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

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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

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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

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Benefits of CDI

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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

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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

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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

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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

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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

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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

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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

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Key Lessons

The most critical factors are:

An empowered community

Supplies delivered regularly, in adequate amounts and on time

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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

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CDI for iCCM Can Build on Existing Programs

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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Approaching the CommunityGaining Support for CDI

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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

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First Meeting with Community Leaders

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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

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Second Meeting with Community Members

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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)

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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

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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

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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

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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

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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

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CDD Skills

Treatment Drugs available Treatment modes,

regimen, requirements, possible reactions, reaction management

Referral Conditions for referral Referral points

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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

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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

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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

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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

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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

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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

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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

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Prompt Diagnosis and Appropriate Treatment

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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

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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

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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

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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