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CDI Module 2: The CDI Process
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services
2
Module 2 Objectives
By the end of this module, learners will: Define the community-directed intervention (CDI)
approach Describe program coverage benefits from using CDI Outline the steps to establish CDI List key approaches in gaining community commitment
for a CDI program Describe the steps in selecting and training community
distributors Explain how CDI can be adapted for use in controlling
malaria
3
What Is CDI?
For many years: Health services and nongovernmental organizations
(NGOs) have been distributing health commodities to communities
We now know that: Communities can carry out this distribution very well
themselves CDI happens when communities take charge of
distributing health commodities themselves with guidance from the health service
CDI and Onchocerciasis
CDI was first tested for use for the African Program for Onchocerciasis (APOC) Control by the Special Program for Research and Training in Tropical Diseases (TDR) as “community-directed treatment with ivermectin” (CDTI)
Research was conducted to learn if communities could deliver the drug ivermectin more effectively than agency outreach had done in the past
When CDI proved successful, it was adopted as APOC’s official strategy
Now over 100,000 villages throughout Africa are benefiting from annual onchocerciasis (river blindness) control through CDI
4
5
Benefits of CDI
68.662.2
01020304050607080
CommunityDirected
AgencyDesigned
Ivermectin Coverage in Eight-Site Project
When communities are in charge, coverage is often better than it is when distribution is centrally organized by a health agency
The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution
Expanding Beyond Ivermectin
Recently, APOC observed that the CDI approach is being used for other issues
Studies have documented that CDI has been used to promote numerous interventions, including: Guinea worm control Immunization programs Vitamin A distribution Water and sanitation projects Schistosomiasis control
6
A Multicountry Study
TDR has specifically tested CDI for malaria control through a seven-site study: In selected districts in Uganda, Nigeria, Cameroon With continued ivermectin distribution plus four
additional interventions:– Vitamin A– Home management of malaria (HMM) with
artemisinin-based combination therapy (ACT)– Insecticide-treated nets (ITNs)– TB case detection and follow-up for case
completion
7
Multicountry Study: Intervention Plan
Stakeholder support gained to combine the five health interventions in selected districts
Two implementation arms (comparison districts versus CDI districts)
Three-year implementation CDI districts
– Year 1: two interventions delivered through CDI (ivermectin plus one additional intervention)
– Year 2: three interventions delivered through CDI (one more intervention added)– Year 3: All five interventions delivered through CDI (remaining two interventions
added)
Comparison districts use conventional delivery of all five interventions for all three years
Source: The CDI Study Group 2010 8
9
Children Sleeping under ITNs
Comparison districts ITN through CDI for 1 year ITN through CDI for 2 years0
10
20
30
40
50
60
70
9 11
35
16
36 33
Year 2 Year 3
% c
hil
dre
n s
lep
t u
nd
er I
TN
pre
vio
us
nig
ht
RBM Target2005
RBM = Roll Back Malaria Partnership Source: The CDI Study Group 2010
10
Pregnant Women Sleeping under ITNs
Comparison districts ITN through CDI for 1 year ITN through CDI for 2 years0
10
20
30
40
50
60
70
84
3733
57
49
Year 2 Year 3
% p
reg
nan
t w
om
en s
lep
t u
nd
er IT
N p
revi
ou
s n
igh
t
RBM Target2005
Source: The CDI Study Group 2010
Children Receiving Appropriate Malaria Treatment
Comparison districts HMM through CDI for 1 year HMM through CDI for two years
0
10
20
30
40
50
60
70
80
21
28
48
29
55
69
Year 2 Year 3
% c
hil
dre
n w
/fev
er r
ecei
vin
gap
pro
pri
ate
trea
tmen
t
11
RBM Target2005
Source: The CDI Study Group 2010
Basic Ivermectin Coverage Improves Even When More Tasks Are Added
Year 2 Year 30
10
20
30
40
50
60
70
80
63 64
72 74
Comparison districts CDI districts
% i
verm
ecti
n c
ove
rag
e
12Annual ivermectin coverage of 65% is needed to control the disease Extra interventions enhance community interest
APOC target
13
Lessons Learned
CDI works when: The disease is perceived as an important health
