributing health commodities themselves with guidance from the health service54

Slide57

Summary and conclusions, cont.

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CDI processes

Slide58

References

CDI Study Group. 2010. Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ

. 88(7):509–518.

doi

: 10.2471/BLT.09.069203.TDR (Special Programme for Research and Training in Tropical Diseases). 2008. Community-Directed Interventions for Major Health Problems in Africa: A Multi-country Study; Final Report. Geneva, Switzerland: TDR/World Health Organization. http://www.who.int/tdr/publications/documents/cdi_report_08.pdf. Accessed October 18, 2018.56

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Thank you!

Any questions or comments?