Applying Community-Directed Intervention (CDI) to Insecticide-Treated Bed Nets (ITNs) Module 7 Version 2

Learning objectives By the end of this module, learners will be able to: Explain how to obtain and safely maintain stocks of ITNs or long-lasting insecticidal nets (LLINs) Estimate ITN/LLIN needs based on community census Discuss the importance of making sure that all women of reproductive age have and use an ITN/LLIN so that they will be protected at the beginning of their next pregnancy Source: Clipartfest.com

Learning objectives, cont. Discuss the need to encourage pregnant women to collect and use ITNs/LLINs as soon as they realize they are pregnant Discuss the need to educate community members on the importance of sleeping inside ITNs/LLINs every night (especially for children and pregnant women) Outline the process of teaching community members how to use the nets Discuss the importance of community health workers (CHWs) following up to encourage continued ITN/LLIN use

Comparison of treated and untreated nets Action Untreated net ITN/LLIN Protects against malaria Provides some protection Provides high levels of protection Kills and repels mosquitoes No Yes Reduces number of mosquitoes inside/outside net Kills other insects (e.g., lice, roaches, bedbugs) Is 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

Modes of ITN/LLIN distribution In some places, nets are given out through: Mass distribution campaigns Routine services like antenatal care CHW distribution to targeted households as part of CDI In any case, we must estimate needs for nets— building from household, to village, to district levels We need to identify different providers and sources of ITNs/LLINs and ensure coordination to meet all coverage needs How are nets distributed in your country?

CHWs inform community members about ITN/LLIN logistics Let people know how they can obtain nets: Routine health services (e.g., antenatal care) Campaigns—in some cases they may need to obtain a voucher first Commercial sales Inform people where they can obtain ITNs/LLINs: CHWs The health facility providing service to their community Shops, markets, pharmacies, etc. Facilitator: Discuss ITN/LLIN logistics that apply to your area

Who gets ITNs/LLINs? Communities need to obtain and safely maintain stocks of ITNs/LLINs based on community census estimates Generally, the goal is at least one net for every two people in a household: Household net need can also be estimated by the number of sleeping spaces in a home In CDI, the CHWs will ensure that all under-5 children, pregnant women, and women of reproductive age living in the community receive ITNs/LLINs Other household members should get nets, but if supplies are limited, priority should go to children and pregnant women

CHW outreach on ITNs/LLINs CHWs 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 Follow up regularly during pregnancy to ensure that women sleep inside the net Photo by Bright Orji, Jhpiego

Community health education on ITN/LLIN benefits

Health education begins with the community Although health workers know malaria is carried by mosquitoes, and therefore, ITNs/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 Overexposure to sun What do people in your area think?

ITN/LLIN benefits to the community Reduces number of sick children and adults, thus helping: Children grow up healthy Adults remain productive Lowers the number of deaths in the community Protects pregnant women against malaria, resulting in less: Anemia Prematurity and low birthweight Risk of maternal and newborn death Retarded fetal growth

ITN/LLIN benefits to the community, cont. Promotes growth and development of the fetus and newborn Protects children from malaria Decreases cost of treating frequent malaria Prevents mosquito bites Helps people sleep better

ITN/LLIN benefits to the community, cont. Repels and kills other insects (e.g., lice, ticks, bedbugs, and cockroaches) When most people use nets, mosquitoes are reduced throughout the community Photo by Enobong Ndekhedehe, Jhpiego

Educate community members on protecting vulnerable groups If possible, everyone should use an ITN/LLIN, but give priority to pregnant women, infants, and children ITNs/LLINs are safe for pregnant women, 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 ITN/LLIN so they are already protected if they become pregnant

Education on proper ITN/LLIN use

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 ITNs/LLINs last for 3 to 5 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 ITNs/LLINs away from smoke, fire, direct sunlight

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

Hanging a net properly in the village can be challenging Discuss net-hanging challenges in your area.

Net-hanging demonstration in a village hall Facilitator: Discuss where you can organize net demonstrations

Demonstration and return demonstration on net hanging

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 Net misuse, cont. Net used for door curtain Net used to cover vegetable garden

Maintaining ITN/LLIN stocks After mass distribution, we may discover that not all households received the required number of nets In some cases, we may need to account for the fact that people have two residences (e.g., town and farm) Therefore, we need to maintain supplies to fill gaps: Frontline health facilities need to keep a supply of nets CHWs may also keep supplies of nets

Replacement and keeping up We also need to maintain supplies to: Meet the needs of newly pregnant women and people who migrate into the community Replace lost and torn nets Photo by Awele Ekpubeni, Jhpiego

Discussion What sources of ITNs/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 plan for net procurement and distribution for campaigns as well as 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 CHWs have an important role in: Helping people handle nets Monitoring the actual household situation Reminding people to use nets correctly

Thank you! Any questions or comments?