problem that affects all sections of the community An intervention is available that is relatively simple to
implement The intervention has a clearly perceived benefit Implementation of the intervention is under the full
control of community implementers The intervention materials are made accessible to the
community in adequate quantities
14
Key Lessons
The most critical factors are:
An empowered community
Supplies delivered regularly, in adequate amounts and on time
15
Start-Up Components of CDI
Approaching the health service includes: Involving stakeholders from all component programs
of integrated community case management (iCCM)—child health, maternal health, disease control
Building a partnership between an affected community and the nearest health facility
Approaching the community includes: Gaining support for CDI Mapping and learning about the community
Training distributors selected by the community
MOHVillage
Leaders
NGO
USAID
VHT
Others
SMOH
LGA PHC
NGO
CDDs
CBOs
Religious Groups
Organizational Partners Community Partners
Other
WHO
UNICEF
Each partner has a well-defined role
16
CDI for iCCM Can Build on Existing Programs
17
In Nigeria, for example: Ivermectin for river blindness control had been
delivered through CDT since 1995 In states with active ivermectin CDT programs, it
was possible to add the iCCM package of interventions to existing community efforts
In districts that did not have CDT previously, state ministry of health staff used their experience in river blindness endemic districts to start the CDI/iCCM program in new districts
Approaching the Health ServiceHealth Service Roles
18
19
Starting with Comprehensive or Integrated Facilities
These facilities offer: Antenatal care (ANC) Safe delivery and postnatal care Family planning services Appropriate management of childhood illnesses Immunization, vitamin A distribution Prevention services such as ITNs
Other facilities may be updated over time
20
Roles for the Health Service
Mapping facility catchment areas Organizing community meetings to mobilize
support and commitment for CDI Training community-directed distributors (CDDs)
selected by and accountable to the community Maintaining stocks of basic health commodities for
CDI Guiding conduct of village census Reviewing census results for estimating needed
commodities, supplies
Staff at Local Clinic Train and Supervise Community-directed Distributors (CDDs)
21
22
Mapping Catchment Areas
CDI training, supervision, commodity storage and recordkeeping are coordinated by frontline health facilities
These facilities ensure that all communities in their service catchment areas participate in the program
Clinics Should Also Have Community Maps
23
24
More Health Department Roles
Conduct supportive supervisory visits to communities
Provide retraining To refresh CDDs To replace dropouts
Coordinate data collection Ensure communities and CDDs submit data in a timely
manner Incorporate village data with facility data to ensure that:
– All data are captured and forwarded, as appropriate– The facility recognizes that catchment community data also
belong to the facility and form part of the facility service delivery output(s)
Reaching Out to the Community
Make contact with community leaders to: Define the problem
jointly Inform leaders about
available services Identify community
roles in accessing the available services
25
Reach the Entire Community
Meet the entire community to: Define the problem jointly Inform about available services Identify community roles in accessing the available
services Remember that visitors, farm workers and others are
also part of the community
Ask the community to meet and discuss the community implementation plan—CDD selection, census, distribution of commodities
26
Ensure Participation
Return to the community for feedback from the community meeting
Document the community implementation plan Reiterate the importance of the community
playing its roles Inform communities that they can select more
than one CDD Collect the list of selected CDDs Provide information on CDD training (timing,
venue, requirements)27
Train Health Workers for Their Roles
Help health service staff members understand their importance as facilitators
Highlight the benefits of CDI to the health system, for example: Reduced workload for health workers Increased contact with the community
Transfer skills for training adults and semi-literate CDDs, using: Role play, demonstration, illustrations, motivation
