1. 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

2. 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

3. 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

4. Comparison of Treated and Untreated Nets
Action
Untreated Nets
LLINs/ITNs
Protection against malaria
Provides some levels of protection
Provides high levels of protection
Kill and repel mosquitoes No
Yes
Reduce number of mosquitoes inside/outside net
Kill other insects (e.g., lice, roaches, bedbugs)
Safe for pregnant women, young children and infants

5. 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

6. Procuring and Maintaining LLIN Stocks

7. 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

8. 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

9. 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

10. 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

11. 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

12. Community Health Education on LLIN Benefits

13. 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?

14. 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

15. 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

16. 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

17. 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

18. 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

19. Education on Proper LLIN Use

20. 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

21. Demonstration and Return Demonstration on Net Hanging

22. Net Hanging Demonstration in a Village Hall
Discuss where you can organize net demonstrations

23. Hanging a Net Properly in the Village Can Be Challenging
Discuss net hanging challenges in your area

24. 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

25. 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

26. Correct Net Use

27. Net Misuse
Net used for goal post
Net used for kiosk

28. Net used for door curtain Net used to cover vegetable garden
More Net Misuse
Net used for door curtain
Net used to cover vegetable garden

29. 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?

30. 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