CDI Module 7: CDI in LLIN Distribution and Use ©Jhpiego Corporation The Johns Hopkins University A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

Module 7 Objectives By the end of this module, learners will: Explain how to obtain and safely maintain stocks of long-lasting insecticide-treated nets (LLINs) Estimate LLIN needs based on community census Discuss the need to educate community members on the importance of sleeping under LLINs every night (especially children and pregnant women) Discuss the need to encourage pregnant women to collect and use LLINs as soon as they realize they are pregnant

More Objectives By the end of this module, learners will: Outline the process of teaching community members how to use the nets Outline follow-up procedures for facility staff and community-directed distributors (CDDs) to encourage continued LLIN use Discuss the importance of making sure that all women of reproductive age have and use an LLIN so that they will be protected from the beginning of their next pregnancy

Comparison of Treated and Untreated Nets Action Untreated Nets LLINs/ITNs Protection against malaria Provides some levels of protection Provides high levels of protection Kill and repel mosquitoes No Yes Reduce number of mosquitoes inside/outside net Kill other insects (e.g., lice, roaches, bedbugs) Safe for pregnant women, young children and infants

Net Program Stages Catch-up: Make sure everyone gets a net Hang-up: People hang and use the nets Keep-up: Replace old nets, give nets to new people

Procuring and Maintaining LLIN Stocks

Modes of LLIN Distribution In some places nets are distributed through mass distribution campaigns In some places LLINs are also made available through routine services like antenatal care (ANC) In either case, we must estimate needs for nets—building from household, to village, to local government area (LGA)/municipal levels We need to identify different providers and sources of LLINs and ensure coordination to meet all coverage needs

Community Net Stocks Communities need to obtain and safely maintain stocks of LLINs based on community census estimates Community distributors will approach the health facility with a community register, based on the community census, and will receive LLINs for their communities The community distributors will sensitize and inform community members on the availability of the commodity through mechanisms agreed upon by the community

Who Gets LLINs? Generally our goal is at least one net for every two people in a household Net need can also be estimated by the number of sleeping spaces in a home The CDDs will ensure that all under-five children, pregnant women and women of reproductive age living in their community receive LLINs Other household members should get nets, but if supplies are limited, priority should go to children and pregnant women

Replacement and Keeping Up After mass distribution, we may discover that not all households received the required number of nets Therefore, we need to maintain supplies to fill gaps We also need to maintain supplies to meet the needs of newly pregnant women and people who migrate into the community In some cases, we may need to account for the fact that people have two residences (e.g., town and farm) Supplies are also needed to replace lost, torn nets

Methods for Filling Gaps and Keeping Up Frontline health facilities need to keep a supply of nets after campaigns have taken place CDDs may also keep supplies of nets for newcomers and newly pregnant women

Community Health Education on LLIN Benefits

Health Education Begins with the Community Although health workers know malaria is carried by mosquitoes, and therefore, LLINs will prevent malaria: Community members may have other ideas (as we see to the right) We must be respectful of local beliefs when we explain net use According to some local beliefs, malaria may be caused by: Red cooking oil Too much alcohol Too much work Over-exposure to sun What do people in your area think?

Inform Community Members of LLIN Benefits LLINs: Repel and kill mosquitoes Prevent physical contact with mosquitoes Repel and kill other insects (e.g., lice, ticks, bedbugs and cockroaches) When most people use nets, mosquitoes are reduced throughout the community

Educate Community Members on Protecting Vulnerable Groups If possible, everyone should use an LLIN, but give priority to pregnant women, infants and children LLINs are safe for pregnant mothers, young children and infants Advise pregnant women to use the net as soon as possible as soon as they know they are pregnant— teach them how to use the nets Ideally all women of reproductive age (15–45 years) should sleep under an LLIN so they are already protected if they become pregnant

Inform Community Members about LLIN Benefits Prevents mosquito bites Helps people sleep better Protects children from malaria Protects pregnant women against malaria, resulting in less: Anemia Prematurity and low birth weight Risk of maternal and newborn death Retarded fetal growth Promotes growth and development of the fetus and newborn

Education about Benefits Inform community members that LLIN use will benefit the community by: Decreasing cost of treating frequent malaria Reducing number of sick children and adults, thus helping Children to grow up healthy Adults to remain productive Lowering the number of deaths in the community

Inform Community Members about LLIN Logistics Let people know how they can obtain nets: Routine health services (e.g., ANC) Campaigns—in some cases they may need to obtain a voucher first Commercial sales Inform people where they can obtain LLINs: The community distributors in their community The health facility providing service to their community Shops, markets, pharmacies, etc. Discuss LLIN logistics that apply to your area

Education on Proper LLIN Use

Educate Women Women play important roles in keeping household members healthy, so remind women: That it is not enough to collect the net; they must use it too To expose the net for 24 hours before use (but NOT in direct sunlight) To hang the net above the bed or sleeping mat—using rope, net hangers or sticks at the four edges of the net To tuck the net under the mattress or sleeping mat To use the net every night, all year round

Demonstration and Return Demonstration on Net Hanging

Net Hanging Demonstration in a Village Hall Discuss where you can organize net demonstrations

Hanging a Net Properly in the Village Can Be Challenging Discuss net hanging challenges in your area

CDDs Visit the People CDDs should: Visit pregnant women and children’s caregivers and remind them that pregnant women and children should sleep under nets regularly Teach pregnant women and children’s caregivers how to care for the nets Make rounds to ensure nets are hung properly and all sleeping spaces are covered Ensure that women sleep under the net regularly during pregnancy

Teach People How to Use and Care for Nets Handle the nets gently to avoid tearing them Fold/tie up the net during the day to avoid damage Regularly inspect the net for holes; repair holes, if found LLINs last for three to five years or 20 washes, but may expire sooner if washed too often Wash only when very dirty, no more than a few times a year Wash nets with gentle soap, NOT detergent Dry nets in the shade—no sun because it will destroy the chemical Keep LLINs away from smoke, fire, direct sunlight

Correct Net Use

Net Misuse Net used for goal post Net used for kiosk

Net used for door curtain Net used to cover vegetable garden More Net Misuse Net used for door curtain Net used to cover vegetable garden

Discussion What different sources of LLINs are available in your communities? Share the different examples of net misuse you have seen and suggest what can be done What challenges do you know that make promotion of net use difficult? Any household factors? Any health system factors? What can the community do about such challenges?

Summary We need to address net procurement and distribution during campaigns and for follow-up People need to be educated about the benefits of using nets Net distribution is not finished until all nets are hung properly and used regularly CDDs have an important role in: Helping people handle nets Monitoring the actual household situation, and Reminding people to use nets correctly