28
Trained Frontline Health Workers Ensure That the Program Reaches the Community
Frontline health workers should be prepared to: Transfer skills for monitoring and supervision as well
as for evaluation Clearly define targets before setting out to supervise Use checklists Appreciate the information from the field Provide immediate feedback Support the supervisee to use the feedback, and
then evaluate immediately
29
Trained Frontline Health Workers Are Essential for Planning and Monitoring
Planning and documentation Addressing the initial
objectives after the job is done
Defining the goal Setting the timeline
Reporting Passing information top-
down-top Assessing how it was
documented and transmitted
30
Approaching the CommunityGaining Support for CDI
31
First Meeting
Begin by: Sending word to the community that health staff
would like to meet with leaders to introduce the program
Including key leaders in this initial meeting (perhaps four to five leaders) whose support is needed to proceed
Explaining CDI to the leaders and answering their questions
Obtaining a clear sense of commitment Arranging a larger community meeting
32
First Meeting with Community Leaders
33
Second Meeting
Ask the leaders to assemble all villagers—men, women, youth and even “visitors” (e.g., life farm laborers—farmers who live on their farms during the farming season and return to the village when the season is over)
This meeting is intended to engage everyone in the CDI process
The slides that follow outline activities that take place at community meetings
It may not be possible to do everything at one meeting The community should hold follow-up planning meetings
34
Second Meeting with Community Members
35
Discuss and Gain Commitment to Community Roles, Including …
Decide convenient days, times and means for distribution of health commodities
Map the community (see earlier slides on community mapping and module on community structure, networks and organization)
Select CDDs Develop criteria to define the types of residents best
suited to the work Select the number of CDDs needed Sponsor CDDs to attend a short training activity Make it clear that CDDs work for/with the community,
not instead of the community36
Roles for the Community
The community should: Conduct a village census to aid in estimating
commodity needs Collect health commodities at the nearest health
facility, based on estimates from the census Maintain a village distribution register Monitor the implementation process
Referrals Compliance CDD performance (adherence to treatment
procedures, treatment of ALL eligible persons)
37
More Roles for the Community
The community should also: Summarize information from the register to report back to the
health facility Provide drug boxes so CDDs can store commodities safely Buy supplementary medicines for the community (e.g.,
analgesics) Make advocacy visits to facilities and local government
headquarters to ensure adequate and timely supply of commodities
Support their own CDDs with appropriate recognition and rewards
Monitor implementation Community self-monitoring is critical
38
39
Training Community-Directed DistributorsRecruitment, Commitment, Responsibilities
Basic Principles for CDD Training
Training should be based on knowledge and skills CDDs will actually use
Training methods should involve local communication processes (e.g., storytelling, songs and proverbs)
As adult learners, CDDs should be asked to contribute their own ideas and experiences throughout the training
Training evaluation and rewards (e.g., certificates) are crucial
40
41
Make a Training Plan for CDDs
The venue should be open and convenient (i.e., it should be within the community) to create community awareness
Involve the community leaders in the training (e.g., these leaders can officiate at training session openings and closings)
Emphasize the limits of the skills CDDs will acquire
CDD skills will not go beyond their job descriptions
Training Plan
Identify training requirements and materials
Design culturally relevant job aids and information, education and communication (IEC) materials that CDDs can take home and use
Plan the refreshments Ensure that training and
facilitators are lively and supportive
42
Choosing Training Content
iCCM Malaria Pneumonia Diarrhea
Prevention of common illnesses, such as: Malaria Diarrhea
Other interventions (immunization, vitamin A, etc.)
