Welcome to our last lecture in Community Change for Public Health. This is Bill Brieger again, and I want to introduce you to the community-directed intervention process, which is an expansion beyond the community-directed treatment with Ivermectin that we've talked about before. For many years we've learned that health systems have tried to bring commodities. Whether it's bed nets, whether it's medicines. whether it's immunizations, out to the community. But we also know that the communities can do a lot for themselves. So, community-directed intervention happens when communities take charge of distributing these health communi commodities themselves with guidance and encouragement from the health service. This idea of the community-directed intervention was first tested as the community-directed treatment with Ivermectin, that we've talked about in two previous lectures. The next question, of course, is what happens? And we learned that communities that distributed their own Ivermectin with their own effort. provided much better outreach, much better coverage than agencies doing it alone through mobile clinics and that type of thing. so this CDI or CDTI in that sense was adopted as the official policy of the African Program for Onchocerciasis Control and is now reaching over 100,000 villages throughout Africa on an annual basis with Ivermectin for river blindness control. the original project, which we've talked about, did achieve a better coverage. they've estimated you need a minimum of 60% coverage every year to eliminate onchocerciasis and we hope that will happen by 2020 or 2025. but even with the original test that was done in 1995, they found that the community taking charge gave a better coverage than if the agencies alone were involved. So, because of this, the African Program for Onchocerciasis Control, the World Health Organization, many groups have been asking, can this approach go beyond Ivermectin? And so, some of the first studies that were done we're observational. What are organizations, what are communities doing in addition to Ivermectin? And they found that the same process of community organizing its own volunteers was working to help control Guinea Worm that promote immunization, for Vitamin A distribution, for water and sanitation projects. Getting communities involved controlling Schistosomiasis and other waterborne disease. Even agriculture extension agents were trying to get the community involved through community directed intervention. But the question still remain, can you add on these additional tasks, these additional commodities, in the community, and will it function? Will it disturb the Ivermectin distribution? Will it enhance it? Can the community take charge of doing other things? And so, this project looked at whether four additional things could be done by the community. Vitamin A distribution, home management of malaria with the artemisinin-based combination therapy drugs, distribution of the insecticide-treated bed nets, and TB case management and follow-up with the docs for the directly observed treatment in the community. So the important thing is it was a three year project, but the big lesson was that the various stakeholders because the Vitamin A distribution was done by a different section of the health department than the Ivermectin distribution. The malaria component was under a different section. So, to get these other stakeholders to buy into the community-directed approach that the River Blindness, Ivermectin Onchocerciasis people had been using, took almost the whole first year to get everybody on board from the national to the regional, or state down to the district level because everyone had to buy into this and trust the community could distribute these things. After the third year, it was discovered that yes, the community did make a difference. The basic services, in this case, the bed nets were made available in all locations at the nearest health center, and people could collect them there. So, the difference is, in the set of bars in the middle and to the right, is that the community took charge of distributing the nets. what we see is the importance of community taking charge because they were able to achieve a much greater level of coverage than just the health center. There's still more challenges facing them to get up to coverage targets and this has a lot to do with the supply of nets and the timely supply. But, the community was able to do better. We see that, in fact with pregnant women sleeping under nets, it was much better than even with children, as we saw in the previous slide. so there was much greater accomplishment of these targets when the community made sure that they distributed the nets. And, see it's not just a question of giving out the nets. But the community volunteers are there to follow up and encourage people to actually use them, to guide them in hanging them up and actually using them. So, the community involvement is not just delivering the commodity but helping people understand and value and use the commodity. what we found with the malaria treatment is that the same issue is that when the community had the treatment available right then and there for people to come and get, there was much greater coverage than if people had to go to the health center to get the same treatment. And one of the big questions that had been asked before is by doing these things, by providing these additional services, would that detract from the annual distribution of Ivermectin. And as we can see in the chart with the pink orange colored bars that the, yes, the community distribution of Ivermectin was actually better. And we found that people were happy to be able to receive these additional services and appreciated the Ivermectin more because of this. One additional activity that was done is that we said, okay, one of the big challenges with malaria is malaria and pregnancy. and we expanded this idea to a state in Nigeria. We made sure that the intermittent preventive treatment using the drug sulfadoxine pyrimethamine, some people know it as Fansidar giving that during pregnancy was a challenge, getting coverage in most countries, and so could this be distributed safely by volunteers? And, of course, the distribution of the nets for pregnant women. So, we can see here in the picture the community volunteer keeps good records, makes sure that the women take this medicine. Being observed so that they're not hiding it or, or refusing to swallow it. Also, home visits are possible by the volunteers to make sure the nets are received and used. So, what we found with the malaria in pregnancy was a similar thing with the other larger study that had covered several countries. But, the smaller bars on the left were at baseline. We had a control community and in the control communities we did just like with the other study, made sure that they had nets and that they had the drugs at the antenatal clinic. And, of course, what we found is that, again, by bringing these things to the community, the coverage was increased. And again, what we want to stress is that, if the community members were not left on their own, they were trained and supervised and supplied by the nearest health center, the staff at the nearest health center. So, it became part of the health program, as we used to call it the health center without walls. So that the health workers would be looking at their whole catchment area instead of just what happened when people entered the walls of the clinic. So, we discovered, of course, that this community directed intervention, works. One, if people perceive the disease or the problem as a priority, as affecting their lives. And clearly, malaria was something that people thought was very important. We also saw that when they were able to tackle a problem, when we were able to tackle a problem that they though was important, they also had a, also had a synergistic effect on the Ivermectin on other components within the program. this is something that is simple to implement. people clearly could see the benefits, they were very happy to have these things right at their doorsteps. and again, when they take charge, aa, things can happen. The big challenge of course, is always been to make the materials available at the health center's so that the community can come and collect them, and then report back to the health center. These are, again, some of the key lessons that the critical factors are, an empowered community. We don't empower the community, but the community, when it has access to these things, can take charge and empower themselves. we also, again, stress the importance of having supplies, materials, supervision available, and the right amount at the right time. again, the community, as we talked way back in the beginning, of, in the ecological model, the community may be willing, but the institution and the policy makers have to make sure the supplies and things are available for them. So, this is our last lecture. We want to thank you for being with us. We hope that in the previous lectures, learning about the definition of communities, learning about the different types of communities, learning about some of the different interventions, like community coalitions and community directed intervention, will help you in your work in public health. Goodbye and thank you.
