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
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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
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Comparison of Treated and Untreated Nets
Action
Protection against malaria
Kill and repel mosquitoes
Reduce number of mosquitoes inside/outside net
Kill other insects (e.g., lice, roaches, bedbugs)
Safe for pregnant women, young children and infants
Untreated
Nets
Provides some levels of protection
No
No
No
Yes
LLINs/ITNs
Provides high levels of protection
Yes
Yes
Yes
Yes
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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
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Procuring and Maintaining LLIN Stocks
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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
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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
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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
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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
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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
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Community Health Education on LLIN
Benefits
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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?
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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
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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
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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
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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
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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
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Education on Proper LLIN Use
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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
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Demonstration and Return Demonstration on Net Hanging
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Net Hanging Demonstration in a Village Hall
Discuss where you can organize net demonstrations
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Hanging a Net Properly in the Village
Can Be Challenging
Discuss net hanging challenges in your area
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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
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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
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Correct Net Use
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Net Misuse
Net used for goal post Net used for kiosk
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More Net Misuse
Net used for door curtain
Net used to cover vegetable garden
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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?
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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
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