1. Applying Community-Directed Intervention (CDI) to Insecticide-Treated Bed Nets (ITNs)
Module 7
Version 2

2. Learning objectives
By the end of this module, learners will be able to:
Explain how to obtain and safely maintain stocks of ITNs or long-lasting insecticidal nets (LLINs)
Estimate ITN/LLIN needs based on community census
Discuss the importance of making sure that all women of reproductive age have and use an ITN/LLIN so that they will be protected at the beginning of their next pregnancy
Source: Clipartfest.com

3. Learning objectives, cont.
Discuss the need to encourage pregnant women to collect and use ITNs/LLINs as soon as they realize they are pregnant
Discuss the need to educate community members on the importance of sleeping inside ITNs/LLINs every night (especially for children and pregnant women)
Outline the process of teaching community members how to use the nets
Discuss the importance of community health workers (CHWs) following up to encourage continued ITN/LLIN use

4. Comparison of treated and untreated nets
Action
Untreated net
ITN/LLIN
Protects against malaria
Provides some protection
Provides high levels of protection
Kills and repels mosquitoes No
Yes
Reduces number of mosquitoes inside/outside net
Kills other insects (e.g., lice, roaches, bedbugs)
Is 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. Modes of ITN/LLIN distribution
In some places, nets are given out through:
Mass distribution campaigns
Routine services like antenatal care
CHW distribution to targeted households as part of CDI
In any case, we must estimate needs for nets— building from household, to village, to district levels
We need to identify different providers and sources of ITNs/LLINs and ensure coordination to meet all coverage needs
How are nets distributed in your country?

7. CHWs inform community members about ITN/LLIN logistics
Let people know how they can obtain nets:
Routine health services (e.g., antenatal care)
Campaigns—in some cases they may need to obtain a voucher first
Commercial sales
Inform people where they can obtain ITNs/LLINs:
CHWs
The health facility providing service to their community
Shops, markets, pharmacies, etc.
Facilitator: Discuss ITN/LLIN logistics that apply to your area

8. Who gets ITNs/LLINs?
Communities need to obtain and safely maintain stocks of ITNs/LLINs based on community census estimates
Generally, the goal is at least one net for every two people in a household:
Household net need can also be estimated by the number of sleeping spaces in a home
In CDI, the CHWs will ensure that all under-5 children, pregnant women, and women of reproductive age living in the community receive ITNs/LLINs
Other household members should get nets, but if supplies are limited, priority should go to children and pregnant women

9. CHW outreach on ITNs/LLINs
CHWs 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
Follow up regularly during pregnancy to ensure that women sleep inside the net
Photo by Bright Orji, Jhpiego

10. Community health education on ITN/LLIN benefits

11. Health education begins with the community
Although health workers know malaria is carried by mosquitoes, and therefore, ITNs/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
Overexposure to sun
What do people in your area think?

12. ITN/LLIN benefits to the community
Reduces number of sick children and adults, thus helping:
Children grow up healthy
Adults remain productive
Lowers the number of deaths in the community
Protects pregnant women against malaria, resulting in less:
Anemia
Prematurity and low birthweight
Risk of maternal and newborn death
Retarded fetal growth

13. ITN/LLIN benefits to the community, cont.
Promotes growth and development of the fetus and newborn
Protects children from malaria
Decreases cost of treating frequent malaria
Prevents mosquito bites
Helps people sleep better

14. ITN/LLIN benefits to the community, cont.
Repels and kills other insects (e.g., lice, ticks, bedbugs, and cockroaches)
When most people use nets, mosquitoes are reduced throughout the community
Photo by Enobong Ndekhedehe, Jhpiego

15. Educate community members on protecting vulnerable groups
If possible, everyone should use an ITN/LLIN, but give priority to pregnant women, infants, and children
ITNs/LLINs are safe for pregnant women, 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 ITN/LLIN so they are already protected if they become pregnant

16. Education on proper ITN/LLIN use

17. 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
ITNs/LLINs last for 3 to 5 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 ITNs/LLINs away from smoke, fire, direct sunlight

18. 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

19. Hanging a net properly in the village can be challenging
Discuss net-hanging challenges in your area.

20. Net-hanging demonstration in a village hall
Facilitator: Discuss where you can organize net demonstrations

21. Demonstration and return demonstration on net hanging

22. Correct net use

23. Net misuse
Net used for goal post
Net used for kiosk

24. Net used for door curtain Net used to cover vegetable garden
Net misuse, cont.
Net used for door curtain
Net used to cover vegetable garden

25. Maintaining ITN/LLIN stocks
After mass distribution, we may discover that not all households received the required number of nets
In some cases, we may need to account for the fact that people have two residences (e.g., town and farm)
Therefore, we need to maintain supplies to fill gaps:
Frontline health facilities need to keep a supply of nets
CHWs may also keep supplies of nets

26. Replacement and keeping up
We also need to maintain supplies to:
Meet the needs of newly pregnant women and people who migrate into the community
Replace lost and torn nets
Photo by Awele Ekpubeni, Jhpiego

27. Discussion
What sources of ITNs/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?

28. Summary
We need to plan for net procurement and distribution for campaigns as well as 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
CHWs have an important role in:
Helping people handle nets
Monitoring the actual household situation
Reminding people to use nets correctly

29. Thank you!
Any questions or comments?