CDI Module 2: The CDI Process
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on CommunityDirected Intervention (CDI) to Improve
Access to Essential Health Services
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
2
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
3
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
4
Benefits of CDI
Ivermectin Coverage in
Eight-Site Project
80
70
60
50
40
30
20
10
0
68.6
Community
Directed
62.2
Agency
Designed
 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
5
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
6
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
7
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
% children slept under ITN previous night
Children Sleeping under ITNs
70
RBM
Target
2005
60
50
40
36
35
33
30
20
10
16
9
11
0
Comparison districts
ITN through CDI for 1 year
Year 2
RBM = Roll Back Malaria Partnership
ITN through CDI for 2 years
Year 3
Source: The CDI Study Group 2010
9
% pregnant women slept under ITN previous night
Pregnant Women Sleeping under ITNs
70
57
60
49
50
RBM
Target
2005
37
40
33
30
20
10
8
4
0
Comparison districts
ITN through CDI for 1 year
Year 2
ITN through CDI for 2 years
Year 3
Source: The CDI Study Group 2010
10
Children Receiving Appropriate Malaria
Treatment
80
69
% children w/fever receiving
appropriate treatment
70
60
RBM
Target
2005
55
48
50
40
29
30
28
21
20
10
0
Comparison districts
HMM through CDI for 1 year
Year 2
HMM through CDI for two
years
Year 3
Source: The CDI Study Group 2010
11
Basic Ivermectin Coverage Improves
Even When More Tasks Are Added
80
74
72
% ivermectin coverage
70
63
APOC
target
64
60
50
40
30
20
10
0
Year 2
Comparison districts
Year 3
CDI districts
Annual ivermectin coverage of 65% is needed to control the disease
Extra interventions enhance community interest
12
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
13
Key Lessons
The most critical factors
are:
 An empowered
community
 Supplies delivered
regularly, in adequate
amounts and on time
14
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
15
Each partner has a well-defined role
Organizational Partners
NGO
Other
NGO
MOH
WHO
UNICEF
SMOH
LGA
USAID PHC
Community
Partners
Religious
Groups
Village
VHT Leaders CBOs
CDDs Others
16
CDI for iCCM Can Build on Existing
Programs
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
17
Approaching the Health Service
Health Service Roles
18
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
19
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
20
Staff at Local Clinic Train and Supervise
Community-directed Distributors (CDDs)
21
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
22
Clinics Should Also Have Community Maps
23
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)
24
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
25
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
26
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 semiliterate CDDs, using:
 Role play, demonstration, illustrations, motivation
28
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
29
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
30
Approaching the Community
Gaining Support for CDI
31
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
32
First Meeting with Community Leaders
33
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
34
Second Meeting with Community
Members
35
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 community
36
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)
37
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
38
Training Community-Directed
Distributors
Recruitment, Commitment, Responsibilities
39
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
40
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
41
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
42
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
43
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
44
CDD Skills
 Treatment
 Drugs available
 Treatment modes,
regimen,
requirements, possible
reactions, reaction
management
 Referral
 Conditions for referral
 Referral points
45
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 surveillance
All of these topics will be covered in detail in the
modules that follow
46
Involve CDDs in Generating
Content 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
47
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
48
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
49
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
50
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
51
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
52
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
53
Prompt Diagnosis and Appropriate
Treatment
54
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
55
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
56
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
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
58