Countries and programs should decide on the package of interventions that best suits local health needs
43
Additional Skill Content for CDDs
Health education to community Target each segment of the community separately,
including men, women, youth, migrant workers, etc. Address drug availability within the community
Identifying eligible persons Make this activity interactive, starting with CDDs’
knowledge (prompt for issues not mentioned)
Recordkeeping and reporting Safe commodity supply management
44
CDD Skills
Treatment Drugs available Treatment modes,
regimen, requirements, possible reactions, reaction management
Referral Conditions for referral Referral points
45
Example of Training Content for Malaria Interventions through CDI
1. Distribution of ITNs and ensuring “hang-up”
2. Intermittent preventive treatment in pregnancy (IPTp) and referral to ANC
3. Prompt diagnosis—rapid diagnostic tests (RDTs)—and appropriate treatment (ACT)
4. Health education on appropriate use of interventions
5. Referral of severe malaria
6. Recordkeeping, monitoring and surveillanceAll of these topics will be covered in detail in the modules that follow
46
Involve CDDs in GeneratingContent and Ideas
Start with a general discussion about the learners’ experience with malaria
Discuss experience with malaria in children, in pregnant women and others
Discuss management of malaria in the community (note the different modes of management) Local practices, beliefs Treatment of different groups, children, pregnant
women, others
47
Distribution of ITNs
There are two possible modes of distribution: CDD collects medicines and
supplies from the nearest facility and distributes them for free
CDD provides an ITN coupon to the pregnant woman and refers her to the nearest facility to collect the ITN
In all cases CDD ensures people hang and use nets
48
ITNs Directly through CDI
The CDD: Collects ITNs or coupons from the health service
Starts with small supply If community responds well, increases supply
Ensures that each household receives enough nets for each sleeping space
Consults with household members on how to hang their nets
Encourages regular nightly use and makes home visits for a reminder
49
50
Medicines Delivered through CDI
Train the CDD to: Collect commodity from agreed point
For malaria—ACT, sulfadoxine-pyrimethamine (SP) for IPTp, RDTs, paracetamol
For diarrhea—oral rehydration solution (ORS) packets, zinc, hand soap
For pneumonia—antibiotics Inform the community leader and co-villagers about
the availability of drugs Provide health education on the importance of
prompt and appropriate treatment
IPTp through CDI
Train the CDD to: Provide health education to the woman Issue drug to the woman and ensure that she
swallows the full dose Record the information about giving IPTp in the
village register Refer pregnant woman to ANC for follow-up
dose and ITN if she has not already received one
51
Train CDD for Health Education on IPTp
Explain to the CDD that: Malaria may be in your
blood, even if you don’t feel sick
Malaria makes your blood weak
When the mother has malaria, the newborn is too small and can get sick easily
IPTp prevents malaria in pregnancy
52
More Health Education on IPTp
Explain to the CDD that: IPTp should only be given after the mother can feel
the baby move inside This is likely to be 16 to 20 weeks after she
becomes pregnant A second dose of IPTp should be taken a month
after the first dose It is best to get the second dose at the antenatal
clinic where trained staff can check and test the mother and baby to ensure that the pregnancy is going well
53
Prompt Diagnosis and Appropriate Treatment
54
Three Main Steps for Case Management
The CDD should:1. Find out what illness the patient has by:
Asking the patient/caregiver to explain signs and symptoms Feeling the body to determine fever Performing RDT for malaria Checking for other signs (e.g., anemia, cough and difficult
breathing) Deciding whether the patient has malaria or another disease
2. Provide the approved anti-malaria drug supplied by the program for those with positive RDT
3. Counsel the patient on taking the full dose of any medicines provided to ensure full recovery
55
Recordkeeping
The village leaders and CDD should create and maintain a village register (the project or community can supply notebooks) in which: Each household has a page Children, pregnant women and others are included All services (case management, provision of LLINs,
etc.) are recorded A monthly summary of services is made from the
register and forwarded to the health system
56
CDDs Monitor and Refer
The CDD: Refers pregnant women to nearest ANC clinic to get
regular examination and other commodities Ensures that children are up to date on
immunizations
Health workers should: Spot check register for beneficiaries to ensure
proper documentation during supervision visits Register should contain enough details for tracing
beneficiaries to ensure:– Accountability– That the register is updated to account for new births, deaths,
new entrants and those leaving the community 57
58
Summary and Conclusions
CDI was first tested for use for APOC by TDR, and it proved successful
Communities can carry out the task of distributing health commodities very well
CDDs do not replace health workers; rather, CDDs complement health worker services
CDI happens when communities take charge of distributing health commodities themselves with guidance from the health service
CDI guarantees that services reach the grassroots