1. The Community-Directed Intervention (CDI) Process
Module 3
Version 2

2. Learning objectives
By the end of this module, learners will be able to:
Define the CDI approach
Describe program coverage benefits of using CDI
Explain the role of the health facility (HF) in the CDI process
Outline the steps to establish a CDI program
List key approaches in gaining community commitment for a CDI program
Describe the steps in selecting and training community health workers (CHWs)
Explain how CDI can be adapted for use in controlling malaria in pregnancy (MiP)

3. What is CDI?
For many years, health services and nongovernmental organizations have been distributing health commodities to communities, for example:
Immunizations
Vitamin A
Bed nets
Ivermectin
Guinea worm filters
CDI happens when communities take charge of distributing health commodities themselves with guidance from the health service

4. What is CDI? (cont.)
“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 intervention
When communities are in charge there is often better coverage than when there is centrally organized distribution by a health agency

5. 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.
Image source: Raw Gist Accessed September 24, uploads/2015/09/onchocerciasis2.jpg.

6. 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.

7. Results of CDI for onchocerciasis
The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution
When 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

8. Expanding CDI beyond onchocerciasis
Recently APOC observed that the CDI approach is being used for other issues
Studies have documented CDI being used to promote:
Guinea worm control
Schistosomiasis control
Immunization programs
Vitamin A distribution
Water and sanitation projects

9. 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 continued
Through CDI, intervention groups received:
Vitamin A
Home management of malaria (HMM) with artemisinin-based combination therapies
Insecticide-treated bed nets (ITNs)
Tuberculosis case detection and follow-up for case completion
The study showed benefits in malaria control and ivermectin coverage

10. Results: Children sleeping under an ITN
Roll Back Malaria (RBM) target
2005
Conclusion: CDI increased proportion of children sleeping under ITNs 9

11. Results: Pregnant women sleeping under ITN
RBM target
2005
Conclusion: CDI increased proportion of pregnant women sleeping under ITNs 10

12. Results: Appropriate treatment of children with fever
RBM target
2005
Conclusion: CDI increased proportion of children with fever who received appropriate treatment 11

13. Results: Ivermectin treatment coverage
APOC target
Conclusion: CDI increased basic ivermectin treatment coverage even when other services were added
Source: TDR 2008 12

14. Lessons learned CDI works when:
The disease is perceived as an important health problem that affects all sections of the community
An intervention or solution is available that is relatively simple to implement
The intervention has a clearly perceived benefit
Implementation of intervention is under full control of the community implementers
The intervention materials are made adequately accessible to the community

15. Key lessons The most critical factors were:
Community empowerment/ownership
Regular, adequate, and timely supply of the materials to be delivered
Net storage in medical stores. Photo by Bill Brieger, Johns Hopkins University/Jhpiego.

16. Learning how to implement CDI

17. Partners: Each partner has well-defined roles*
In the CDI process, the project belongs to the community and the health service:
Communities:
Community leaders
Community members
CHWs
Health service:
Ministry of health maternal and child health or reproductive health divisions
National malaria control or elimination program
Subnational and district health offices, especially malaria-related ones
Frontline HF staff and health care workers
CDI focal persons
Partners 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
*See Community Intermittent Preventive Treatment for Malaria in Pregnancy: Implementation Guide chapter “Roles and responsibilities” for more detail.

18. Start-up components of CDI for malaria control
1. Approaching the health service to build a partnership between an affected community and the HF nearest to it
2. Reaching out to the community
Gaining support for CDI
Mapping and learning about the community
3. Training CHWs selected by the community
4. Implementing c-IPTp with SP
Identification of eligible women
Counseling
Giving SP with DOT
Referral
Abbreviations: c-IPTp, community-directed intermittent preventive treatment in pregnancy; DOT, directly observed therapy; SP, sulfadoxine-pyrimethamine.

19. 1. Approaching the health service
Photo by Emmanuel Otolorin, Jhpiego.

20. Start at the facility nearest to the community
This may be:
Community primary health care facility
District comprehensive health center
These facilities may offer services such as:
Antenatal care (ANC)
Safe delivery and postnatal care
Family planning
Appropriate integrated management of childhood illnesses
Routine immunization
Vitamin A distribution
Commodities to prevent malaria such as ITNs/LLINs (long-lasting insecticidal nets), SP
Photo by Gabriel Alobo, Jhpiego.

21. Meet facility in-charge
Explain the purpose of the program:
Importance of health service staff as CDI facilitators/trainers
Benefits of CDI to the health system
Reduced workload for health workers
Increased contact with community
Map facility catchment areas*
Train health care workers
Choose CDI focal persons for further training
*See Module 5 for more detail.

22. 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-tests
Illustrations
Motivation
Interactive learning methods such as:
Role-play (e.g., health education counseling)
Demonstration (e.g., how to set up ITNs/LLINs)
Observed practice and feedback
Teach skills for monitoring and evaluation (see Module 8 for details)

23. 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 supervision
Use checklists to assess performance
Appreciate the information from the field
Provide immediate feedback to CHWs
Coach the CHW to use the feedback; if possible, have the CHW try again and then immediately evaluate

24. 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 trainings
Reporting
Passing 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)

25. 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 CDI
Facilitating community census and mapping
Reviewing census and mapping results to estimate needed commodities, supplies
Providing drug box so CHWs can keep commodities

26. 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 commodities
Maintaining stocks of basic health commodities for CDI, for example:
Quality-assured SP
ITNs/LLINs
Community registers

27. Roles of the CDI focal person, cont.
Coordinating:
CDI training:
Training community-selected CHWs
Providing retraining to refresh CHWs and replace dropouts
Supervision:
Conducting supportive supervisory visits
Commodity storage
Recordkeeping:
Ensuring communities and CHWs submit data in a timely manner
Incorporating community data with facility data for onward transmission

28. 2. Reaching out to the community
Mothers Savings and Loans Club members in Nigeria.
Photo by Karen Kasmauski.

29. Meetings with the community
1. Community entry meeting with community leaders
2. CDI orientation and facilitation meeting with community representatives
3. Community-wide meetings of community representatives and all community members
4. Feedback meeting of community representatives and CDI focal persons

30. 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 proceed
Jointly define the problem
Inform them about available services to address the problem
Identify community roles in accessing the available services
Community leaders are gatekeepers

31. 1. Community entry meeting, cont.
Explain CDI to the leaders and answer their questions
Obtain a clear sense of commitment
Arrange a larger CDI orientation and facilitation meeting with community representatives

32. 2. CDI orientation and facilitation meeting
It 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

33. 2. CDI orientation and facilitation meeting, cont.
Jointly define the problem
Inform them about available services or solutions
Identify potential community roles in accessing the available services or solutions
Decide on criteria for CHW selection
Discuss and gain commitment for community roles

34. Roles for the community
Map the community
Conduct 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).

35. 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)

36. Roles for the CHW
Collect health commodities at nearest HF
Distribute 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 HF

37. 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 process
It may not be possible to do everything at one meeting; the community should hold follow-up meetings as needed

38. Discuss and gain commitment for community roles including...
CHW selection: Developing criteria of type of residents best suited to the work of CHW
Census/mapping exercises
Conducting village census to aid in estimating commodity needs
Mapping the community (see Module 5 for more detail)

39. 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 commodities
Document the community action plan
Reiterate the importance of community playing its roles

40. 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 CHWs
Plan training of CHWs:
Sponsor/support CHWs to attend c-IPTp training
Identify timing, venue, requirements
Share information on training logistics with CHWs and training facilitators

41. Training CHWs for their roles
Recruitment, commitment, responsibilities
CHW Training Session in Nigeria. Photo by Eno Ndekhedehe

42. 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 level
Plan for refreshment
Make training and trainers lively and supportive

43. Make a training plan for CHWs, cont.
Training plan template
Module #
Proposed dates
No. of CHWs
Venue
Training facilitators
Resources needed

44. 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 MiP

45. 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 women
Early detection of malaria fever and treatment with appropriate antimalarial drugs in accordance with national guidelines
Discuss drug availability within the community
Direct discussion to management of MiP, especially c-IPTp with quality-assured SP

46. 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 provision
Pregnancy wheel for gestational age estimation

47. Skills training for CHWs, cont.
Prevention:
How to hang ITNs/LLINs
How to assess women for IPTp eligibility
Giving IPTp with SP by DOT
Treatment:
Drugs available (artemisinin-based combination therapies)
Treatment modes, regimen, requirements, possible reactions, reaction management
Referral:
Conditions for referral
Referral points

48. 4. Implementation of c-IPTp with SP

49. Review of major MiP interventions
Remember—prevention of malaria in the pregnant woman reduces low birthweight in babies
ITNs/LLINs:
Get a net early in pregnancy
Sleep inside this net every night
IPTp: Minimum of three doses recommended:
First dose of SP between 13 and 16 weeks or after quickening
Second dose at least 4 weeks later
Third dose at least 4 weeks after second dose
Fourth to sixth doses, if possible, with at least 4 weeks between each dose
Case management
IPTp
ITNs/LLINs

50. 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/LLIN
For both modes:
Start with small supply
If CHW is found capable, increase supply
CHW maintains village register of pregnant women
CHW collects ITNs/LLINs or coupons from health service
CHW records delivery of ITN/LLIN or coupon for each woman who received it
Facilitator: Work out actual steps and procedures here. Note whether CHWs will have supplies of nets or coupons. Use more slides as needed.

51. IPTp through CDI
CHW:
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 Chart
Identifies pregnant women eligible for IPTp dose
Facilitator: Work out actual steps here. Use more slides as needed.

52. IPTp through CDI, cont.
Issues drug to eligible women and ensures they swallow full dose (DOT)*
Records the information about giving IPTp in CHW register
Refers 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.

53. Notes on IPTp dosing
When 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.

54. Key health education messages on IPTp
CHW delivers key messages using the Counseling Flip Chart:
Malaria parasites 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 at birth and can get sick easily
IPTp with SP prevents MiP

55. 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

56. Summary and conclusions
CDI was first tested for use by TDR for APOC and the approach proved successful
Communities 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 services
CDI happens when communities take charge of distributing health commodities themselves with guidance from the health service

57. Summary and conclusions, cont.
CDI processes
1. Approaching the health service and training CDI focal persons
2. Community entry meeting with community leaders
3. CDI orientation and facilitation meeting with community representatives
4. Community meets on its own to discuss the project
5. Feedback meeting with community representatives
6. Training selected CHWs
7. c-IPTp implementation (counseling, referrals, provision of SP, etc.)
8. Monthly CHW meetings with CDI focal persons

58. References
CDI Study Group Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ. 88(7):509–518. doi: /BLT
TDR (Special Programme for Research and Training in Tropical Diseases) Community-Directed Interventions for Major Health Problems in Africa: A Multi-country Study; Final Report. Geneva, Switzerland: TDR/World Health Organization. Accessed October 18, 2018.

59. Thank you!
Any questions or comments?